IMPLEMENTATION TIME -- CHANGE IS COMING
2016 is a Presidential year and history would suggest that one should not expect significant Congressional developments, especially in the highly politicalized health care area. The Republicans seem intent upon repealing Obamacare; the Democrats are internally arguing what, if any, modifications might be pursued. The U.S. Supreme Court has consistently held that P.L. 111-148 is constitutional. Thus, the status quo? It is important for psychology to appreciate that one of the underlying tenets of President Obama’s Patient Protection and Affordable Care Act (ACA) is its emphasis upon interdisciplinary collaboration (i.e., integrated care). Public service psychologists, especially those within the Departments of Veterans Affairs (VA) and Defense (DoD), have excellent track records demonstrating the clinical and leadership contributions that mental/behavioral health providers can make and further, the benefits of working collaboratively with colleagues in other disciplines, including clinical pharmacy and advanced practice nursing (APNs). Over the years, both Departments have developed cutting-edge post-doctoral training initiatives (our personal thanks to the visionary leadership of now-retired Robert Zeiss) addressing the intimate relationship between the “mind and body.” This represents a significant societal maturation.
For those interested in the psychopharmacology (RxP) agenda, this gradual evolution towards interdisciplinary collaboration provides an excellent vehicle for its ultimate acceptance, at least at the “bed-side” operational level. Last year, significant efforts were finally initiated to implement the Guam RxP statute which had become law on December 30, 1998, thanks to the dedication of Lyndsey Miller on Guam and Hilo’s Judi Steinman, Program Coordinator of the University of Hawaii at Hilo’s College of Pharmacy training program – which recently received APA RxP designation. On June 25, 2014 Governor Pat Quinn signed the Illinois Psychological Association’s (IPA) RxP legislation into public law. Without question, the key to IPA’s amazing legislative success (over strong objections from organized medicine) was the persistence and commitment of Beth Rom-Rymer, a long-time member of the APA Council of Representatives. She has subsequently gone beyond Illinois in her seeking allies for the RxP movement.
“On two occasions, I discussed the paradigm of prescriptive authority for psychologists with President Barack Obama at events in Chicago -- first in July 2009 and then in August 2012. In response to my giving him some information about RxP and my asking him for his thoughts, the President replied: ‘Yes, I agree that we need better access to care for the underserved. I especially agree that non-MD providers, like psychologists, when given specialized training, can provide integrative care for the mentally ill, including effective treatment with psychotropic medication.’ I have recently been in touch with a group of researchers at Princeton University, colleagues and students of the prominent health economist, Uwe Reinhardt. They are doing groundbreaking research on “scope of practice” expansion across disciplines, research that now includes the introduction of prescribing psychologists into communities. One research group found that when psychiatric APNs are given independent prescriptive authority, many patients report that previously unidentified psychiatric symptoms remitted. Even more significantly, this research group reported that giving independent prescriptive authority to nurse practitioners significantly reduces the suicide rate.” [Beth, forever the trail blazer, was in the first freshman class at Princeton that admitted women as full-time students (Class of ’73)].
VA Secretary Robert McDonald visited the Uniformed Services University of the Health Sciences (USUHS) last September. “The Secretary focused on highlighting current strengths while executing his vision for the VA. As a former soldier who became a business executive, his point of view combined both passion for Veterans’ care and business-minded solutions. Impressively, he reiterated his support of full practice authority for nurses in the VA. He suggested that this support will help respond to current physician and nurse shortages across the VA, which are echoed throughout the civilian health care system. He spoke of touring the country’s medical schools to recruit top talent and improving salaries for current staff at all levels of the VA to compete with the private market. The Secretary also spoke of the VA’s responsibility to lead the nation in reforming mental health care by increasing access and eliminating stigma through team-based care models that include mental health care providers. Notably, the Secretary insisted that he be called “Bob,” explaining that, in his view, companies and organizations should have non-hierarchical structures to reduce barriers between management and staff. Further, he explained that removing these barriers helps prevent “cooking the books,” withholding information, and avoiding asking questions. Unfortunately, he did not expressly mention psychology during his visit” (Joanna Sells). Nursing leadership had obtained the support of the previous VA Secretary – also a former soldier – for the adoption of a national scope of practice protocol, notwithstanding local scope of practice limitations. We understand that, after considerable public comment (including objections from organized medicine), this far-reaching policy document is presently before OMB for clearance.
The successes of the prescribing psychologists within the DoD and U.S. Public Health Service are impressive; however, at the policy level “scope of practice” issues are usually decided at the individual state legislative level. In the State of California, the Little Hoover Commission is beginning their review of occupational licensing. The Commission’s mission is to investigate state government operations and – through reports, recommendations and legislative proposals – promote efficiency, economy, and improved service. By statute, the Commission is a balanced bipartisan board composed of five citizen members appointed by the Governor, four citizen members appointed by the Legislature, two Senators, and two Assembly members. Our colleague Le Ondra Clark Harvey, Chief Consultant for the Assembly Committee on Business and Professions, is scheduled to testify. In its description of their proposed study, the Commission noted: “Critics contend that these regulations at times go beyond consumer protection and unjustifiably restrict competition…. The Commission also will examine the result of occupational licensing on the cost and availability of services provided by licensed practitioners to consumers.” These, in essence, are psychology’s fundamental arguments in support of RxP.
Since the release of the landmark Institute of Medicine (IOM) report The Future of Nursing, nursing’s leadership has been impressively successful in obtaining significant financial support from national foundations. The American Academy of Nursing: “[We] received a grant from the Robert Wood Johnson Foundation (RWJF) to partner with the RAND Corporation to examine nurse-designed models of care that will address many key social determinants of health and to empower and support people to lead healthier lives…. Nursing has long focused on patient- and family-centered care, pursuing a holistic view of individuals that incorporates aspects of their family, community and work environment. This perspective makes nurses uniquely positioned to break down the current siloed approach to health care and advocate for social action and policy changes on behalf of patients. The Academy’s Edge Runner initiative, previously originally funded by RWJF, identifies nurses who have developed innovative models of care that have good clinical and financial outcomes. The new grant will examine how these models address elements that have been identified as contributing to the creation of a shared value of health among individuals, families and communities…. To date, the Academy has publicly recognized 54 individual Edge Runners who have created 42 innovative care models delivering evidence-based high quality care at reduced cost. Many of these models focus on fostering a culture of health through building multi-sector partnerships and promoting equitable access to high-quality services.” Step by step, the vision underlying the ACA is steadily taking hold. Aloha,
Pat DeLeon, former APA President – Division 18 – February, 2016
