One of the most important and rewarding responsibilities of public service psychology is to continually look to the future to explore how to best address the most pressing needs of the nation. The National Academy of Sciences -- which recently celebrated its 150th anniversary, having been chartered by President Abraham Lincoln in 1863 to "investigate, examine, experiment, and report upon any subject of science" -- provides an exciting vision; for those educated within the health sciences, in particular the deliberations of its Institute of Medicine (IOM). As the nation steadily implements the provisions of President Obama's landmark Patient Protection and Affordable Care Act (ACA), one must expect increasing dialogue among health policy experts (including those "paying the bills") at the local and national level in order to most effectively address the inherent challenges in such a fundamental change.
On April 27, 2004 then-President George W. Bush noted: "The way I like to kind of try to describe health care is, on the research side, we're the best. We're coming up with more innovative ways to save lives and to treat patients. Except when you think about the provider's side, we're kind of still in the buggy era…. It's like IT, information technology, hasn't shown up in health care yet…. We're here to talk about how to make sure the Government helps the health care industry become modern in order to enhance the quality of service, in order to reduce the cost of medicine; in order to make sure the patient, the consumer, is the center of the health care decision-making process. And we've made great progress. There's a role for the Federal Government…. (T)he Federal Government can lead because we're spending a lot of money in health care. We're a large consumer on behalf of the American people. Think about it: Medicare, Medicaid, veterans' benefits, Federal employee health insurance plans… and therefore it provides a good opportunity for the Federal Government to be on the leading edge of proper reform and change…. And there's the ways to make sure that the Federal Government's role is helpful in expanding information technology…. If properly used, it is an industry-changer for the good. It enables there to be a better cost structure and better quality care delivered, in this case in the health field. And, yet the health care industry hasn't touched it, except for certain areas. And one area that has is the Veterans Administration…. By introducing information technology, health care will be better, the cost will go down, the quality will go up…."
Institute of Medicine (IOM): A critical issue which the IOM recently addressed is Variation in Health Care Spending, where research has long shown that Medicare spending varies greatly in different regions of the country, even when expenditures are adjusted for variation in the costs of doing business; meaning that certain regions have much higher volume and/or intensity of services than others. Having been involved in the public policy/political arena for nearly four decades, one appreciates that those involved in providing clinical services quite reasonably seek to maximize their reimbursement levels. For years, the particular rationale of a geographically based value index seemed to make intuitive sense. Nevertheless, the IOM ultimately recommended that Congress not adopt this for Medicare payments as the majority of health care decisions are made at the provider or health care organization level, not by geographical units.
Health care in the United States is more expensive than in other developed countries, costing $2.7 trillion in 2011, or 17.9 percent of the national gross domestic product. Increasing costs strain budgets at all levels of government and essentially threatens the solvency of Medicare which is the nation's largest health insurer. At the same time, despite advances in biomedical science, medicine, and public health, health care quality remains inconsistent. In fact, underuse, misuse, and overuse of various services often put patients in danger. Many of the current efforts to improve this situation focus upon Medicare, which mainly pays practitioners on a fee-for-service basis and hospitals on a diagnoses-related group basis (which is essentially a fee for a group of services related to a particular diagnosis). As indicated, Medicare spending varies greatly in different regions of the country and those regions that deliver more services do not appear to achieve better health outcomes than those that deliver less.
The ACA calls for renewed examination of the role of geography in how Medicare reimburses hospitals, physicians, and other providers. The IOM concluded that regional differences are real and persist over time. However, there is much variation within geographic areas, no matter how broadly or narrowly defined. Accordingly, the IOM recommended that Congress notadopt a geographically based value index for Medicare payments because the majority of health care decisions are made at the provider or health care organization level, not by geographic units. Adjusting payments geographically based on any aggregate or composite measure of spending or quality would unfairly reward low-value providers in high-value regions and punish high-value providers in low-value regions. To promote high-value services from all providers, Medicare should continue to test payment reforms that offer incentives to providers to share clinical data, coordinate patient care, and assume some financial risk for the care of their patients. Sound like the underlying themes of President Clinton's Managed Care initiative?
In a series of studies spanning three decades – and the subject of a U.S. Senate Appropriations Committee hearing in November, 1984 -- experts at the Dartmouth Institute for Health Policy have demonstrated significant variation in Medicare spending and quality across geographic regions. In addition, the IOM commissioned extensive research examining populations with specific diseases or clinical conditions. This analysis confirmed that the regional differences in both spending and use of services are large. For example, hospital referral regions whose spending was at the 90th percentile spent 42 percent more per Medicare beneficiary each month than regions at the 10th percentile, without adjustments for any differences between regions. An overall explanation for the variations remains elusive. Variation in patient preferences, provider discretion, and other differences in health status and market factors that are not captured in the data could be responsible for the unexplained variation. Differences in the use of post-acute care (PAC) and acute care services stood out as key drivers of variations in Medicare spending. If there were no variation in PAC spending, variation in total Medicare spending would fall by 73 percent. If there was no variation in both acute care and PAC spending, total Medicare spending variation would drop by 89 percent. In the commercial insurance market, regional differences in price markups, rather than the utilization of health care services, are the prime influence on geographical variation in spending.
Focusing upon the ACA, the IOM recommended that in order to improve value, CMS (which administers Medicare) should continue to test payment reforms such as value-based purchasing, Patient-Centered Medical Homes, bundled payments, and Accountable Care Organizations. [Note, psychology is not expressly mentioned in either the underlying statute or implementing regulations for Patient-Centered Medical Homes or Accountable Care Organizations.] These reforms are directed at decision-making entities and provide incentives for health care providers to integrate care delivery, coordinate care with other providers, and share data on service use and health outcomes in real time. CMS should also pilot programs that allow beneficiaries to share in the savings for higher-value care. Finally, CMS should make Medicare and Medicaid data more accessible for research purposes, as well as collaborate with private insurers so that new payment models can be evaluated across payers. Medicare covers more than 47 million Americans, including 39 million people age 65 and older and 8 million people with disabilities.
NIMH: In January, 2013 Thomas Insel, Director of the National Institute of Mental Health (NIH) testified: "The burden of mental illness is enormous. In the United States, an estimated 11.4 million American adults (approximately 4.4 percent of all adults) suffer from a serious mental illness (SMI) each year, including conditions such as schizophrenia, bipolar disorder, and major depression. According to a 2004 World Health Organization report, neuropsychiatric disorders are the leading cause of disability in the United States and Canada, accounting for 28 percent of all years of life lost to disability and premature mortality. The personal, social and economic costs associated with these disorders are tremendous. Suicide is the 10th leading cause of death in the United States, accounting for the loss of more than 38,000 American lives each year, more than double the number of lives lost to homicide. A cautious estimate places the direct and indirect financial costs associated with mental illness in the United States at well over $300 billion annually, and it ranks as the third most costly medical condition in terms of overall health care expenditure, behind only heart conditions and traumatic injury. Even more concerning, the burden of illness for mental disorders is projected to sharply increase, not decrease, over the next 20 years.
"NIMH-supported research has found that Americans with SMI die eight years earlier than the general population. People with SMI experience chronic medical conditions and the risk factors that contribute to them more frequently and at earlier ages…. (T)he vast majority (80.1 percent) of people having any mental disorder eventually make contact with a health care professional to receive treatment, although delays to seeking care average more than a decade…. NIMH aims to support research on earlier diagnosis and quicker delivery of appropriate treatment, be it behavioral or pharmacological…. Research has taught us to detect diseases early and intervene quickly to preempt later stages of illness." Later on that year, Alan Kraut, Executive Director of the Association for Psychological Science (APS), as well as several APA senior staff, attended a high level meeting at NIMH in which considerable interest was expressed in working with the IOM to explore establishing appropriate matrixes for determining the quality of mental health services being provided. Interestingly, as Alan pointed out, this was the subject of U.S. Senate Finance Committee hearing in August, 1978 entitled "Proposals to Expand Coverage of Mental Health under Medicare-Medicaid." Substantive change takes time, notwithstanding its importance.
Taking the Next Step: The newest clinical psychopharmacology training program for RxP is located at the University of Hawaii at Hilo, College of Pharmacy, from which active duty psychologist M. Todd Bell graduated. "Just over a year ago, I completed the Masters of Science in Clinical Psychopharmacology program. When I began this two year program, I had no idea how rigorous or comprehensive the training would be, but looking back now, I realize it was, without exception, the most strenuous (and mentally exhausting) professional training in which I have participated. It has deepened my understanding of my patients by having a greater appreciation for their biological functioning, which has led to a more 'balanced' biopsychosocial perspective. Obviously, the training significantly increased my knowledge of psychotropic medications, but it also provided enough broad focus in general pharmacology to afford me a degree of competence and comfort in discussing medication as well as to feel confident in incorporating pharmacological treatment strategies into a patient's comprehensive plan of care. What was not so obvious to me at the time I participated in the program was that I would go on to feel a greater sense of companionship with other healthcare professionals as we share cases and collaborate more frequently. This new sense of familiarity is contrasted with the 'silo' effect of more traditional mental health services which I had been accustomed to and is mostly isolated from the rest of a patient's healthcare.
"As for practice following credentialing, I have discovered increased kinship and camaraderie with other healthcare providers. I enjoy sharing cases with other professionals and have been excited at the prospect of having additional tools to incorporate into my practice. I have found that I have not altered my usual scope of practice much in that I still provide assessment and psychotherapy for patients rather than seeing patients 'only' for medication. In particular, I have found the collaboration with Nurse Practitioners and the consultation with fellow Psychologists to be very rewarding. I am completely satisfied with the quality of training and feel that it really did prepare me for prescribing medication in a safe and effective manner."
"Speaking as an official 'Old Person,' one who was required to start collecting Social Security benefits eight years ago, I believe that organizational memory is very important, and I am ever fascinated by the history of things – especially since, as time passes, I meet more and more people with no personal knowledge of things that I and my same-age peers have lived through. The disconnect is amazing [Gerald Leventhal]." "What's Past is Prologue." Aloha,
Pat DeLeon, former APA President – Division 18 – January, 2014
