COLLEAGUES MAKING A REAL DIFFERENCE

   The Affordable Care Act (ACA):  With the steady implementation of President Obama's Patient Protection and Affordable Care Act (ACA), psychology's practitioners and nursing's Doctors of Mental Health Nursing Practice (DNP) are increasingly being held to the requirements of the more generic healthcare system.  This evolution is especially relevant to integrated care models; for example, the Accountable Care Organizations and Patient-Centered Medical Homes fostered by the Act.   Central to this evolution is the necessity of appreciating the common procedural terminology (CPT) system which has become the most widely accepted nomenclature used in the reporting and reimbursement of health services under public and private health reimbursement programs.  From a policy perspective, it is evident that the CPT system is just beginning to address the complexity involved in recognizing that mental health and physical health are intimately intertwined, as well as the critical contributions of the psychosocial-economic-cultural gradient to "quality" health care.

            Tony Puente has been working at the interface of practice and policy with the CPT system since the late 1980s.  He served as APA's first representative to AMA and for 15 years has been working with them.  He is presently a voting member of their CPT Editorial Panel.  Tony's report: "The CPT was developed almost 50 years ago by surgeons and physicians and today is copyrighted by the AMA and owned by the Centers for Medicare and Medicaid Services (CMS).  A new code for psychological services would be developed by a Health Care Professional Advisory Committee, all non-physicians, then is edited and researched by a selected work group and referred to the CPT panel on which I serve for review and possible approval.  If successful, this process can take anywhere from two years to twelve years.

            "Out of the approximately 8,000 codes, around 60 are possible codes for psychologists to utilize.  These fall within a few major categories including Psychiatric/Mental Health, Central Nervous System Assessment, and Health and Behavior.  Miscellaneous codes also cover preventive measures, evaluation and management (E&M), and telehealth.  Psychiatric/Mental Health codes were added in the 1970s, testing codes 20 years later, and Health and Behavior codes soon thereafter.  Biofeedback codes have also been included.  Due to changes in practice patterns and increasing recognition of co-morbidities, codes established for psychotherapy underwent major changes last year.  Most current procedure codes reimburse for 'silo' or non-interactive procedures, such as psychotherapy.  There is an expanding vision to create codes that financially incentivize professionals to integrate health services.  APA is well represented by Neil Pliskin and James Georgoulakis in the AMA process and Randy Phelps as Director of APA's new Office of Healthcare Financing."  Tony ran for APA President in 2014 and we fully expect he will be on the ballot for 2015.

            Being at the Table:  At the annual APA State Leadership Conferences (SLC), Katherine Nordal has consistently stressed the importance of psychology becoming actively involved in policy discussions at the local and national level -- "If we're not at the table, it's because we're on the menu."  A Longtime Friend to Hawaii, now in our Nation's Capital:  Diane Elmore: "After spending summers in Hawaii as a child and completing my doctoral internship at the Honolulu VA Medical Center/National Center for PTSD, Pacific Islands Division, I moved to Washington, DC in 2002 to pursue a career in health policy.  I spent nearly a decade at the APA where I served as Associate Executive Director of the Public Interest Government Relations Office, Director of the APA Congressional Fellowship Program, and Coordinator of APA's military and Veterans activities.  During my tenure at APA, I worked on key federal legislation focused on the needs of underserved/priority populations, including indigenous populations, older adults, survivors of trauma across the lifespan, and military service members and Veterans.  As a member of the APA health care reform policy team, I helped to successfully secure key provisions in the ACA related to issues including integrated health care, prevention and wellness, and workforce development.

            "As the former Director of the APA Congressional Fellowship Program, I served as a mentor to dozens of psychologists who came to Washington, DC to experience the policymaking process up close and personal.  My own experience as an APA Congressional Fellow inspired me to help other Fellows navigate and adjust to the fast-paced and exhilarating landscape on Capitol Hill.  I served in the Office of then-U.S. Senator Hillary Rodham Clinton, where I was a member of the health team working on a range of health policy issues.  Among the federal policies the Senator helped to advance were new mental health initiatives for older adults (as part of the reauthorization of the Older Americans Act) and federal legislation to address the needs of family caregivers across the lifespan (Lifespan Respite Care Act), which both became law in 2006.  I helped to share scientific/clinical expertise on timely initiatives related to the mental health of military service members and Veterans and the psychological consequences of terrorism, in the aftermath of 9/11.

            "My passion for engaging scientists and practitioners in policy and advocacy efforts led to a multi-year collaboration with colleagues in the APA Education Government Relations Office to develop the APA PsycAdvocate® Series, which is available on the APA Continuing Education website.  This series of training modules provides psychologists, psychology students/trainees, and others with the skills to become effective public policy advocates at the federal, state, and local levels.

            "Last year, I joined the UCLA/Duke University National Center for Child Traumatic Stress as its Washington, DC-based Policy Program Director.  In this role, I help to lead the National Child Traumatic Stress Network (NCTSN) efforts to educate and inform federal, state, and local policymakers about the critical issue of child trauma.  Today, nearly two-thirds of children in the U.S. are exposed to a traumatic event before age 16.  The cost of child trauma is not only felt in human terms (e.g., physical and mental health effects), but also in billions of dollars in estimated associated costs.

            "The NCTSN was created by Congress in 2000 to raise the standard of care and increase access to services for children and families who experience or witness traumatic events.  Our policy team works closely with current NCTSN grantees and affiliates (formally funded centers) working in hospitals, universities, and community based programs in 43 states across the U.S.  Included among the NCTSN affiliate programs is Catholic Charities Hawaii, Youth Enrichment Services Division.  NCTSN grantees and affiliates provide clinical services, develop and disseminate new interventions and resource materials, offer education and training programs, collaborate with established systems of care, engage in data collection and evaluation, and inform public policy and awareness efforts.  Please visit http://www.nctsn.org/."

With the future stressing integrated and interprofessional care, it is exciting that nursing's leadership is strategically implementing a vision similar to that proposed by Katherine and Diane.  The American Academy of Nursing has announced their participation in the Nurses on Boards Coalition, which is a group of national nursing organizations dedicated to increasing nurses' presence on corporate and non-profit health-related boards of directors throughout the nation.  The coalition is working on implementing a national strategy to bring nurses' valuable perspective to governing boards, as well as to state-level and national commissions with an interest in health.  Their goal is to put 10,000 nurses on boards by the year 2020, pursuant to the recommendations of the Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health (2011).  This effort is being supported by the Robert Wood Johnson Foundation and AARP.  Pursuant to this challenge the Nursing Campaign for Action, which has coalitions in all 50 states and the District of Columbia, is actively seeking to promote healthier lives, supported by a system in which nurses are essential partners in providing care and promoting health.

True Quality Care:  Mike Sullivan, who was instrumental in passing psychology's earlier RxP bills in his APA Practice Directorate State Leadership role: "The September Monitor's article 'On the Reservation' about the Crow/Northern Cheyenne Indian Health System hospital in Montana with RxP is outstanding!  Marie Greenspan's quote 'We maintain a policy of no pills without skills.  If we're giving medication, people also need to come in and talk with us and learn non-pharmacological ways of managing their issues as well.'  That's psychology's contribution to prescribing in a nutshell.  Especially when these services would otherwise be unavailable."  Aloha,

Pat DeLeon, former APA President – Hawaii Psychological Association – December, 2014

 

A LONG DISTANCE RUN

 Hills and Valleys:  During the exciting 2013 APA State Leadership Conference (SLC), Katherine Nordal noted: "The clock is ticking toward full implementation of the law and January 1, 2014 is coming quickly.  But January 1^st is really just a mile marker in this marathon we call health care reform….  We can't hope to finish the marathon called health care reform if we're not at the starting line.  Fortunately, many psychology leaders have embraced our call to action."  With the steady implementation of President Obama's Patient Protection and Affordable Care Act (ACA), our nation's mental and behavioral health providers (regardless of professional discipline) are increasingly being held to the standards and nuances of the overall healthcare system.  For over two and a half decades, Jim Georgoulakis has represented psychology's voice on the American Medical Association's (AMA's) Resource Value Update Committee, which is responsible for advising the Centers for Medicare and Medicaid Services (CMS) on payment policy for services contained in the Current Procedural Terminology (CPT) reimbursement system.  His visionary perspective on the considerable challenges facing our practitioners as they face the inevitable integration of federal, state, and private sector requirements:

"Psychologists and Compliance Plans:  Recently various lit-serves and publications have raised the issue of compliance plans which have unfortunately left a number of psychologists confused as to whether they should develop compliance plans for their practices.  The answer is clearly an unequivocal 'Yes' and there should be no further debate on this matter.  This fall, in an AntiFraud newsletter, the former Department of Health and Human Services (HHS) Inspector General (IG) Richard Kusserow made a number of statements regarding Medicare and Medicaid mental health fraud to the effect that mental health benefits have been 'a special enforcement problem that stretches back decades.'  'Many healthcare fraud investigators believe mental health caregivers such as psychiatrists and psychologists have the worst fraud record of all medical disciplines.'  Support for this assertion comes from Assistant U.S. Attorney Ted Radway, who stated that in Medicaid there has been 'an explosion of fraud in community-based mental health treatments, including billing for services not rendered.'

            "The current IG of HHS Daniel Levinson is also very clear on the need for a compliance plan.  In his keynote address to the Health Care Compliance Association 2014 meeting, he stated that every provider should have a compliance plan.  He noted that a one or two person practice will have a different compliance plan than a large organization.  He also emphasized that each compliance plan should be unique to the practice – he cautioned against an off the shelf program.  The IG also discussed the training materials (written, audio, and video) that his office has produced to assist providers.  These materials can be located on the OIG web site which includes a section titled Compliance 101.  In this package it is important to note specific videos on compliance program basics, documentation, and operating an effective compliance program.  Additionally, there is a caption that states 'ultimate responsibility for complying with federal fraud and abuse laws lies with the provider of the service.'

            "In the main psychologists were very supportive of the passage of the ACA.  However, the ACA included a new section [Section 6401 (a)] which established a new Section 1866 (j) (8) which reads that a provider of medical or other items or services or a supplier shall, as a condition of enrollment in Medicare, Medicaid, or CHIP, establish a compliance program that contains certain 'core elements' of a Federal Compliance Program.  The core elements of such a compliance program have been available on the OIG web site since 1999.  As to be expected when reviewing the compliance plan requirements of the 50 states, there is considerable variability among the states with New York having the most comprehensive and the oldest requirements (i.e., mandatory plans since 2009).

            "The AMA provides CE credit for participating in the OIG training on compliance.  This training is web based and is included in the OIG's web site.  Similar to physicians, I would hope at some time in the near future psychologists would stop debating on whether compliance plans are necessary, develop similar training CE programs, and move forward and improve our standing in the health care compliance community."

            Exciting New Faces and New Agendas:  The Illinois Psychological Association, with the guidance and leadership of Beth Rom-Rymer, in particular, succeeded this year in passing prescriptive authority legislation, which is the first RxP bill to be signed into public law since Louisiana's on May 6, 2004.   "With the passage of our prescriptive authority bill, that gives opportunity for graduate students to take the core component of their training in Clinical Psychopharmacology pre-doctorally, close observers have wondered if only the young students will take the training.  Others have asked, 'Will access to care issues really be addressed?'  Still others have questioned, 'In what ways will the identity of the clinical psychologist change as (s)he also takes on the identity of the prescribing psychologist?  As we are only at the beginning of our prescriptive authority journey, I will, today, address the question of 'Who wants to prescribe' by drawing some portraits of just a few psychologists who have expressed their intention to prescribe in Illinois and/or who are already in the process of gaining their eligibility to prescribe.  These examples are in no way exhaustive but represent the diverse spectrum of psychologists, in Illinois, who will be prescribing.

"* Karla is an early career psychologist, is Director of Behavioral Health and Pastoral Care at a Federally Qualified Healthcare Center (FQHC) that serves a largely Hispanic and African American population on the west side of Chicago.  She has almost completed her training in clinical psychopharmacology from Fairleigh Dickinson University and is looking forward to soon completing the other components of her training.  * Jane has wanted to be a prescribing psychologist since she was a teenager and she is now 62 years old!  A practicing clinical psychologist, she is currently taking the core training in clinical psychopharmacology from Fairleigh Dickinson University.  She is looking forward to taking the undergraduate science courses on-line and/or at a nearby community college.  * Dick is a mid-career clinical psychologist who had been in a joint practice with his pediatrician father for 25 years.  He had been a pre-med major as an undergraduate and has completed all of the undergraduate sciences courses; the core training in clinical psychopharmacology from NOVA Southeastern University; and has taken and passed the PEP.  These dedicated colleagues are leading the way to our future.

            "Since the passage of our legislation, I have been in contact with leaders in more than 10 states in which prescriptive authority initiatives have been reinvigorated.   Indiana is one of those states, where, although never implemented, their original effort became public law back in 1993.  Other states include Hawaii, California, Idaho, Arizona, Texas, Nebraska, Missouri, Michigan, Ohio, Florida, Virginia, and Maryland.  It was a particular pleasure to be able to speak at the convocation of the most recent graduating class of the New Mexico State Psychopharmacology training program where we honored Elaine LeVine for the monumental pioneering work that she has done for all of us in the RxP arena.  The enthusiasm at the grass roots level is contagious!" (Beth Rom-Rymer).  A journey of a thousand miles begins with a single step.  Aloha,

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

 

YESTERDAY, ALL MY TROUBLES SEEMED SO FAR AWAY

 The Newly Elected 114^th Congress:  With the Republican Party having an outstanding election eve, the Grand Old Party controls both the U.S. House of Representatives and the U.S. Senate for the first time since 2006, when President George W. Bush occupied the White House.  Their margin of victory in the House takes them close to surpassing their largest majority of the post-World War II era.  Accordingly, one must expect an extensive public debate regarding the fundamental role of government in our society through a number of different venues, including whether Obamacare (or critical aspects of it) should be repealed.  During my tenure on the U.S. Senate staff, Bob Ax, who worked for the federal Bureau of Prisons for 20 years and before that for the Trenton State Prison in New Jersey, was a frequent visitor, bringing his psychology interns to the Hill to get a firsthand glimpse of the public policy/political process.  From his vantage point of retirement, he has been reflecting upon whether our current federal and state health care systems (including that of DoD and the VA) might undergo a significant privatization evolution in the foreseeable future – as he personally experienced with the prison system.  And, if so, what might be the impact on quality of care and psychology. 

            "The private prison initiative began in America three decades ago and has grown exponentially since then.  Since 2000, an increasing percentage of federal and state inmates have been housed in private facilities, even as the overall prison population plateaued and then dropped slightly.  Privately owned or operated prisons now exist in many first-world countries.  Notwithstanding numerous criticisms about their operations, private prisons are less accountable than those operated through the civil service.  More information can be legally withheld as proprietary, a problem that led to Representative Sheila Jackson Lee introducing the Private Prison Information Act of 2011 as a corrective measure.  The Act died in committee.

            "Many of the immigrant detainee facilities around the country are privately owned and/or operated.  Since 2009, the Department of Homeland Security's funding appropriations bills have included a provision mandating that 34,000 beds in these facilities be available each day, ensuring that tax-payer dollars continue to flow into the coffers of for-profit corporations.  In 2013, Immigration and Customs Enforcement (ICE) detained almost 441,000 aliens.  About half of these were housed in privately-owned or operated facilities.

            "To ensure the continuity of the revenue streams, private prison corporations have contributed directly to political campaigns and otherwise funneled money to politicians to influence the passage of favorable legislation.  They favor states with some of the toughest sentencing laws, particularly those that had enacted legislation to lengthen the sentence given to any offender who was convicted of a felony for the third time.  Between 2000 and 2004, private-prison interests gave almost $2.1 million in 22 states that had a so-called 'three strikes law,' compared with $1.2 million in 22 states that did not pass such legislation.  That is to say, they are actively engaged in the public policy/political process.

The underlying business model relies in part on monetizing inconvenient people: individuals whose behavior and/or status (e.g., as a person with serious and persistent mental illness, indigent, or a member of racial minority group) renders them disproportionately vulnerable to arrest and incarceration.  More behavior criminalized means more prisoners and a greater return on investment.  Tax dollars follow them out of the 'free world' community (where the funds might have been spent on schools, hospitals, or job programs) and into housing these men, women, and children in the criminal justice system.  Private prisons seemed at first to be a necessary stop-gap solution to the burgeoning prison population in the 1980s and 1990s.  Now they've become entrenched within the so-called prison-industrial complex.

            "Under the best of circumstances, correctional health care, whether delivered through the private or public sector, is going to be problematic.  On a day-to-day basis, treatment is inevitably a mission subordinated to safety and security concerns.  Whereas health care providers are trained to consider individual differences, the criminal justice system emphasizes uniformity.  Too often ignored as health care issues are the iatrogenic effects of incarceration, both on those incarcerated and on those impacted by extension: family members and communities.

            "If we want healthier inmates, we should have fewer of them.  Prevention is good health care, but bad business for a company that gets reimbursed for keeping prison cells full.  The public needs to decide where it wants its tax dollars to go: toward healthier, stronger individuals, families and communities, or prisons and jails.  We spent the last four decades tearing down psychiatric hospitals and building prisons.  Now the discourse has begun to shift, with intimations of a move towards reducing incarceration.  However, the incarceration rates – still near, if slightly below, record highs – reflect our abiding ambivalence toward prison reform, which would necessarily impact private prison companies" (Bob Ax).

            The Long Term Policy Contributions of "Think Tanks":  As those currently responsible for determining the role of government (i.e., our elected officials) engage in their ongoing debates, it is incumbent upon healthcare professionals and those of other disciplines to systematically bring to the nation's public consciousness agendas and concerns which should be addressed.  To the extent to which the best of science informs this process, the nation will be well served.  The Board on Children, Youth, and Families, directed by psychologist Kimber Bogard, of the Institute of Medicine (IOM) and the National Research Council recently released its report entitled Investing in the Health and Well-Being of Young Adults.

            Young adulthood – ages approximately 18 to 26 – is a critical time in life.  What happens during these years has profound and long-lasting implications for future employment and career paths and for their economic security, health, and well-being.  Young adults are key contributors to the nation's workforce and military services and, since many are parents, to the healthy development and well-being of the next generation.  In recent decades, the world has changed to place greater demands on young adults and provide less latitude for failure.  The disruption and lengthening of established social and economic pathways into adulthood have presented more choices and opportunities for some young adults and more barriers for others.  Providing educational, economic, social and health supports will help young adults assume adult roles, develop marketable skills, and adopt healthy lifelong habits that will benefit them, their children, and the nation.  Despite popular attention to some of the special circumstances of young adults, however, they are too rarely treated as a distinct population in policy, program design, and research.  Instead they are often grouped with adolescents or, more often, with all adults.

Focusing on the health and well-being of the current cohort of young adults is especially important because of the powerful (and perhaps transformative) economic and social forces now at work – the restructuring of the economy, widening inequality, a rapidly increasing "elder dependency ration" (i.e., the ratio of the population aged 65 and older to the working-age population).  The future well-being of the nation rests on the investments made in all young adults today – particularly those whose background and characteristics put them at risk of experiencing the greatest struggles.  Providing more of the educational, economic, social, and health supports they need will help ensure equal opportunity, erase disparities, and enable more young adults to successfully embrace adult roles as healthy workers, parents, and citizens.

            The IOM report emphasized that: * Young adulthood is a critical developmental period; * The world has changed in ways that place greater demands on young adults; * Young adults today follow less predictable pathways than those in previous generations; * Inequality can be magnified during young adulthood; * Young adults are surprisingly unhealthy; And, * Supporting young adults will benefit society.  Addressing the health status of young adults: Young adulthood is a critical period for protecting health, not just during the transitional years but over the life-course.  Unfortunately, the dominant pattern among young adults today is declining health, seen most clearly in health behaviors and related health statuses.  As adolescents age into their early and mid-20s, they are less likely to eat breakfast, exercise, and get regular physical and dental checkups, and more likely to eat fast food, contact sexually transmitted diseases, smoke cigarettes, use marijuana and hard drugs, and binge drink.  In many areas of risky behavior, young adults show a worse health profile than both adolescents and older adults.  For example, they are more likely to be injured or die in motor vehicle crashes and to have related hospitalizations and emergency room visits.  Many risky behaviors peak, but it is also the time when involvement in risky behaviors begins to decline.  It is a time of heightened psychological vulnerability and onset of serious mental health disorders, a problem compounded by failure to recognize illness or to seek treatment.  Almost one-fifth of young adults had a mental illness in the past year and four percent had a serious mental illness.  Yet, two-thirds of those with a mental illness and almost half of those with a serious mental illness did not receive treatment.  Not surprisingly, the current generation of young adults appears to be in the forefront of the obesity epidemic and is more vulnerable than previous generations to obesity-related health problems consequences in later years.

The higher levels of poor health in young adulthood have important consequences for future health, educational attainment, and economic well-being.  Rapid technological changes, economic challenges, and a prolonged transition to adulthood appear to be contributing to the health problems of young adults by increasing their stress and sedentary habits.  Nevertheless, the report made it clear that it was not intended to imply the creation of an extensive set of new programs targeted only at young adults as this would have the potential to create new silos and concerns about lack of coordination across various ongoing programs.  Rather the intent is to increase focus on how policies and programs are working for young adults.  New policies, programs, and practices should be recommended only when the evidence indicates that young adults' specific needs are not being met.  Three common themes emerged: 1.) Current policies and programs addressing this population too often are fragmented and uncoordinated.  2.) These policies and programs often are inadequately focused on the specific developmental needs of this population.  And, 3.) The evidence base on interventions, policies, programs, and service designs that are effective for young adults is limited in most areas.

            Retirement:  "If you've been a workaholic, it's important to have plans for a 'new mission' in retirement to give your life focus and meaning.  Otherwise, retirement can feel empty initially.  There are unexpected disruptions, financial expenses or losses, deaths of significant friends and family.  But most of those who functioned at a high level in their careers get through it with new activities and new values appropriate to the post-retirement phase of life" (Kris Ludwigsen).  Oh, I Believe In Yesterday.  Aloha,

Pat DeLeon, former APA President – Division 29 – November, 2014