As President Obama's landmark Patient Protection and Affordable Care Act (ACA) is steadily implemented over the next several years, psychology has an unprecedented opportunity to provide proactive and visionary leadership. At this year's inspirational APA State Leadership Conference, Katherine Nordal stressed the importance of psychology's active presence at the state level and effectively demonstrating to the public-at-large psychology's "value-add" to quality healthcare. "At this time last year, the future of the ACA seemed uncertain. Since then, we've had a Supreme Court decision that upheld the ACA and the November reelection of President Barack Obama. The ACA has survived, and implementation of the largest expansion of the health care safety net will proceed. The clock is ticking toward full implementation of the law and January 1, 2014 is coming quickly. But January 1st is really just a mile maker in this marathon we call health care reform. We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us. The details of ACA implementation vary from state to state, and so do the key players. I believe that if we are not valued as a health profession, it will detract from our value in other practice arenas as well. So regardless of how we feel about the current state of our health care system, psychology must take its seat at the table and contribute to the solutions needed to fix our ailing system. No one else is fighting the battles for psychology and don't expect them to. Health care reform is a marathon – we're in it for the long haul. New models of care and changes in health care financing won't take shape overnight. We can't hope to finish the marathon called health care reform if we're not at the starting line. Fortunately, many psychology leaders have embraced our call to action."
Earlier this year I had the opportunity of attending the Alaskan Native Southcentral Foundation Nuka conference where former Centers for Medicare and Medicaid Services (CMS) Administrator Donald Berwick described the revolutionary magnitude of change coming to our nation's health care environment and the pain that today's practitioners will experience as their daily professional lives are inevitably significantly altered. The underlying objective of the ACA is to foster a data-driven, patient-centered system in which priority is given to preventive, holistic, and wellness-oriented care and where state-of-the-art advances in communications technology will be effectively utilized. Cross provider and cross patient population comparisons (i.e., a public health oriented approach) will become the norm. Isolated professional "silos" will give way to coordinated systems of care. If one reads through the statutory text of "ObamaCare" there are very few express references to psychology – and, very few (if any) actual limitations on our potential contributions. The ACA represents a major expansion of our nation's "safety net" which has historically been the responsibility of Medicare and Medicaid. Critical policy decisions are once again being made primarily at the state level. If we are honest with ourselves, we must recognize that organized psychology has not been systematically engaged in addressing the pressing needs of these underserved beneficiary populations, nor in working collaboratively with other disciplines (such as Advanced Practice Nurses and Clinical Pharmacists) to foster interdisciplinary, patient-centered, integrated primary health systems – either clinically or within our training institutions. These are the signature elements of the ACA and health policy experts appreciate that the various components (e.g., licensure mobility, comparative effectiveness research, and matching educational requirements to clinical needs) have been deliberated in a number of far-reaching health policy conferences and documents (including those sponsored by the Institute of Medicine (IOM)) over the past several decades. Professional isolation (i.e., silos) may be comfortable, but must radically change.
Unprecedented Opportunities: The ACA will provide for the largest expansion of mental health and substance-use coverage in a generation, with 32.1 million Americans gaining access to these services, while another 30.4 million currently with some coverage will gain federal parity protection. Under ACA insurance offered in the new marketplace must cover a core set of "essential health benefits," including mental health and substance-use disorder services. The coverage for behavioral health services must be generally comparable with coverage for medical and surgical care. Ken Pope recently shared a similar perspective, noting that in 2009 public and private mental health spending totaled approximately $150 billion, more than double its level in inflation-adjusted terms in 1986. Those criticizing the ACA for primarily political reasons might naively ask whether the nation or the Administration is really committed to this magnitude of change. Early this year a Kaiser Foundation/ Robert Wood Johnson Foundation/ Harvard School of Public Health survey found that seniors (i.e., those utilizing the program) were most likely to report that Medicare is working well (80%) and that the majority of Americans (67%) believe that federal spending on improving health actually saves money. This summer representatives from the 16 states that by then had elected to run state exchanges met with senior Administration officials in our nation's Capital. According to Hawaii's Coral Andrews, they were very pleasantly surprised to hear President Obama himself join their conference call, requesting a personal briefing on the progress (and tribulations) they were experiencing. Recently I was on a conference call during which Vice President Biden reached out to approximately 3,000 nurses seeking their leadership and active support for educating the public regarding the benefits of the ACA, under which 95% of uninsured Americans will see lower than expected health care premiums in 2014. Also present were two high ranking Administration officials, the Administrators of HRSA (Mary Wakefield) and of CMS (Marilyn Tavenner), both nurses! Opportunities always exist for those who are engaged, as Katherine Nordal proffered. Now is the time to develop and promote creative initiatives that will actively integrate behavioral health within primary health care. This is a major challenge. However, with the expected U.S. Senate retirements, the next Chairman of the Senate Finance Committee, which has jurisdiction over Medicare and Medicaid (i.e., major components of ACA), will most likely be Senator Ron Wyden, a longtime friend of psychology and professional nursing. Colleagues James Werth, Jr.; Greg Hinrichsen, and Mary Polce-Lynch served with Senator Wyden as APA Congressional Fellows.
Psychology's Future Really Depends Upon Our Next Generation: "My introduction to Former APA President James Bray's vision of Speed Mentoring occurred several years ago at the APA convention in Toronto. Like 'speed dating', the APA program is designed to offer graduate students and early career psychologists (ECPs) the opportunity to meet briefly with a number of renowned psychologists in a very compressed period of time. I so happened to be talking with one of these renowned psychologists as he was walking to the invited event. As we approached the registration desk, the event coordinator received a last minute cancellation from a scheduled mentor. My colleague volunteered me as a last second (albeit un-renowned) fill in.
"In this program, mentors meet with 4 separate groups of no more than 10 'mentees' in an hour's time. Each brief group encounter lasts approximately 12 minutes. The discussions tend to be very lively and a surprising number of topics are covered in this fast-paced Q&A session. Then the bell rings and the mentees move on to another station. As the un-renowned, fill-in mentor, the students and ECPs were politely inquisitive as to who in the world I might be. I told them that I worked at a major medical center within the Department of Defense where a psychologist was the chief of an independent Department of Psychology. In addition to the traditional adult, child, and neuropsychology programs, I mentioned that our psychologists were also responsible for a chronic pain program (where a psychologist-nurse supervises the work of anesthesiologists, nurses, chiropractors, psychologists, acupuncturists, and massage therapists), a traumatic brain injury program (supervising physicians, nurses, and psychologists), and a behavioral telehealth program (supervising a dozen psychologists and psychiatrists providing health care exclusively via computer video). I also mentioned that we had an APA-approved internship program, a post-doc residency program, and three APA-approved fellowship programs (child psychology, neuropsychology, and health psychology); the last offering a post-doctoral Master's degree in clinical psychopharmacology as an option.
"To a person, the students and ECPs were very surprised. I was surprised, as well, that they had not heard of psychologists serving in these roles (yes, they knew we were members of multidisciplinary teams, but not leaders of these specialized programs.) Nor had they heard of a clinical psychopharmacology degree (which would prepare them for state or DoD privileges in psychopharmacology) incorporated into a specialized fellowship program. For many, the notion that we could deliver needed services to underserved and rural populations via telehealth was also a novel idea. The ensuing questions and discussion focused on the role of psychologists as leaders in health care and the opportunities to expand our scope of practice.
"It was a great pleasure interacting with these young professionals and, to my own surprise and delight, I have been invited to participate in every subsequent Speed Mentoring event now held annually at the APA convention. While there have been significant gains and losses for our psychology programs in these interim years, the students and ECPs at the Speed Mentoring event appear to find the unusual things we are doing at the medical center quite interesting [Ray Folen]." Aloha,
Pat DeLeon, former APA President – National Register – October, 2013
