THE FOUNDATION FOR AN EXPANDED VISION (RxP History)

 Federal Involvement:  On November 30, 1984, at the Hawaii Psychological Association (HPA) annual convention, U.S. Senator Daniel K. Inouye urged the membership to amend their state practice act to allow them to independently utilize drugs where appropriate so that their "clients will be well-served."  After the Senator's challenge, the HPA Executive Committee agreed to pursue legislation which would study the feasibility of obtaining this clinical responsibility.  At that time there was little enthusiasm for the proposal within the psychological community and extreme opposition within the psychiatric community.  During the 1989 legislative session, hearings were held on eight separate bills.  A House Resolution was enacted "Requesting the Center for Alternative Dispute Resolution to convene a series of roundtable discussions."  Thus, Hawaii became the first state in the nation in which the issue of psychologists prescribing (RxP) was seriously debated.  Interestingly, their RxP legislation was ultimately vetoed on July 10, 2007 – more than two decades after the Senator's address.  In the 2015 legislative session, renewed HPA and grassroots interest resulted in their RxP bill passing the House of Representatives on March 10, 2015, by a vote of 23 yes, 13 yes with reservations, and 15 no.

            During Congressional deliberations on the Fiscal Year 1989 Appropriations bill for the Department of Defense (DoD) [P.L. 100-463], Senator Inouye included language which directed the Department to establish a "demonstration pilot training project under which military psychologists may be trained and authorized to issue appropriate psychotropic medications under certain circumstances."  Organized psychiatry raised considerable objections.  The following year the conferees stated: "the Department cannot ignore direction from Congress and therefore should develop such a training program…."  A DoD Blue Ribbon Panel was established, with Russ Newman representing APA, and recommended a two year fellowship, combing didactic and practicum activity.  To begin on time, two psychologists were initially assigned to the Army Physician Assistant program at Ft. Sam Houston Texas.

The Walter Reed/Uniformed Services University of the Health Sciences training program (PDP) began in the summer of 1991, and was closely monitored by the American College of Neuropsychopharmacology (ACNP).  ACNP concluded: "All 10 graduates of the PDP filled critical needs, and they performed with excellence wherever they were placed."  On June 17, 1994, Navy Commander John Sexton and Lt. Commander Morgan Sammons became the first graduates.  RxP training has continued in various venues, particularly in the private sector.  DoD and USPHS credentialing policies have been issued.  The seminal contribution of the DoD initiative is to affirmatively demonstrate that psychologists could be trained to safely prescribe in a cost-effective manner.  Interestingly, individual psychologists had been prescribing within the VA and Indian Health Service (Floyd Jennings) during this time period; however, without any formal organized training.

            APA Governance:  In 1989, under the leadership of Norma Simon, the APA Board of Professional Affairs (BPA) held a special meeting to explore this intriguing phenomenon.  BPA recommended: "focused attention on the responsibility of preparing the profession to address… needs of the public for psychologically managed psychopharmacological interventions be made APA's highest priority."  In August 1990, the Council of Representatives established an ad hoc Task Force on Psychopharmacology, chaired by Michael Smyer.  Its report concluded that practitioners, with combined training in psychopharmacology and psychosocial treatments, "could 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.  Further, the proposed new providers had the potential to dramatically improve patient care and make important new advances in treatment."  In August 1995, Council formally endorsed RxP for appropriately trained psychologists as APA policy and called for the development of model legislation and a model curriculum.  Subsequent Councils adopted these (1996); called for a national examination (1997); and formal APA recognition of Designated Postdoctoral RxP Training programs (2009).  APAGS adopted its Resolution of Support in 1997.  Bob McGrath estimates today there are more than 1750 psychologists who have completed their post-doctoral psychopharmacology training.

            State Legislation:  In March 1993, Indiana and in December 1998, Guam passed psychology RxP authorization legislation, although neither has been implemented to date.  In March 2002, New Mexico and in May 2004, Louisiana passed RxP legislation with John Bolter signing the first civilian script on January 20, 2005.  Elaine LeVine was the first female civilian prescriber.  More than a decade later, Illinois enacted its RxP legislation which was signed into law on June 25, 2014.  What is unique to Illinois is the decision to legislatively address the specifics of the required training (including at the undergraduate level) and its openness to incorporating RxP training at the graduate level.  Previous policy discussions had focused exclusively upon post-doctoral training.

            Future Challenges:  Although military and USPHS prescribing psychologists have provided quality psychopharmacotherapy services for more than two decades, there has been continued resistance within the VA and the federal Bureau of Prisons.  Ron Fox, former APA President: "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."  Along with enacting additional state practice laws, future challenges will include expanding to Federally Qualified Community Health Centers, state and local mental health clinics, and the evolving Accountable Care Organizations and Patient-Centered Medical Homes envisioned under President Obama's Patient Protection and Affordable Care Act.  Aloha,

Pat DeLeon, former APA President – Division 12 – April, 2015

 

HERE COMES THE JUDGE

  Perhaps it is due to growing up in a family where both parents were lawyers.  Perhaps it was serving as the first chair of the APA ad hoc Committee on Legal Issues (COLI).  More likely, it was profoundly enjoying Laugh-In.  For whatever reason, like former Division President Andy Benjamin, I have always been impressed by the commonality of interest between psychology and the legal profession.  The needs of psychology's patients often parallel those of the attorney's clients.  In 2008, the first Veteran's court was established in Buffalo in an attempt to seriously address this interface.  Former Massachusetts Psychological Association President and APA President Ron Levant heralded this transformative movement.  At the national level, APA and ABA cosponsor impressive conferences.  Another former APA President Don Bersoff, the association's first General Council, noted that by 2013, APA had submitted 147 amicus briefs, 58 of which were filed in the U.S. Supreme Court.  Why don't we hear about more state psychological associations working collaboratively with their local state bar associations?

            The FY' 2016 budget for the HHS Administration for Community Living (ACL) proposes to prevent, detect, and respond to elder abuse, neglect, and exploitation.  As the population of older Americans increases, these problems continue to grow.  Yet, there is no single set of national elder abuse prevalence data.  A 2004 national survey of State Adult Protective Service programs showed a 16% increase in the number of elder abuse cases from an earlier 2000 study.  Estimates are that 84% of all elder abuse incidents go unreported.  The most recent data suggest that at least 10%, approximately 5 million older Americans, experience abuse each year, many in multiple forms.

            The Administration reports extensive negative effects of abuse, neglect, and exploitation on the health and independence of seniors.  Older victims of even modest forms of abuse have dramatically higher (300%) morbidity and mortality rates than non-abused older individuals.  Adverse health impacts include an increased likelihood of heart attacks, dementia, depression, chronic diseases and psychological distress.  As a result, a growing number of seniors access the healthcare system and are ultimately forced to leave their homes and communities prematurely.

ACL envisions building a foundation and establishing best practices for States to expand and improve the protection of elderly individuals living in their communities and in long-term care settings; increase the information and technical assistance available; protect the rights of older adults and prevent their exploitation; and reduce health-care fraud and abuse.  Its Ombudsman Program relies heavily upon volunteers who make up the bulk of those who resolve resident issues.  The landscape is changing as individuals in need of long-term care services and supports increasingly choose to live in community settings.  Fortunately there is a growing federal awareness of the uncharted area of abuse, neglect, and exploitation of older adults and persons with disabilities.  These challenges must be effectively addressed.  We would rhetorically ask: What better topic for a joint conference or dinner discussion between our local state psychological and bar associations?  Aloha,

Pat DeLeon, former APA President – Division 31 – March, 2015

UNITED WE STAND, DIVIDED….

 The Critical Nature of State Associations:  Early on in my career I worked for the State of Hawaii Division of Mental Health at a time when state employees were being unionized.  Dues were an "expense" that I never regretted; for with the union, our collective voice was heard.  A very small, but illustrative example: When the inpatient psychiatrist was going away for two weeks, he pinned a notice on the bulletin board that I was in charge.  Upon his return, I submitted a request for a small amount of additional pay.  The head of the Division (a physician) took the position that a non-physician could nothave been in charge.  The union representative successfully argued that I was, in fact, in charge -- "See the pin hole where the notice was posted."  Several years later, psychologist Joe Blaylock was appointed Head of the Division of Mental Health.  As individuals, we may sincerely believe that our expertise is beneficial and serves society well.  However, the reality is that organized medicine has, over many years, consistently opposed any expansion of the clinical practice of all non-physicians, including their ability to serve in administrative or policy setting positions.  Without developing a cohesive collective voice, the past will all too accurately continue to predict the future.

The enactment of President Obama's Patient Protection and Affordable Care Act (ACA) heralds the beginning of unprecedented change in our nation's health care environment.  Former APA Congressional Science Fellow Sandra Wilkniss points out that the ACA provides one of the largest expansions of mental health and substance use disorder coverage in a generation.   She has also urged psychology to appreciate the magnitude of transformation occurring as the nation's health care system moves steadily towardsintegrated, interdisciplinary care – and thus away from its historical reliance upon fee-for-service, independent practice.  Data-based gold standard "best practices" will be tomorrow's expectation.

            I sincerely appreciate the 25+ years that I have been able to be involved in the APA governance and particularly the opportunity during my Presidency in 2000 to visit a number of smaller rural state psychological associations.  Nationwide, there are over 46 million citizens living in rural America who face ongoing challenges in accessing health care.  Rural America is where psychology can truly make a demonstrable difference in the lives of so many Americans.  Rural residents have historically struggled with issues related to access to care, recruitment and retention of health care providers of all disciplines, and maintaining the economic viability of hospitals and health care providers in isolated rural communities.  Rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than their urban counterparts.  Interestingly, the goal of President Obama's "Improving Rural Health Care Initiative" is to build healthier rural populations and communities through evidence-based practices.  This is an important mission for which psychology and the other behavioral sciences can make a unique contribution.  Exciting opportunities exist for those with visionary leadership.

            A number of our colleagues do not seem to understand that as one of the nation's educated elite, they have a societal responsibility to become personally involved in effectively addressing society's most pressing needs.  Collectively, they do not seem to appreciate that through their own state psychological association, and at the federal level APA, they can have a profound impact upon the public policy/political process.  During my involvement within the APA governance, I came to deeply appreciate that our profession is only where it is today because of the efforts of the visionary leaders of the past.  Gene Shapiro, Nick Cummings, Suzanne Bennett Johnson, Bill McKeachie, and the late John Gardner (former Secretary of HEW under President Lyndon Johnson and President of Common Cause) to name just a few to whom we owe so much.  Today's challenge is for each of us to reach out to colleagues and convince them to join (and especially, to rejoin) the only collective voice they have – the Arkansas Psychological Association.  This is particularly true for our senior colleagues who thereby will have the opportunity to mentor the next generation.  During my early days with the Hawaii Government Employees Association (HGEA), I saw how effective this personalized approach can be.  This challenge is about the very future of the field in a dramatically changing world – it is not exclusively a practitioner, academic, or science issue.  It is about survival and addressing unprecedented change.  It is about setting achievable goals.  And it is, above all else, about taking advantage of new exciting opportunities.

            Telepsychology – A Future For Many:  The unprecedented advances occurring within the computer and technology fields continue to have a major impact upon all aspects of society including our economy, except, most health policy experts would proffer, the health care industry.  The ACA is dedicated to rapidly changing this in furtherance of targeting the critical health policy goal of accomplishing "the triple aim" -- i.e., improving the experience of care, improving the health of populations, and reducing the cost of health care.  Psychology is very fortunate that 2011 APA President Melba Vasquez possessed the vision to appreciate the significance of the advent of the era of Telemental Health/Telepsychology for the profession and for all of behavioral health.  Acknowledging the successes of pioneering colleagues within the Departments of Veterans Affairs (VA) and Defense (DoD) who have been particularly responsive to its exciting potential, she established in close collaboration with the Association of State and Provincial Psychology Boards (ASPPB) and the APA Insurance Trust (APAIT), a telehealth task force which systematically addressed a number of the complex issues surrounding utilizing this evolving technology.  In August, 2013 at our annual convention, Council passed their recommended Telepsychology Guidelines on the consent agenda.

Telemental health services were initiated within VA in 2004-2005, and under the leadership of Antonette Zeiss, the first psychologist to be appointed chief consultant for the Office of Mental Health Services, VA was soon leading the way for the nation.  In fiscal year 2013, more than 600,000 veterans accessed care using telehealth programs for a total of over 1.7 million episodes of care.  It is estimated that VA telehealth services are increasing by approximately 22% annually.  We are indeed most fortunate that one of the truly visionary leaders in this area is Steve DeMers, ASPPB Chief Executive Officer.  His colleagues Fred Millan and Janet Pippin Orwig have been working diligently with both nursing and medicine, as well as the Council of State Governments, to coordinate developing an innovative Telepsychology Licensure Compact.   The critical implementation steps will be at the state level until sufficient national consensus is ultimately developed justifying a federal approach.  Working out the details will become one of the Arkansas Psychological Association's priorities over the next several years.  "It ain't quite this simple, so I better explain just why you got to ride on the union train."  Aloha,

Pat DeLeon, former APA President – Arkansas Psychological Association – February, 2015