I’M SO PROUD TO KNOW

It was extraordinarily satisfying to learn from Beth Rom-Rymer that the Illinois Psychological Association (IPA) was successful in enacting your prescriptive authority (RxP) legislation this past June.  It has been a decade since Louisiana achieved their startling success, during which time leaders in the RxP movement have been steadily working to develop a "critical mass" of postdoctoral trained psychopharmacology clinicians.  Bob McGrath, Director of the Fairleigh Dickinson University Clinical Psychopharmacology training program, estimates that today there are 1750 graduates.  As vigorous as your opposition has been, it was impressive from a public policy perspective to see that, in the end, the Illinois Psychiatric Society and the Illinois Medical Society conceded that psychologists can prescribe.  Clearly this was a concession that only came after a hard-fought battle.  It was the perseverance and the determination of your IPA leaders, looking after the interests of the most vulnerable and at-risk residents in Illinois, that ultimately won the day.  And, as you now move quickly to implement your RxP legislation, with the drafting of the rules and regulations of the law and the signing up of various training facilities and universities and colleges throughout the state to train Illinois's prescribing psychologists, undoubtedly you will find that achieving the collaborative partnership of psychiatrists and medical directors has been greatly facilitated by your eleventh hour negotiated bill.  Congratulations!

            Our collective RxP discussions frequently refer to the successes of New Mexico (2002), Louisiana (2004), and colleagues in the Department of Defense (DoD) and U.S. Public Health Service (particularly, the Indian Health Service [IHS]).  Few seem to appreciate that the first state to pass RxP legislation was actually Indiana (1993, thanks to Mike Murphy), which was followed by Guam (1998, thanks to Mamie Balajadia).  Neither of these states has implemented their statutes to date; although progress has been reported in Guam.  Interestingly, Floyd Jennings was prescribing in the IHS back in 1988-1989 under the authority of the Santa Fe Indian Hospital bylaws.  Former APA President Ron Fox: "As of December 31, 2013 when I was chair of the APA Insurance Trust, I can attest to the fact that prescribing psychologists do NOT have to pay higher premiums for professional liability insurance as the Trust deemed an increase unnecessary; and, because the Trust policy provides insurance to cover expenses related to licensing board complaints I know that there have been NO complaints or actions taken by state licensing boards regarding prescribing abuses by appropriately trained psychologists."

Having been an informed observer throughout psychology's RxP quest, I was particularly pleased that your legislation recognizes, for the first time, the importance of encouraging pre-doctoral training.  This is an educational policy position that had been urged by practice visionary Gene Shapiro from the beginning and most recently by APA Past President Bob Resnick.  The initial requirement for postdoctoral training was a reasonable political compromise, addressing the sincere concerns of those who feared that our next generation of colleagues might never appreciate what psychological expertise could contribute to our patients' quality of life.  Their view was that otherwise "we would take the easy way out and become junior psychiatrists; substituting medication for therapy."  Over the years, the evidence has clearly not supported that contention.  In fact, our prescribing colleagues frequently report significantly modifying previously ordered medication protocols.  "The power to prescribe is the power to unprescribe," as New Mexico's Mario Marquez has stated on numerous occasions.

            The 1992 report submitted to the APA Council of Representatives by the ad hoc Task Force on Psychopharmacology, chaired by Mick Smyer, clearly appreciated the long term significance of "the importance of developing a subspecialty of psychology with comprehensive knowledge and experience in psychopharmacology.  Practitioners with combined training in psychopharmacology and psychosocial treatments can reasonably be viewed as a new form of health care professional, expected to bring to health care delivery the best of both psychological and pharmacological knowledge.  The contributions of this new form of psychopharmacological intervention have the potential to improve dramatically patient care and make important new advances in treatment."  And, as you have successfully demonstrated, the Task Force then focused on "the potential impact of the proposed training on two important concerns of consumers: (1) meeting unmet need for mental health services, and (2) effectively serving special populations."  Anita Brown was one of the APA staff liaisons to the Task Force.  She subsequently became one of the DoD prescribing psychologists.

            During his 2009 APA Presidency, James Bray hosted a Presidential Summit on the "Future of Psychology Practice."  One of the major themes presented was that "mental health care cannot be divorced from primary medical care, and that all attempts to do so are doomed to failure."  The enumerated Summit Principles were * Expand the focus of traditional psychological practice.  * From mental health to health care providers: Integrated health care.  * Integrating technology into practice.  * Meeting the needs of our diverse society.  And, * Apply basic and applied scientific evidence in our practice.  Shortly after the signing of your historic legislation James noted: "To stay as a viable profession psychology needs to take advantage of new opportunities in health care and business, otherwise we are likely to continue to financially decline.  Reimbursement rates for traditional mental health services have decreased in the past 10 years, while health care insurance premiums have seen double digit increases – Why is this?  Psychologists are being replaced by Masters level trained clinicians who will work for less and provide many of the same services.  We need to evolve into new positions of clinical leadership, consulting with business and gaining prescriptive authority where our services of doctoral trained psychologists will be rewarded.  If we don't step up now, other professions will and we will continue to see our incomes and opportunities drop."

            President Obama's landmark Patient Protection and Affordable Care Act (ACA) provides many opportunities for non-physicians with vision.  Combined with the recently enacted Mental Health Parity legislation this represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation.  It provides a priority for prevention, wellness care, and services which are high quality and cost-effective, and aims to move our health care system towards a population health-based system.  The ACA affirmatively calls for the development of integrated, interdisciplinary systems of patient-centered care which will be transformational.  Chief among them is the integration of behavioral health and medical health care systems.  Under the law mental health and substance use treatment are deemed "essential health benefits."  The foundation now exists for the steady integration of the advances occurring within the communications and health information (HIT) technology fields into the health care environment.  From this perspective alone, your success in obtaining the support of the American Nurses' Association-Illinois chapter and the Illinois Society for Advanced Practice Nursing for your RxP legislation is extraordinarily futuristic.

Substantive change always take time; often far longer than one expects.  Throughout today's discussions regarding the appropriateness and cost-effectiveness of integrating behavioral health/mental health within primary care settings, the high incidence of depression among patients is frequently noted.  The Agency for Health Care Policy and Research (AHCPR) was established by the Omnibus Budget Reconciliation Act of 1989 to enhance the quality, appropriateness, and effectiveness of health care services and access.  Among its responsibilities was facilitating the development and updating of clinical practice guidelines to assist practitioners in the prevention, diagnosis, treatment, and management of clinical conditions.  More than two decades ago (April 1993), AHCPR issued its guideline on Depression in Primary Care: Detection and Diagnosis – then-APA's Deputy Executive Director for Professional Practice, Russ Newman, was involved in ensuring that psychology's voice would be heard.

"Depression was selected as a topic for guideline development because: * Depressive disorders are commonly encountered in primary care, as well as in other treatment settings.  * Most depressed patients seek care from primary care practitioners.  * A range of effective treatments are available and commonly provided for these conditions.  * There is a large body of scientific evidence on which to base these guidelines.  * Practice surveys indicate that improvements are needed in primary care practitioners' ability to recognize and treat depressive disorders.  * Depressive disorders result in significant morbidity and mortality.  (And) * Depressive disorders have a high prevalence in the general population….  Despite the high prevalence of depressive symptoms and full major depressive episodes in patients of all ages, depression is underdiagnosed and undertreated by primary care and other nonpsychiatric practitioners, who are, paradoxically, the most likely to see these patients initially….  The social stigma surrounding depression is substantial and often prevents the optimal use of current knowledge and treatments.  The cost of the illness in pain, suffering, disability, and death is high….  Clinically significant depressive symptoms are detectable in approximately 12 to 36 percent of patients with another nonpsychiatric, general medical condition…. "  More than two decades ago….  GOOD DAY SUNSHINE.  Aloha,

Pat DeLeon, former APA President – Illinois Psychological Association – September, 2014

 

INTRIGUING REFLECTIONS

The 122^nd APA convention provided an excellent opportunity to reflect upon how far psychology has come in developing into a bona fide healthcare profession, advancing beyond viewing ourselves exclusively as metal health specialists.  It was wonderful to see Beth Rom-Rymer receive well deserved recognition for enacting prescriptive authority (RxP) legislation in Illinois, a decade after Louisiana's success.  For those who naively believe that her success in the backyard of the American Medical Association (AMA) was chance or a "lucky break," that is not at all true.  "The Illinois Medical Society and the Illinois Psychiatric Society vigorously and vociferously lobbied against our RxP bill until they realized that we wouldn't stop fighting and until they had already spent $1 million to keep us out of the prescribing community!"  The key to long term legislative success is community involvement.  Accordingly, we are very pleased that IPA and its state NAMI had each signed on as co-sponsors of their respective annual conferences in 2013 and are already making commitments to do the same for 2014/2015.   Perhaps our colleagues in Hawaii and Oregon, where earlier legislative efforts were vetoed, should reengage in this important legislative quest.

            This was also the 40^th anniversary of the APA Congressional Fellowship program which began with Pam Ebert and continues on today, joined by the APA Executive Branch program.  As Norman Anderson noted the program has supported 121 Fellows.  "As ambassadors for the field, APA Congressional Fellows consistently represent psychology in the best possible manner – to policymakers, their staff, and the scientists from other fields participating in the AAAS program."  This is another proactive initiative that State Associations could emulate at the local level, in conjunction with their academic colleagues.  We are confident that APA's Judith Glassgold, Micah Haskell-Hoehl, and Heather Kelly would be pleased to provide guidance for those interested.  It would be a worthwhile investment in the profession's future.

            Since my retirement from the ever-hectic U.S. Senate staff, I have become increasingly interested in how other colleagues have been adjusting to this new, essentially uncharted role.  Not surprisingly, I have found considerable interest across the country.  During the convention, Rod Baker, Ruth Paige, and Mike Sullivan discussed their personal journeys before an engaged audience reflecting all ages.  Rod has embarked upon a writing career; Ruth is learning not to accept every request for her time – thus spending more with those she really wants to, like family; and Mike continues his volunteer efforts from Peace Corps to Meals on Wheels.  "If you are not happy doing what you are doing, there is only one person you have to talk to!"  Informal discussions afterwards strongly suggest that physical concerns are becoming increasingly common; economic concerns much less so.  As a relatively young healthcare profession, we are increasingly maturing with a number of our individual colleagues actually aging.  We would suggest that this would be an excellent topic for our State Associations to address at annual conferences; especially when held in conjunction with other professions and/or interest groups such as NAMI.  Aging is an agenda which will ultimately impact every one of us.  Aloha,

Pat DeLeon, former APA President – Division 31 – September, 2014

 

COLLEGIAL EFFORTS REQUIRED FOR INCREASING ACCESS TO QUALITY CARE

Reflecting upon the extraordinarily successful APA-ABA 2014 National Conference on Violence, it intrigues me that I never hear about similar events in which State Psychological Associations collaborate with their counterparts representing other non-physician health care providers (or local Bar Association interest groups) in sponsoring joint conferences or annual meetings.  From a public policy frame of reference, there is considerable overlap of interests and clientele.  Throughout President Obama's Patient Protection and Accountable Care Act (ACA) there are a number of provisions encouraging the development of integrated systems of care, which are to be patient-centered and which will rely upon data-based clinical decision making (i.e., gold standard evidence-based protocols).  As the advances occurring within the communications and technology fields (e.g., telehealth, comparative effectiveness research, and various transformational initiatives sponsored by NIH) increasingly impact the health care environment, cross-provider and cross-population comparisons will become the norm.  There is no question that in this changing environment, psychologists will have to objectively demonstrate their "value-add," as APA Practice Directorate Executive Director Katherine Nordal keeps stressing at her annual State Leadership Conferences (SLCs).  Underlying these policy developments is the fundamental question of whether historical "scope-of-practice" limitations and geographical "licensure restrictions" really are in the best interest of patient care?  Unprecedented change is the future of practice.

            In 2010, the Institute of Medicine (IOM) released its report The Future of Nursing: Leading Change, Advancing Health.  Among its recommendations were: Nurses should practice to the full extent of their education and training; Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States; and, not surprisingly, Historical scope-of-practice barriers should be removed.  At the suggestion of the Chairperson, former HHS Secretary Donna Shalala, the Federal Trade Commission (FTC) was urged to: * Review existing and proposed state regulations concerning advanced practice registered nurses (APRNs) to identify those that have anticompetitive effects without contributing to the health and safety of the public.  States with unduly restrictive regulations should be urged to amend them to allow APRNs to provide care to patients in all circumstances in which they are qualified to do so.

            This Spring, the FTC held a public workshop to study activities and trends that may affect competition in the evolving health care industry.  Specifically, the intent was to explore current developments related to professional regulations; innovations in health care delivery; advancements in health care technology; measuring and assessing health care quality; and price transparency for health care services.  In the FTC's view: "Professional regulations may protect patient safety, improve quality of care, and provide useful information to consumers who are choosing among health care providers.  Greater competition may result when regulatory changes expand the number of health care providers or services available to consumers by increasing the use of advanced nurse practitioners, dental therapists, and other qualified non-physician or non-dental professionals.  Such increased competition may provide consumers with benefits such as lower prices and improved access to health care services.  Some regulations may, however, unnecessarily restrict the ability of non-physician health care professionals to practice to the full extent of their training, imposing costly limitations on professional services without well-founded consumer safety justifications or other consumer benefits to offset those costs.  Such overly restrictive professional regulations are likely to suppress beneficial competition by non-physician health care providers and may prevent institutional providers (such as hospitals) from developing innovative health care delivery models that rely more heavily on non-physician providers to provide efficient, safe care.  While all patients may be affected by reduced competition from non-physician health care professionals, the impact may be particularly severe for vulnerable and underserved patient populations."

            Some of the critical issues for which public comment was requested include: * To what extent do professional regulations vary by state?  Does state-by-state variation affect patient health, health care spending, or other important measures?  * How do current regulations concerning licensure and credentialing affect the ability of health care professionals to relocate or practice in more than one geographical area, particularly across state lines?  * Would greater state-to-state licensure portability improve competition?  What issues would increased licensure portability raise?  * To what extent is telemedicine being used today?  What new developments are occurring in telemedicine?  What role is telemedicine projected to play in the future?  * Are there regulatory or commercial barriers that may restrict the use of retail clinics, telemedicine, or other new models of health care delivery?  If so, are there any valid justifications to support such restrictions?  And, * What, if any, changes in government regulations would facilitate the emergence of new health care delivery models, enhance competition among health care providers, and encourage additional innovation?

            Earlier in the year, the FTC shared their views with the Massachusetts House of Representatives which was considering legislation (H. 2009) which would remove certain supervision requirements on the state's nurse practitioners (NPs) and nurse anesthetists (NAs).  "We recognize that patient health and safety concerns are of critical importance when states regulate the scope of practice of health care professionals, and FTC staff defer to Massachusetts on the ultimate health and safety standards that the Commonwealth may choose to establish.  We recommend, however, that the legislature seek to maintain only those NA and NP supervision requirements that advance patient protection….  H. 2009 would streamline APRN regulation and permit APRNs to more fully employ their education and experience in serving Massachusetts health care consumers, with regulatory oversight, but without certain formal physician supervision requirements now imposed under Massachusetts law.  Absent countervailing safety concerns regarding APRN practice, removing these supervision requirements has the potential to benefit consumers by improving access to care, containing costs, and expanding innovation in health care delivery."

            Psychology must appreciate that organized medicine's "public health hazard" concerns are not limited to any particular discipline.  In another New England state, a board-certified psychiatric pharmacy specialist "consults" for the University of Connecticut's Student Health Services.  His presence reflects the growing stress on college counseling centers nationally, with an overwhelming proportion of centers reporting seeing increases in the number of students with severe psychological problems.  Yet, the chair of the ApA's Committee on College Mental Health notes that while he understands the pressures on college counseling centers that might make this model seem attractive, it is not an approach he could embrace.  "I think that kind of care ought to be delivered by psychiatrists.  I think it's a very creative idea, in large part driven by cost savings to the university.  But it's not possible for me to be enthusiastic about it….  For me it's a quality of care issue for students at a university.  And the university is obliged to provide the best care possible."  Over time, advances in technology will make possible systematic cross-provider/cross-population comparisons, thereby providing objective data addressing the validity of organized medicine's alleged "patient safety" concerns.  Aloha,

Pat DeLeon, former APA President – Division 42 – August, 2014