Change Is Forever Upon Us: One of the advantages of working on Capitol Hill for an extended period of time is developing an appreciation for evolving national trends. It would seem, for example, that there are increasing signs of bipartisan Congressional collaboration which will eventually allow state delegations to once again effectively address the unique needs of their constituents (perhaps even through the "ear-mark" process). It is also clear that our nation's health care environment is undergoing unprecedented and fundamental change as a result of the enactment of President Obama's Patient Protection and Affordable Care Act (ACA), as well as the increasing application of computer technology to health care delivery, including research and educational endeavors. At this year's exciting APA State Leadership Conference (SLC), visionary Practice Directorate Executive Director Katherine Nordal provided an optimistic view: "Health care reform implementation is a work in progress. And there are hopeful signs, especially related to the goal of increasing the ranks of Americans with health insurance coverage. As we confront serious problems and the uncertainty of a health care system in flux, psychology continues to demonstrate that we're poised to face those challenges. 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 -- especially our early career colleagues -- seem attuned to this evolution. We achieve good results when psychologists get energized and commit themselves to making positive things happen."
Unchartered Waters: One of the most valued bipartisan (i.e., nonpartisan) health care resources for those serving on Capitol Hill is the Alliance for Health Reform, led by Ed Howard, a former staffer for then-Congressman Sparky Matsunaga. This past month the Alliance addressed "Patient-Centered Medical Homes (PCMH): The Promise and The Reality" -- a critical element of the ACA in which psychology is not mentioned. While the PCMH model has increasingly been embraced by providers and payers as a way to improve health care and lower costs, many questions remain about its effectiveness. Definitions of medical homes vary, but they are generally known as a model that aims to transform primary care through increased coordination and communication among a team of providers. Recent medical home initiatives have encouraged primary care practices to invest in capabilities such as patient registries and electronic health records (EHRs), and to achieve medical home recognition. Health plans offer to pay more to the practices that achieve recognition. What do these models look like under different payers? Given variation in how PCMHs are set up and reimbursed, how scalable are these models? How long does it take for practices to make the PCMH transformation? What are some of the challenges practices face when making the transition? Do these models have an effect on costs? Do they improve quality of care?
Another Alliance briefing focused upon "Health Centers at the Launch of the Coverage Expansion." Eighty-four percent of health center patients earn under 200% of the federal poverty level. Implementation of health information technology (HIT) by health centers has more than doubled since 2009; however, many health center leaders report provider shortages, especially with the anticipated influx of new patients and focusing upon integrating behavioral health. Health centers may face a funding cliff after the $11 billion mandatory trust fund created by the ACA expires in 2015. This calls into question whether or not there is adequate continued support for health centers and whether or not they have the stability to continue to meet the needs of new patients. Funding for health centers is not only about grants, but payment models. Total grant income is only 9% of the budget of one highlighted center, while Medicaid accounts for 60%. The evidence suggests that health centers save money by providing good quality primary care to people who otherwise would have difficulty getting it. There are 1.1 million people currently utilizing health centers who would be eligible for insurance coverage if their state expands Medicaid to the 133% of poverty level. In those 24 states that have chosen not to expand Medicaid, these individuals remain uninsured and yet must still be served. The Commonwealth Fund reports that spurred by federal investments and financial incentives to more fully embrace HIT, 85% of centers report they had achieved advanced HIT capacities in 2013 – meaning they could perform at least nine of 13 key functions, such as electronically prescribing medications. The 2009 rate was just 30%. Pursuant to Senator Inouye's vision, there is now a federally qualified community health center on every island in Hawaii, including Molokai and Lana'i. Robert Hirokawa is the Executive Director of the Hawai'i Primary Care Association (HPCA).
Integrated Care: The movement towards integrated care, interdisciplinary collaboration, and effective utilization of computer technology (i.e., HIT, Telepsychology, and Comparative Effectiveness Research exploring cross population and cross provider outcomes) was also highlighted at the 17th annual VA Psychology Leadership (AVAPL) Conference – "Serving Veterans through Interprofessional Care and Expanding Partnerships." APA President Nadine Kaslow and former VA Chief Consultant for Mental Health Toni Zeiss provided a visionary global perspective. Kathy McNamara, Theodora Stratis, and Henry Beck represented Hawaii. The VA has been the national leader in these areas, especially under the leadership of Toni and her husband Robert Zeiss who has made post-doctoral training a high VA priority, which is expected to support 400 positions in 2014-15. It was fascinating to listen to early career colleagues talking about their work on cancer units, organ transplant units, and with local police departments. Half of the highly enthusiastic attendees were early career psychologists or interns/post-doctoral fellows. The poster sessions emphasized transformational change, burnout among veterans, weight loss predictions, and the importance of active community involvement. The leadership of AVAPL announced that henceforth their scholarships will be named in honor of APA's Randy Phelps for all that he has done for public service psychology over the decades. From a public policy perspective, the one missing element was representation from Division 19, the Society for Military Psychology – they are the Veterans of tomorrow.
USUHS: Having the opportunity to teach at the Uniformed Services University of the Health Sciences (USUHS) provides a unique perspective on the contributions psychology and advanced practice nursing can make to our nation's military and their families. I have been especially pleased with the extent to which APA and APS, as well as national nursing organizations, have been willing to provide USUHS students with special training experiences. APA's Donna Beavers, for example, invited LT. Chantal Meloscia, a Navy officer studying clinical psychology, to attend the recent conference titled "Confronting Family and Community Violence: The Intersection of Law and Psychology." "The conference was hosted by both APA and the American Bar Association (ABA) with a focus on the effects of violence on communities and families, as well as exploring ways to integrate law and psychology services in response to community and family violence. The conference participants included psychologists, attorneys, other clinicians, educators, child advocates, judges, and many more professionals involved in both the law and psychology fields. The keynote speaker addressed how the intersection of psychology and law can help to reduce the exposure of children in the United States to trauma and violence. Another important theme that emerged from a series of the sessions was the role of the collaboration between law and psychology to support military members and Veterans. Across these various talks, the message portrayed was that stress, trauma, and exposure to violence can influence the way military members and Veterans behave, leading to increased interaction with the criminal justice system. The creation of specialized Mental Health, Substance Abuse, and Veterans Treatment courts has shifted the focus of courts for these populations to rehabilitation. Particularly important in focusing on rehabilitation is the increased benefit not just for the individual, but for the family of the individual, especially if children are involved. As legal and psychology professionals continue to work together to develop informed policy and rehabilitative court systems, military members and Veterans affected by stress, trauma, and violence will obtain the support they need to heal. The APA and ABA conference provided an inspiring forum for those professionals to continue this incredibly important collaboration." Interdisciplinary collaboration is the future. Accordingly, we would be very pleased to learn of plans for a similar HPA-HBA conference in the near future.
At USUHS, we strive to facilitate health policy experiences, which are a required competency within nursing – but not psychology. Following up from SLC -- "Thanks for sharing this. I have recently had some conversations with students and colleagues about the lack of training that we as psychologists receive in policy. I often speak about how it was difficult for me to forge a path into the policy arena with no psychology mentors who were doing work in policy and no models for how to get into the policy arena. As the healthcare system and models of care become more and more integrated, it is incumbent that psychologists be prepared to work in inter/multidisciplinary settings and also learn about how to interact with and impact the policy arena" (Le Ondra Clark, consultant California Senate Committee on Business, Professions and Economic Development). California Dreamin'. Aloha,
Pat DeLeon, former APA President – HPA – June, 2014
