State Leadership Conference (SLC): At this year's exciting Practice Directorate State Leadership Conference (SLC) titled "Creating Roadmaps for Practice," visionary Executive Director Katherine Nordal emphasized: "The way the Affordable Care Act [ACA] is unfolding reminds us that no single advocacy strategy for psychology can address the diverse legislative, regulatory and marketplace environments we see from one state to another. Meanwhile, our country still doesn't pay nearly enough attention to mental health and substance use treatment. We've carved out this treatment from medical care and made people jump through hoops to get the psychological services they need. And mental health is chronically underfunded. About 20% of our population experiences a mental health disorder in any given year, compared to a lifetime incidence of 6% for adults with cancer. Yet, in 2012, the federal government invested more than 5 billion dollars in the National Cancer Institute but less than 1.5 billion dollars in NIMH. Health care reform implementation is a work in progress. There are hopeful signs, especially related to the goal of increasing the ranks of Americans with health insurance coverage. A combination of professional, marketplace, legislative and regulatory developments encourages more collaborative, multi-disciplinary practice models. As the landscape shifts towards more integrated care, new reimbursement mechanisms will emerge. The demand for evidence-based practices and use of quality measures related to process and outcome, including behavioral health measures, will grow. And the increasing use of technology for electronic health record keeping and telepsychology service delivery will continue to evolve. Many of our members seem attuned to this evolution." As Katherine also indicated at last year's SLC conference: "Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care. If we are not valued as a health profession, it will detract from our value in other practice arenas as well. 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."
Integrated Care: Katherine's description of the "changing winds" of health care reform is extraordinarily accurate. The Alliance for Health Reform recently sponsored a Hill briefing – "Is the Mind Part of the Body? The Challenge of Integrating Behavioral Health and Primary Care in a Reform Era." "As more people gain coverage that includes behavioral health benefits, and given a limited supply of mental health professionals, analysts and advocates are raising concerns over how and whether new laws and regulations will be able to change that situation. One option being explored in many settings is the integration of behavioral health services with primary care. There is early evidence that coordinating care in this manner may deliver high-quality care more efficiently. For almost 20 years, bipartisan majorities in Congress have been legislating ways of bringing behavioral health services to the 62 million Americans in need of them. Beginning with the 1996 Mental Health Parity Act, Congress has steadily broadened access to these services.
"All state Medicaid programs and plans sold on the health insurance marketplaces cover behavioral health services. Yet 60% of adults and 70% of children with a mental health disorder do not receive treatment. In children, the average time between onset and treatment of mental illness is nine years. And one in six adults has co-morbid mental health and medical conditions. More commonly their medical condition is being treated while their mental health condition goes undiagnosed and untreated. Do current models of integrating behavioral and physical health hold promise? Are there enough providers to meet the demand of the newly insured? What is needed to help primary care fill the gap? How are the states meeting the budgetary challenge in Medicaid programs? Is parity a reality?"
Our colleagues in the American Psychiatric Association (ApA) would appear to agree with Katherine, recently calling for much tighter integration of primary care and mental health care, thereby providing better services with a reduction in costs. "Studies have shown that concurrently treating behavioral and physical conditions leads to better control of the illness itself, but also better patient satisfaction, quality of life, and reduced costs [ApA President]." The ApA commissioned report shows that effective integration could save $26 billion to $48 billion a year in general medical care. Almost half of people with a mental disorder first consult with a primary care physician and approximately 50% of the 38,000 individuals who commit suicide each year have seen a primary care physician within a month of the completed attempt. Their report, which drew on claims data for 20 million enrollees, found that only 14% of those who had a mental disorder were receiving treatment but that they accounted for 30% of the spending reviewed. "Even though they are insured and are being treated for their mental illnesses, the lack of coordinated care represents lost opportunities…. The higher costs were mostly attributable to patients falling through the cracks or not getting proper care – which showed up in more emergency room visits, more hospitalizations, and hospital readmissions [ApA President-Elect]."
In our judgment, critical to the success of Katherine's vision of psychology being recognized as a bona fide "health care profession" is affirmatively embracing our societal responsibility to provide proactive leadership in addressing society's most pressing needs. Psychology is one of the "learned professions" and with that come a fundamental obligation to effectively utilize our clinical skills, beyond the confines of traditional practice. Last year we were very pleased to learn of Gaby Toloza's efforts on behalf of the Hawaii Psychological Association (HPA) to address the needs of families with an autistic child. Her "call to action" this year: "We are in need of about 6-7 psychologists to volunteer ONE hour of their time on Saturday at the Windward YMCA to give an interactive psycho-educational talk about an aspect of Self Care to a group of 15-20 parents of autistic children. Some previous topics related to mind body connection, achieving balance, how to change behavior, role of nutrition, stress management, financial stress management and relationship health. This is a wonderful way to give back to the community and promote psychology as a profession, but more importantly the necessity of self-care and a wellness model. This supports HPA and APA initiatives for public education and it's just a fun, simple and meaningful experience for both the families and providers. It is a collaborative project with HPA, YMCA, Hawaii Autism Foundation and Creative Connections Foundation, so it also represents yet another way that the work of psychologists can be integrated and effectively used to support a given population. Thank you for your time and hope I hear back from many of you wonderful helping professionals (Yes, shameless positive feedback in hopes of soliciting your time)."
Interdisciplinary Training For The Next Generation: The Robert Wood Johnson Foundation (RWJ) Nursing and Health Policy Collaborative at the University of New Mexico reports that over 100 doctoral level nursing programs have stand-alone, required courses in health policy, with numerous other programs incorporating health policy content into related courses. In sharp contrast, we have been able to find very few related courses within psychology' training programs. An appreciation of the legislative and administrative process is essential for all health professions. For example, the Institute of Medicine (IOM) found that although the primary purpose of a state licensing board is specifically to protect the interests of the public, 52% of dentists thought that the primary purpose of their state dental board was to protect the interests of dentists and 32% thought they protected the interests of both dentists and the general public. The IOM report also concluded that publicly funded health programs should not separate oral health from overall health. The IOM President: "Can you imagine a time when we fully incorporate mental and dental health into our thinking about health? What is it about problems above the neck that seems to exclude them so often from policy about health care?"
At the Uniformed Services University of the Health Sciences (USUHS), the next generation of psychologists and doctors of nursing practice (DNP) train together in a number of venues, including health policy. "My colleague, CPT Kathleen Young and I had the pleasure of attending the American Association of Colleges of Nursing (AACN) Student Policy Summit held in Washington, DC. The Summit provided a panoply of distinguished nursing professionals and activists committed to the advancement of nursing and nursing practice that bestowed upon us the importance of uniting as a profession to influence changes that affect our profession and the care that we provide to our patients. Astonishingly we have approximately 3.1 million nurses of which only approximately 100,000 belong to the American Nurses Association (ANA). While this statistic does not include the many other nursing organizations that nurses may be members of, it is nonetheless an astonishing fact that nurses make up the majority of the healthcare industry, yet we have the least amount of members participating in organizations that influence the very policies that impact our profession.
"The AACN Summit provided an opportunity to show the ease with which nurses can become politically involved to improve health status and the delivery of healthcare. Mindful of relevant DoD Directives, my colleague and I were graciously allowed to accompany Dr. Jane Kirschling, President of the AACN and Dean of the University of Maryland School of Nursing, as well as several bright undergraduate and graduate nursing students from the State of Maryland as they were welcomed by the offices and staff of the Maryland Senators and Congresspersons. The well-spoken students impressed upon their Representatives the importance for continued support for Title VIII funding for nursing education, increased funding for nursing research, and support for nursing practice bills designed to promote the role of Advanced Practice Nurses in the healthcare delivery system.
"The AACN Student Summit Policy Summit was an extraordinary opportunity to network with nursing leaders, advocates for the advancement of nursing practice, and colleagues with the common goal of imparting change. In an era of unprecedented health care reform nurses, one of the most trusted health professions in the nation, have a unique opportunity and dare I say obligation, to provide our expertise in matters that affect the profession of nursing and the delivery of care that we provide [Capt. Kellie Webb-Casero, USAF]." Aloha,
Pat DeLeon, former APA President – Division 42 – May, 2014
