AS WE LIVE A LIFE OF EASE

The Accountable Care Act:  With the implementation of President Obama's Patient Protection and Affordable Care Act (ACA), our nation's health care environment is gradually undergoing fundamental change.  Change of such magnitude that we would suspect the majority of practitioners do not yet fully comprehend how it will eventually impact upon their daily professional lives.  In December, 2014 the Commonwealth Fund (CF) reported that for the first time in modern U.S. history, the uninsurance rate fell precipitously – from 20 percent to 15 percent – among adults ages 19 to 64 by the end of the first open enrollment period for the ACA health insurance marketplace.  An estimated 10 million fewer Americans were uninsured.  And based upon preliminary figures for the still-open second enrollment period, the uninsured rate seems likely to plunge even further.  In 2014, health expenditures grew more slowly than at any time since Medicare was enacted 50 years ago.  Medicare spending alone is $1,200 less per beneficiary per year than predicted just four years ago.

The CF report further noted that the Republican Party will begin 2015 with firm control over both Houses of Congress (for the first time since 2006), 31 governorships, and an advantage of more than 800 members in state legislatures around the country.  Whether divided government at the federal level will lead to an armistice over health reform, or intensified trench warfare, is anyone's guess.  Full repeal of the ACA is unlikely as long as President Obama remains in the White House.  However, more targeted attacks – perhaps through the budget reconciliation process – should be expected.  At the state level, Republican control will likely mean slower-than-expected expansion of Medicaid eligibility.  As an aside, we would note that this is in spite of the fact that during the initial U.S. Senate committee deliberations, a concerted effort was made to include Republican recommendations in order to develop bipartisan consensus – for example, carefully looking at the specifics of Governor Romney's Massachusetts Health Care Reform legislation.

More than 600 public and private accountable care organizations (ACOs) already exist, covering an estimated 20 million Americans.  The percentage of private health insurance payments that are "value-based" jumped from 11 percent to 40 percent in the past year.  ACOs and value-based payments are central components of the ACA and reflect efforts to encourage higher-quality care and lower costs through increased provider accountability for cost and quality.  Systematic efforts to reduce hospital-acquired conditions were estimated to save 50,000 lives and $12 billion since 2010.  And the practice implications not to be underestimated, five years after the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, there were $25.4 billion in incentive payments resulting in 80 percent of eligible professionals and 98% of eligible hospitals having qualified for these payments by adopting electronic health records (EHRs), potentially resulting in a transformative digital revolution within the health care system.  This technological evolution alone will significantly increase the likelihood of systematically developing across-provider and across-clinical population and diagnostic comparisons (i.e., clinical effectiveness research) with its accompanying public health orientation.  One must expect the utilization of data-based, gold standard protocols to increasingly impact clinical decision making and eventually include the all-important psychosocial-economic-cultural gradient of care.

            Interprofessional Care:  Under the visionary leadership of APA President Nadine Kaslow, the Council of Representatives endorsed moving towards Competency-Based Education and Training.  Espousing a similar training philosophy, in 2009 the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges, and the Association of Schools and Programs of Public Health formed the Interprofessional Education Collaborative (IPEC) in order to promote and encourage efforts to advance substantive interprofessional learning experiences with the goal of preparing future clinicians for the team-based care of patients.  Fundamental to the ACA is the development of integrated systems of holistic patient-centered primary care, provided by integrated interprofessional teams of providers.  Although psychology's training institutions are just beginning to appreciate the magnitude of this paradigm shift in orientation, studying health policy and developing skills to practice collegially with colleagues from other disciplines is one of the required competencies for the Doctor of Nursing Practice degree.

            The Doctor of Nursing Practice – Growing Acceptance:  The Alliance for Health Reform, which in our judgment is one of the most objective sources of non-partisan policy information for congressional staff, recently held a briefing entitled "Preparing the Nursing Workforce for a Changing Health System: The Role of Graduate Nursing Education."  The key messages were: * Nurse practitioners can help alleviate the growing demand for primary care.  Using nurse practitioners and physician assistants as part of a team can reduce the primary care shortage, improve access, and deliver more cost effective services.  * Graduate nursing education demonstrations are showing early positive results.  Cost estimates of advanced practice nursing (APN) clinical education derived from the Center for Medicare and Medicaid Services (CMS) graduate nursing education demonstration (GNE) show a favorable return on investment.  Enrollments and graduations doubled during the first two years of the demonstration.  * New models of care integrate nurses into the community.  The CMS demonstration benefits the community by integrating more nurse practitioners into community clinics.  And, * Advance practice nurses must receive post-baccalaureate training.  APNs (nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists, and certified nurse midwives) must complete baccalaureate plus master's or doctorate-level training.  The American Association of Nurse Practitioners estimates that today there are 205,000 NPs, double the 2004 number.

            A recent editorial in The New York Times rhetorically asked: "Are Midwives Safer Than Doctors?"  Citing the findings of Britain's National Institute for Health Care Excellence that it is safer for healthy women with uncomplicated pregnancies to give birth under the supervision of midwives than in a hospital maternity ward run by doctors, the Times concluded that there is "no good reason that midwives should not play a more important role in childbirth here, despite a longstanding turf war between obstetricians and midwives that has tended to keep midwives under the thumb of doctors."  Last year there were more than 3.9 million births in the U.S., only nine percent of which were attended by nurse midwives.  The professional society for obstetricians consistently raises the traditional "public health hazard" argument.  Notwithstanding, the Times concluded: "In a time of spiraling medical costs and increasing demand for health care, midwives can offer a cost-effective way of providing good maternity care.  They could also provide greater geographical reach:  Nearly half the counties in the United States have no maternity care professional, either midwife or obstetrician."  [This, of course, has historically been the essence of psychology's public policy argument for expanding its coverage.]

            Serving at the Department of Defense (DoD) Uniformed Services University of the Health Sciences (USUHS), I have become particularly interested in programs targeting military personnel, their families, and veterans.  Last fall, the Jonas Center for Nursing and Veterans Healthcare announced its Policy Scholars Program, which in conjunction with the American Academy of Nursing, will recruit 12 doctoral and post-doctoral nursing students for a two-year experience whereby they will be matched with an expert panel to learn from leading nursing experts about major health policy issues.  The underlying strategic objective is to develop leadership in the policy work that is needed to create healthy communities and to transform the nation's health care system.  "The Jonas Policy Scholars will create a pipeline of early-career nursing scholars who will contribute to shaping practice, education, and research policy relevant to nursing and the work of the Academy of Nursing; provide a mechanism for Academy expert panel leaders to mentor early-career Jonas Policy Scholars on key issues relevant to the panel's area of focus and strategies for shaping those policies; and support expert panel chairs in advancing work to inform and shape policy and improve the health of the public."

The Jonas Center for Nursing and Veterans Healthcare was established in 2006 by Barbara and Donald Jonas and is dedicated to improving healthcare by advancing nursing scholarship, leadership, and innovation.  Its two main programs are the Jonas Nurse Leaders Scholar Program, which aims to address the dire shortage of nursing faculty by preparing nurses with doctoral degrees to step into this critical role; and the Jonas Veterans Healthcare Program, which seeks to improve the health of veterans by supporting doctoral-level nursing candidates committed to advancing veterans' healthcare.  These programs currently support more than 600 doctoral scholars nationwide, with the goal of supporting 1,000 Scholars by 2016.

A Personal View:  "As a Psychiatric Mental Health Nurse Practitioner who is not only educated to provide psychotherapy and pharmacotherapy but also trained to embrace a holistic model of care, I am especially grateful to have the training and skills to provide acupuncture therapy to psychiatric patients.  In my practice, acupuncture has been an effective adjunct treatment of complex psychological and physical trauma acquired from combat.  I found that my patients benefited from the unique practitioner-patient interaction that happens during acupuncture treatment.  Patients verbalized satisfaction as they report relief from debilitating symptoms such as insomnia, pain, and anxiety.  They appreciate the relaxation component that happens outside psychotherapy when they receive acupuncture.  They become proactive in their care by requesting and calling for more acupuncture time.  Albeit some of the effects of acupuncture are short term for those who have severe psychiatric symptoms, the momentary relief they gain could be revitalizing and result in increased function even for a few days.  After an acupuncture therapy, some of my patients report: 'I haven't slept that well in a long time since deployment;"  'I was able to spend time with my child without feeling tired and fatigued;'  'I did not have an anxiety attack this week.'  These momentary gains in quality of life are significant as we care for those who have experienced trauma in combat settings [LCDR Jane Abanes]."  Prior to enrolling in the USUHS Daniel K. Inouye Graduate School of Nursing Ph.D. program, Jane was Head, Mental Health Department & Substance Abuse Rehabilitation Program, Naval Health Clinic Hawaii.

Unmet Needs; Uncharted Waters; Unprecedented Opportunities?  I recently participated in a conference call for a HRSA national advisory committee during which it was noted: "Mental health disorders rank in the top five chronic illnesses in the U.S.  An estimated 25 percent of U.S. adults currently suffer from mental illness and nearly half of all U.S. adults will develop at least one mental illness in their lifetime.  In 2007, over 80 percent of individuals seen in the emergency room (ER) had mental disorders diagnosed as mood, anxiety and alcohol related disorders."  And the band begins to play.  We all live in a yellow submarine.  Aloha,

Pat DeLeon, former APA President – Division 29 – February, 2015

 

THERE’S A MAN GOIN’ ‘ROUND TAKIN’ NAMES

  With the convening of the 114^thCongress (2015-2016), and the Republican controlling both the U.S. House of Representatives and U.S. Senate for the first time since 2006, public service colleagues should expect somewhat different legislative agendas and federal budgetary priorities to evolve.  The newly elected Senate Majority Leader has proclaimed: "It's time for a new direction.  We can have real change in Washington, and that's just what I intend to deliver."  It is too early to predict with any sense of certainty what specifically will evolve.  However, change is definitely in the air.  Accordingly, this might be a good time to reflect upon several developments that were occurring right around election time.

            Evolving Treatment Programs:  One of the foundations of President Obama's Patient Protection and Affordable Care Act (ACA) is the development of interprofessional (i.e., interdisciplinary) integrated systems of data-driven primary care which will provide a priority for preventive care and wellness, while eliminating historical barriers for receiving mental health/behavioral health services.  The ACA invested heavily in expanding the Federally Qualified Community Health Centers (FQCHC) initiative, which was established under President Lyndon Johnson's Great Society Era.  Bob McGrath, Director of Integrated Care for the Underserved of Northeastern New Jersey at Fairleigh Dickinson University and their clinical psychopharmacology program:  "Thanks to the efforts of APA to improve funding for the Graduate Psychology Education program, in July this year I unexpectedly received funding for a grant that had been recommended but not funded in 2013.  The grant was to create a clinical training site in the primary care services of a local federally qualified health center called North Hudson Community Action Center.  We got the notice a week before the grant start date, so since then has been a whirlwind of creating a program from scratch, including finding students, hiring supervisors, creating protocols, developing a training program, establishing a legal relationship between the university and the site, and developing a personal relationship with staff.  The many months of work finally paid off, and in early December we began offering behavioral health services on an as-needed basis within the women's health and internal medicine services.  The population is overwhelmingly poor and Hispanic.  Few have ever had contact with mental health services before.  In just two days, we've seen people (including several staff members) suffering with chronic pain, overwhelming life stress, suicidality and depression, family problems.  It's remarkable how great the need is, and how limited the resources are.  It's exhausting work – I don't know how the staff keeps up this pace day after day – but it feels like we're finally connecting with people in real need who can benefit from what we have to offer.  I'm excited, and I know my students are already being reshaped as clinicians by what we've created."

Bob's visionary efforts to move psychology into the future are most timely.  I recently participated in a conference call for a HRSA national advisory committee during which it was noted: "Mental health disorders rank in the top five chronic illnesses in the U.S.  An estimated 25 percent of U.S. adults currently suffer from mental illness and nearly half of all U.S. adults will develop at least one mental illness in their lifetime.  In 2007, over 80 percent of individuals seen in the emergency room (ER) had mental disorders diagnosed as mood, anxiety and alcohol related disorders."

            The Advent Of Social Media:  Congressional Management Foundation Findings (CMF):  Advocacy groups have relied heavily on constituent email communications for years, and yet a recent CMF survey of Capitol Hill communications directors, legislative directors, and legislative assistants found that three quarters of senior Hill staff report that between one and 30 comments on social media platforms like Facebook and Twitter would get their attention on an issue.  Thirty-five percent indicated that even less than 10 comments were sufficient.  Social media interactions are viewed as authentic communications and its influence was perceived as rising.  Seeing an issue "pop up" in tweets or comments in just one instance is generally not enough to get congressional attention.  Similarly, when numerous advocates tweet a prearranged message at an account all at once (i.e., "thunderclaps"), these are not viewed as authentic communications.  However, if tweets and comments on an issue appear over the course of many days on social media accounts, they are definitely noticed.  To be effective, these repeated interactions have to be viewed as having a human element expressing a genuine concern.  Because many staffers have grown up with social media, they are adept at separating out constructive comments on Facebook and Twitter from the noise.

As is the case with email, the tone and level of influence a sender has will boost the likelihood of a message being heard.  It is particularly effective when constituents interact with the specific content Hill staff have posted on the Member's Facebook.  Genuine conversations are valued.  When asked which constituent types were most influential with Congress when commenting on social media, the CMF survey found that 77% cited multiple constituents commenting within a group; 75% cited leaders of a group or organization; 69% cited a single constituent self-identifying with a group; and 58% cited a single constituent on his or her own.  While email is still the dominant form of communication, social media is expected to increase over emails and individual phone calls during the next five to 10 years.  Hill staff reported that social media is often seen as a barometer of public opinion.  APA is well ahead of the curve.  Rhea Farberman reports that APA's main website (APA.org) averages 3 million visitors per month and that 282,000 people follow APA's Facebook page.  Most impressive!

            Substantive Change Takes Time – Often Far Longer Than One Might Imagine:  In 2004, when the Republicans were in the majority, the Senate HELP Committee recommended adoption of the Act for Elder Justice [S2940], which would amend the Older Americans Act to create the Office of Elder Abuse Prevention and Services.  The accompanying Senate Report: "The proportion of the United States population age 60 years or older will drastically increase in the next 30 years as 77,000,000 baby boomers approach retirement and old age.  Each year, anywhere between 500,000 and 5,000,000 elders in the United States are abused, neglected, or exploited.  This variance reflects the unfortunate fact that there is a general lack of comprehensive data on such abuse, with 500,000 reflecting the number being reported and a significantly higher number of cases that go unreported.  Elder abuse, neglect, and exploitation have no boundaries, and cross all racial, social class, gender, and geographic lines.  Victims of elder abuse, neglect, and exploitation are not only subject to injury from maltreatment and neglect, they are also 3.1 times more likely to die at an earlier age than expected than elders who were not victims of such maltreatment….

"For over 20 years, Congress has been presented with facts and testimony calling for a coordinated Federal effort to combat elder abuse, neglect, and exploitation.  The Federal Government has been slow to respond to the needs of the victims or to undertake prevention efforts.  No Federal law has been enacted that comprehensively addresses the issues of elder abuse, neglect, and exploitation and there are limited resources available to those in the field directly dealing with these issues (Sen Rpt. #108-391)."  Enacted as a provision of the ACA on March 23, 2010, this was the first legislation authorizing specific federal funding addressing elder abuse.  Listen to the words long written down, When the man comes around.  Aloha,

Pat DeLeon, former APA President – Division 18 – February, 2015

 

THE FOUNDING FATHERS

 One of the foundations of President Obama's Patient Protection and Affordable Care Act (ACA) is the active encouragement of patient-centered, data-based interprofessional (i.e., interdisciplinary) integrated care models to be established within comprehensive systems of care, such as Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes.  In many ways, the envisioned clinical structures are very similar to President Nixon's HMOs and President Clinton's Managed Care initiatives, of which organized psychology has historically been less than supportive.  The ACA provides for a priority on preventive care and eliminating traditional barriers to receiving mental health and behavioral health care.  The all-important psychosocial-cultural-economic gradient of care is to be systematically encouraged.   We would suggest, however, that in order to successfully function (if not thrive) within this exciting evolving environment, it would be very helpful for our educators and clinicians to become intimately familiar with the training, orientation, and clinical skills of the other health care professions – not to mention developing a public health perspective.

            Under the leadership of visionary APA Past President Nadine Kaslow, the Council of Representatives voted last year to encourage psychology's training programs to affirmatively embrace Competency-Based training.  In 2007, Nadine opined: "Professional psychology is moving towards competency-based models with attention to competency-based education, training, and credentialing."   In 2009, six national schools of health professions education associations formed the Interprofessional Education Collaborative (IPEC) in order to promote and encourage efforts to advance substantive interprofessional learning experiences with the goal of preparing future clinicians for the team-based care of patients.  The IPEC collaborative partners are the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges, and the Association of Schools and Programs of Public Health.  APA cannot be one of the core groups as it is not an association of schools/programs; nevertheless, the Education Directorate has been working closely with IPEC.

            From a health policy perspective, it is significant that whereas one of the required competencies for our colleagues in nursing is Health Policy (including teaching their next generation how to become actively involved in the political process), this is not the case for psychology's training programs.  In fact, a review of psychology's literature found very few training programs offering any relevant courses or "hands-on" training experiences.  The one notable exception is APA's Congressional (and now also Executive) Fellowship program which celebrated its 40th anniversary last year, having provided this transformative experience for 119 colleagues.

            The former Speaker of the U.S. House of Representatives Tip O'Neill noted that "All politics is local."  Described slightly differently by former APA Congressional Fellow Neil Kirschner: "More often than not, research findings in the legislative arena are only valued if consistent with conclusions based upon the more salient political factors….  If I've learned anything on the Hill, it is the importance of political advocacy if you desire a change in public policy."  Having personally served on the U.S. Senate staff for 38+ years, I would suggest that the key to effective advocacy is developing quality personal relationships with one's elected officials and their staff over a prolonged period of time.  The most common professional background of elected officials has consistently been law, followed by business.  Most obtain their health care knowledge from personal or family experiences or through the popular media.  To assume they are aware of the nuances of health care or of the extent of psychology's training and thus potential contributions, would be extremely naïve.

To become an effective advocate for one's cause (including for one's profession) one must be present, possess patience and persistence, and be committed to the long haul.  It is definitely helpful to develop an appreciation for how one's legislative or administrative agenda fits into a larger societal context.  Has the time arrived for the changes you desire and are there any natural allies for what you propose?  What, for example, might be the priorities of the newly elected Republican controlled Congress?  The ACA currently places much of the responsibility for implementation of the broad underlying statute at the local and state level.  Unfortunately, as drafted, psychology is not expressly enumerated under the ACO or Medical Home provisions of the law, although the clinical services psychology could provide are clearly possible if local administrators or policy makers so desire.  Similarly, the details of the various state Medicaid programs (which form the underlying basis for the ACA's expansion of health coverage for 32 million Americans) are also determined at the state level, where once again, unfortunately, psychology has generally been silent.

When meeting with one's elected officials and/or their staff, visits to their home office, especially during a Congressional recess, can be highly productive.  Those colleagues who are fortunate to be invited to the APA Practice Directorate's exciting annual State Leadership Conferences, will receive "hands-on" training regarding psychology's national agendas, as well as experience "mock-visits" with an elected one.  However, as the former Speaker of the House noted, local is best.  To arrange such a meeting, simply call their local offices.  One does not need detailed briefing materials or a comprehensive agenda.  Their job is to make you comfortable.  If requested, APA will provide background information as well as their legislative priorities.  Professor John Linton knows the APA governance and can be an excellent advisor, as can your State Association.  Being present is the most important ingredient.

Congress is organized every two years within a committee/subcommittee structure with those elected gravitating to areas that personally interest them.  Your job is to explore how they can be most helpful to your broader agenda, based upon their committee assignments.  When I think of West Virginia psychology, I warmly reflect upon the tireless dedication of Tom Stein.  Psychology's successful inclusion in Medicare was a prolonged journey, significantly influenced by Tom's vision and dedication.  For over a decade, I could see Tom's colorful map of West Virginia – highlighting the accessibility of psychology – on Senator Rockefeller's wall.  Psychology's true Medicare champion.  Aloha,

Pat DeLeon, former APA President – West Virginia Psychological Association – January, 2015