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
