“WHEN JOHNNY COMES MARCH HOME AGAIN”

  Developing The Foundation:  APA President Tony Puente has a long history of being on the cutting-edge of advocacy for professional psychology, especially in his efforts to effectively shape federal policies which directly impact the field's future.  Tony, Randy Phelps, Neil Pliskin, and Stephen Gillaspy have been working diligently for years to update the Medicare Current Procedural Terminology (CPT) codes for psychological testing.  Psychology expert groups were convened and they regularly consulted with the Centers for Medicare and Medicaid Services (CMS).  During the first few days of June they represented APA at the second of three meetings of the American Medical Association CPT Editorial Panel in Boston.  Years of relationship building, intimate knowledge of an extremely complicated process, and great teamwork set the foundation for regular interfacing with CMS and the CPT Panel.  "Bottom line, health policy in the making sets the foundation for the future of professional psychology."

            Change Is Coming:  Earlier this summer, the Association for Psychological Science (APS) held its 29^th Annual Convention also in Boston, attended by approximately 4,500 enthusiastic colleagues.  APS was instrumental in establishing the Psychological Clinical Science Accreditation System (PCSAS) in 2007, as an independent psychology program accreditation body.  Alan Kraut, formerly of APA and the recently retired CEO of APS, is heading up this initiative.  Currently, 35 university psychology programs have obtained accreditation status.  Last year, the Department of Veterans Affairs (VA), which is the largest trainer and employer of psychologists, recognized PCSAS as an appropriate accrediting body for meeting their internship and hiring criteria.  Pending regulations at the USPHS would recognize PCSAS graduates for hiring also.  To date, five states (New York, California, New Mexico, Delaware, and Illinois) have similarly determined that such status fulfills their licensure requirements.  Accordingly, one should expect an increasing number of jurisdictions to follow suit as PCSAS steadily matures and their graduates enter the profession.

            Substantive Change Takes Time:  A decade ago, the Traumatic Brain Injury Health Enhancement and Long-Term Support Act of 2007 [H.R. 2199] noted: "Brain injury has become a leading health issue for civilians and the military.  According to the Centers for Disease Control and Prevention (CDC), in the United States civilian population 1.4 million individuals sustain TBI annually, resulting in 235,000 hospital admissions and 50,000 deaths.  Additionally, 80,000 survive with residual long-term impairments.  CDC estimates that long-term disability as a result of brain injuries affects 5.3 million Americans."  TBI is considered by many as the "signature injury" of our current armed conflict, which is the longest in our nation's history.

The accompanying House report emphasized the issues of accessibility of mental health care services and outreach in rural communities.  "The National Guard and Reserve components have been deployed in record numbers to help fight the wars in Afghanistan and Iraq.  Many of these units come from rural parts of the country.  Currently, over 40 percent of the returning OEF/OIF veterans are from rural areas.  Oftentimes it is difficult for these veterans to access quality health care and mental health services in a timely manner."  We would ask: Whether our state psychological associations are working collaboratively with local Veterans organizations and the VA to address this national need?  Former APA President Jack Wiggins was recently installed as Post Surgeon for VFW Post 7507.  Former APA Interim CEO Cynthia Belar appointed Heather O'Beirne Kelly as APA's first ever Director of Military and Veterans Health Policy, housed within the APA Practice Organization.  "Hurrah!"  Aloha,

Pat DeLeon, former APA President – Division 31 – June, 2017

 

Sent from my iPhone

ALOHA - D31 column

“WHEN JOHNNY COMES MARCH HOME AGAIN”

            Developing The Foundation:  APA President Tony Puente has a long history of being on the cutting-edge of advocacy for professional psychology, especially in his efforts to effectively shape federal policies which directly impact the field’s future.  Tony, Randy Phelps, Neil Pliskin, and Stephen Gillaspy have been working diligently for years to update the Medicare Current Procedural Terminology (CPT) codes for psychological testing.  Psychology expert groups were convened and they regularly consulted with the Centers for Medicare and Medicaid Services (CMS).  During the first few days of June they represented APA at the second of three meetings of the American Medical Association CPT Editorial Panel in Boston.  Years of relationship building, intimate knowledge of an extremely complicated process, and great teamwork set the foundation for regular interfacing with CMS and the CPT Panel.  “Bottom line, health policy in the making sets the foundation for the future of professional psychology.”

            Change Is Coming:  Earlier this summer, the Association for Psychological Science (APS) held its 29^th Annual Convention also in Boston, attended by approximately 4,500 enthusiastic colleagues.  APS was instrumental in establishing the Psychological Clinical Science Accreditation System (PCSAS) in 2007, as an independent psychology program accreditation body.  Alan Kraut, formerly of APA and the recently retired CEO of APS, is heading up this initiative.  Currently, 35 university psychology programs have obtained accreditation status.  Last year, the Department of Veterans Affairs (VA), which is the largest trainer and employer of psychologists, recognized PCSAS as an appropriate accrediting body for meeting their internship and hiring criteria.  Pending regulations at the USPHS would recognize PCSAS graduates for hiring also.  To date, five states (New York, California, New Mexico, Delaware, and Illinois) have similarly determined that such status fulfills their licensure requirements.  Accordingly, one should expect an increasing number of jurisdictions to follow suit as PCSAS steadily matures and their graduates enter the profession.

            Substantive Change Takes Time:  A decade ago, the Traumatic Brain Injury Health Enhancement and Long-Term Support Act of 2007 [H.R. 2199] noted: “Brain injury has become a leading health issue for civilians and the military.  According to the Centers for Disease Control and Prevention (CDC), in the United States civilian population 1.4 million individuals sustain TBI annually, resulting in 235,000 hospital admissions and 50,000 deaths.  Additionally, 80,000 survive with residual long-term impairments.  CDC estimates that long-term disability as a result of brain injuries affects 5.3 million Americans.”  TBI is considered by many as the “signature injury” of our current armed conflict, which is the longest in our nation’s history.

The accompanying House report emphasized the issues of accessibility of mental health care services and outreach in rural communities.  “The National Guard and Reserve components have been deployed in record numbers to help fight the wars in Afghanistan and Iraq.  Many of these units come from rural parts of the country.  Currently, over 40 percent of the returning OEF/OIF veterans are from rural areas.  Oftentimes it is difficult for these veterans to access quality health care and mental health services in a timely manner.”  We would ask: Whether our state psychological associations are working collaboratively with local Veterans organizations and the VA to address this national need?  Former APA President Jack Wiggins was recently installed as Post Surgeon for VFW Post 7507.  Former APA Interim CEO Cynthia Belar appointed Heather O’Beirne Kelly as APA’s first ever Director of Military and Veterans Health Policy, housed within the APA Practice Organization.  “Hurrah!”  Aloha,

Pat DeLeon, former APA President – Division 31 – June, 2017

 

LIVING LABORATORIES FOR MEANINGFUL CHANGE

  In many ways, these are truly "interesting times" which can provide public sector psychology with unprecedented opportunities to make a real difference in the daily lives of their patients.  Public service often represents society's "safety net."  This spring, as Interim APA CEO, Cynthia Belar established the position of Director of Military and Veterans Health Policy, to be located within the Practice Organization.  And, Cynthia appointed Heather O'Beirne Kelly as the director for this new and exciting initiative.   Heather has worked for APA for nearly two decades and one of her top priorities is to facilitate the acceptance of appropriately trained prescribing psychologists (RxP) within the Department of Veterans Affairs (VA).  She recently testified before the House of Representatives Appropriations Committee urging the adoption of a pilot RxP project, similar to that once contemplated by then-VA Secretary Anthony Principi under President G.W. Bush.  Data recently provided by Bob McGrath and Beth Rom-Rymer indicates that New Mexico has 12 conditional prescribers and 45 prescribers; while Louisiana has 120 medical psychologists.  The Department of Defense (DoD) and the U.S. Public Health Service (including the Indian Health Service) utilize prescribing psychologists.  Morgan Sammons, John Sexton, and Floyd Jennings (1986) were among the first colleagues to be formally authorized to use these clinical skills – decades ago.

            Over the years we have come to appreciate that in order to make a significant and lasting difference in the public policy arena, one must possess vision, be personally involved, and be willing to remain committed over a prolonged period of time.  The public sector has historically provided psychology with outstanding opportunities to develop creative, cutting-edge training initiatives.  For example, DoD initiated the first RxP training program with Morgan and John graduating in 1994.  Today, thanks to the leadership of Robert Zeiss and his successor Ken Jones, the VA Office of Academic Affiliations supports 440 post-doctoral positions annually.

            It would seem highly appropriate, therefore, for those interested in advancing the RxP agenda to capitalize upon the closed-system, interdisciplinary/integrated nature of the public sector to provide psychopharmacology training experiences for interns/trainees, thereby effectively capitalizing upon these "living laboratories."  The beneficiary population's need for these services cannot be questioned; the relevant professional shortages are well documented.  For example, shouldn't our next generation of colleagues have ready access to the didactic RxP training modules during their internship experiences when they could simultaneously receive face-to-face consultation from their clinical supervisors?  Across the various health professions, on-line and distance/virtual reality training opportunities are increasingly being utilized.  Advances occurring within the communications field are making this technologically feasible.

            Uniformed clinical psychology students at the DoD Uniformed Services University of the Health Sciences (USUHS) incur a seven year service pay-back obligation upon completion of their degree.  During their clinical training they are routinely exposed to a wide range of clinical and operational experiences which ultimately can lead to assignments aboard the aircraft carrier U.S.S. George H.W. Bush (CVN 77) and in Antarctica; being embedded on the front lines; exposed to natural, man-made, and global disasters, as well as population responses to deadly epidemics; utilization of telehealth; mountain and wilderness training, etc.  In many ways, these future colleagues should (and perhaps, must) possess the broadest range of clinical skills.  At USUHS there is interest among the students in obtaining their RxP training at the graduate school level, as their psychiatric nursing student (DMHP) colleagues do.  Appropriately, teamwork, interdisciplinary training, and operational mental health experiences are a priority of the university.

            Several years ago with the active support of Division 18 leadership, Steve Tulkin and Beth proffered the vision of encouraging public service psychologists to enroll in the Alliant International University RxP training program.  The next logical evolution would seem to be encouraging public service oriented-graduate students to systematically obtain this knowledge.  The issue of the appropriateness of post-doctoral status vs. graduate student status, as conceptualized by the APA Council of Representatives back in 1996, could appropriately be debated at the state licensure level and perhaps during the administration of the revised PEP (Psychopharmacology Examination for Psychologists) exam, which is currently being developed by the Association of State and Provincial Psychology Boards (ASPPB).  Psychology prides itself on being one of the "learned professions."  "Giving away psychology" and enhancing educational opportunities are fundamental values of the field.  Accordingly, I recently raised this possibility with two of the RxP training directors urging that their programs actively encourage the enrollment of USUHS students.  To my surprise, each independently raised the specter of APA designation procedures being the major obstacle.

            The Case Example:  "I am a graduate student hoping to enroll in the M.S. in Clinical Psychopharmacology program while in graduate school.  However, I need the program director to waive the requirement of having a license in psychology to enroll.   I feel my previous academic experiences have prepared me well for this program.  I have previously taken graduate coursework in: physiology (with doctoral nursing students), psychopharmacology, neurobiology, and endocrinology.   I also completed several research projects in the field of psychopharmacology.  I have recently completed my core coursework required for my Ph.D. at USUHS and want to further my education in this area.  I am hoping to start courses in clinical psychopharmacology in 2018 (USUHS graduate student)."

            "This is an issue with the APA Designation criteria.  In our APA designation review this became a significant issue and I agreed to stop any future admits of students who had not yet received their doctorate.  I feel I must be consistent with what I agreed to in our last designation review.  Is there some process for seeking a waiver?  I would not only want to admit military students, but would make it possible for there to be some tuition scholarship for your colleague and other students in military training/placements.  The APA Designation Criteria: P1. Admissions: To participate in postdoctoral education and training in psychopharmacology, programs must require that students meet the following prerequisites: 1. Be a graduate of a doctoral program in psychology; 2. Hold a current state license as a psychologist; and, 3. Practice as a 'health service provider' psychologist as defined by state law, where applicable, or as defined by APA (Alan Lincoln, Interim RxP Program Director, Alliant International University)."

            APA's Catherine Grus subsequently clarified that the model curriculum states: "The program could develop policies for allowing credit from a previous graduate or postdoctoral education and training program(s).  To ensure that the training experience is up-to-date, sequential, and cumulative, transfer of a limited number of credits as appropriate for previous coursework is not to exceed twenty percent (20%) of the postdoctoral curriculum and is to be limited to the basic science and neuroscience domains (Domains I & II)."

I would raise the underlying educational policy question: Is it appropriate for APA's designation system to preclude future members of our profession from obtaining the most up-to-date clinical knowledge?  I personally do not think so and believe that such an approach clearly does not fulfill, or even support, our societal obligations.  Former APA President Ron Fox, who has been involved in the RxP quest from the very beginning: "As a Past President of APA and Division 55 and as chair of the committee which wrote the designation guidelines, admitting such students to help them get a leg up in the academic portion of their RxP studies seems logical and in keeping with what the original drafters had in mind.  To be threatened with loss of designation status seems an overreach that does not serve the best interest of our profession, our students, or society."  Change can be uncomfortable for many.  Aloha,

Pat DeLeon, former APA President – Division 18 – June, 2017

 

Sent from my iPhone

ALOHA - D 18

“LIVING LABORATORIES FOR MEANINGFUL CHANGE”

            In many ways, these are truly “interesting times” which can provide public sector psychology with unprecedented opportunities to make a real difference in the daily lives of their patients.  Public service often represents society’s “safety net.”  This spring, as Interim APA CEO, Cynthia Belar established the position of Director of Military and Veterans Health Policy, to be located within the Practice Organization.  And, Cynthia appointed Heather O’Beirne Kelly as the director for this new and exciting initiative.   Heather has worked for APA for nearly two decades and one of her top priorities is to facilitate the acceptance of appropriately trained prescribing psychologists (RxP) within the Department of Veterans Affairs (VA).  She recently testified before the House of Representatives Appropriations Committee urging the adoption of a pilot RxP project, similar to that once contemplated by then-VA Secretary Anthony Principi under President G.W. Bush.  Data recently provided by Bob McGrath and Beth Rom-Rymer indicates that New Mexico has 12 conditional prescribers and 45 prescribers; while Louisiana has 120 medical psychologists.  The Department of Defense (DoD) and the U.S. Public Health Service (including the Indian Health Service) utilize prescribing psychologists.  Morgan Sammons, John Sexton, and Floyd Jennings (1986) were among the first colleagues to be formally authorized to use these clinical skills – decades ago.

            Over the years we have come to appreciate that in order to make a significant and lasting difference in the public policy arena, one must possess vision, be personally involved, and be willing to remain committed over a prolonged period of time.  The public sector has historically provided psychology with outstanding opportunities to develop creative, cutting-edge training initiatives.  For example, DoD initiated the first RxP training program with Morgan and John graduating in 1994.  Today, thanks to the leadership of Robert Zeiss and his successor Ken Jones, the VA Office of Academic Affiliations supports 440 post-doctoral positions annually.

            It would seem highly appropriate, therefore, for those interested in advancing the RxP agenda to capitalize upon the closed-system, interdisciplinary/integrated nature of the public sector to provide psychopharmacology training experiences for interns/trainees, thereby effectively capitalizing upon these “living laboratories.”  The beneficiary population’s need for these services cannot be questioned; the relevant professional shortages are well documented.  For example, shouldn’t our next generation of colleagues have ready access to the didactic RxP training modules during their internship experiences when they could simultaneously receive face-to-face consultation from their clinical supervisors?  Across the various health professions, on-line and distance/virtual reality training opportunities are increasingly being utilized.  Advances occurring within the communications field are making this technologically feasible.

            Uniformed clinical psychology students at the DoD Uniformed Services University of the Health Sciences (USUHS) incur a seven year service pay-back obligation upon completion of their degree.  During their clinical training they are routinely exposed to a wide range of clinical and operational experiences which ultimately can lead to assignments aboard the aircraft carrier U.S.S. George H.W. Bush (CVN 77) and in Antarctica; being embedded on the front lines; exposed to natural, man-made, and global disasters, as well as population responses to deadly epidemics; utilization of telehealth; mountain and wilderness training, etc.  In many ways, these future colleagues should (and perhaps, must) possess the broadest range of clinical skills.  At USUHS there is interest among the students in obtaining their RxP training at the graduate school level, as their psychiatric nursing student (DMHP) colleagues do.  Appropriately, teamwork, interdisciplinary training, and operational mental health experiences are a priority of the university.

            Several years ago with the active support of Division 18 leadership, Steve Tulkin and Beth proffered the vision of encouraging public service psychologists to enroll in the Alliant International University RxP training program.  The next logical evolution would seem to be encouraging public service oriented-graduate students to systematically obtain this knowledge.  The issue of the appropriateness of post-doctoral status vs. graduate student status, as conceptualized by the APA Council of Representatives back in 1996, could appropriately be debated at the state licensure level and perhaps during the administration of the revised PEP (Psychopharmacology Examination for Psychologists) exam, which is currently being developed by the Association of State and Provincial Psychology Boards (ASPPB).  Psychology prides itself on being one of the “learned professions.”  “Giving away psychology” and enhancing educational opportunities are fundamental values of the field.  Accordingly, I recently raised this possibility with two of the RxP training directors urging that their programs actively encourage the enrollment of USUHS students.  To my surprise, each independently raised the specter of APA designation procedures being the major obstacle.

            The Case Example:  “I am a graduate student hoping to enroll in the M.S. in Clinical Psychopharmacology program while in graduate school.  However, I need the program director to waive the requirement of having a license in psychology to enroll.   I feel my previous academic experiences have prepared me well for this program.  I have previously taken graduate coursework in: physiology (with doctoral nursing students), psychopharmacology, neurobiology, and endocrinology.   I also completed several research projects in the field of psychopharmacology.  I have recently completed my core coursework required for my Ph.D. at USUHS and want to further my education in this area.  I am hoping to start courses in clinical psychopharmacology in 2018 (USUHS graduate student).”

            “This is an issue with the APA Designation criteria.  In our APA designation review this became a significant issue and I agreed to stop any future admits of students who had not yet received their doctorate.  I feel I must be consistent with what I agreed to in our last designation review.  Is there some process for seeking a waiver?  I would not only want to admit military students, but would make it possible for there to be some tuition scholarship for your colleague and other students in military training/placements.  The APA Designation Criteria: P1. Admissions: To participate in postdoctoral education and training in psychopharmacology, programs must require that students meet the following prerequisites: 1. Be a graduate of a doctoral program in psychology; 2. Hold a current state license as a psychologist; and, 3. Practice as a ‘health service provider’ psychologist as defined by state law, where applicable, or as defined by APA (Alan Lincoln, Interim RxP Program Director, Alliant International University).”

            APA’s Catherine Grus subsequently clarified that the model curriculum states: “The program could develop policies for allowing credit from a previous graduate or postdoctoral education and training program(s).  To ensure that the training experience is up-to-date, sequential, and cumulative, transfer of a limited number of credits as appropriate for previous coursework is not to exceed twenty percent (20%) of the postdoctoral curriculum and is to be limited to the basic science and neuroscience domains (Domains I & II).”

I would raise the underlying educational policy question: Is it appropriate for APA’s designation system to preclude future members of our profession from obtaining the most up-to-date clinical knowledge?  I personally do not think so and believe that such an approach clearly does not fulfill, or even support, our societal obligations.  Former APA President Ron Fox, who has been involved in the RxP quest from the very beginning: “As a Past President of APA and Division 55 and as chair of the committee which wrote the designation guidelines, admitting such students to help them get a leg up in the academic portion of their RxP studies seems logical and in keeping with what the original drafters had in mind.  To be threatened with loss of designation status seems an overreach that does not serve the best interest of our profession, our students, or society.”  Change can be uncomfortable for many.  Aloha,

Pat DeLeon, former APA President – Division 18 – June, 2017

 

 

“I’VE BEEN STANDING AT THE EDGE OF THE WATER”

 The Importance of Focusing Upon the Bigger Picture:  Generating tremendous enthusiasm from our public service colleagues, then-interim CEO Cynthia Belar and President Tony Puente established the APA Office of Military and Veterans Health Policy, appointing long-time staffer Heather O'Beirne Kelly as its first director.  The VA is the largest employer of psychologists and leads the way in developing cost-effective, integrated, interdisciplinary health care initiatives; telehealth (tele-psychology), and quality internship and most recently post-doctoral training opportunities.  As always, there remain many areas for psychology to provide visionary leadership and innovative clinical services.  The Secretary of the VA reports that even today, 20 Veterans commit suicide daily and as the special edition of the Division 18 journal Psychological Services highlighted, under the editorship of Lisa Kearney, Jack Tsai, and Thomas O'Toole, the issue of Veterans' homelessness remains a national tragedy.  One of Heather's personal priorities is to educate and excite our next generation of colleagues regarding their societal responsibility to become personally engaged in order to bring the best of psychological knowledge to focus upon the nation's societal priorities.

            This spring Heather invited mental health psychology and nursing graduate students and faculty at USUHS to attend a special presentation/Congressional briefing in the House of Representatives entitled "Veterans Health Research: A Showcase of Advancements."  Medical and clinical psychology graduate student Omni Cassidy:  "I attended the Veterans Health Research briefing on Capitol Hill, which showcased groundbreaking technological advances in medical and prosthetic research for military Veterans.  The briefing was hosted by the Friends of VA Medical Care and Health Research (FOVA) whose executive committee includes a number of organization representatives, including APA's Heather Kelly, Director of Military and Veterans Health Policy.  The showcase highlighted four outstanding projects.

            "Dr. Ann Spungen from the Bronx VA Medical Center discussed the ReWalk exoskeleton, an exoskeleton suit that provides powered hip and knee motion to help those with spinal cord injuries to stand and walk.  Dr. Leigh Hochberg from the Providence VA Medical Center discussed his research project, BrainGate, which is a system that uses brain electrodes to identify neural signals that help a user control the movement of electronic or robotic devices.  Dr. Gary Goldish from the Minneapolis VA Healthcare System has worked with engineers and Veterans to develop a standing wheelchair prototype that allows individuals to move from a traditional seated position to an upright standing position in order to increase function, mobility, and reach.  Lastly, and the one I found particularly fascinating, was Dr. Dustin Tyler from the Louis Stokes Cleveland VA Medical Center.  He discussed his work on developing sense of touch for those with prosthetic limbs.  Through an electronic nervous interface connected to the prosthetic limb that his team developed, sensors can measure the pressure applied to the prosthetic limb and send electrical signals to other parts of the arm and then to the brain allowing the user to sense what he/she is touching.

            "The most incredible and noteworthy portion of the briefing were the showcases of the devices and the testimonies from Veterans themselves who's quality of life has been significantly improved through these technologies.  Through tear-stained eyes, one Veteran user of Dr. Tyler's 'sensing' prosthetic hand expressed his immense gratitude for the opportunity to feel the sensation of squeezing a piece of fruit – something many might take for granted.  And, most importantly, his new ability to pick up his granddaughter and actually feel her in his hand, a sensation he hasn't felt in a long time and one he was not sure he would be able to do again.  These projects, and many more through the VA, highlighted the enormous impact research funding has on the lives of those who have risked their lives for the freedoms we experience every day."  Thanks to the vision and dedication of Robert Zeiss and his successor Ken Jones, the VA Office of Academic Affiliations currently supports approximately 440 post-doctoral positions annually, which allows the next generation of psychologists to actively engage in interdisciplinary, collaborative research and practice initiatives and thereby move the nation's rehabilitation efforts into the 21 century – in many ways, these post-doctoral opportunities are implementing the vision of former APA President Jack Wiggins and then-VA Secretary Anthony Principi.

            The Best of Public Service:  This spring the VA Psychology Leadership conference celebrated its 20^th anniversary in San Antonio – formerly known as the Dallas conference having been established in 1998 with the strong support of Russell Lemle and APA's Randy Phelps.  Over the years, many Hawaii colleagues have attended.  APA President Tony Puente, on the 125^th anniversary of APA, presented his friend and colleague Kathy McNamara with a Presidential Citation.  "She has served the profession of psychology in countless ways from being in the leadership of the AVAPL, the Department of Veterans Affairs, the National Academies of Practice and the American Psychological Association including serving on its Board of Directors….  To the Veterans and their families, she is known as Dr. Mc.  To the Veterans on the Island of Moloka'i she is known as the Mother Teresa of Moloka'i.  She has not only touched the minds and hearts of the Veterans and their families but also the people of Hawaii….  APA and AVAPL are so proud to have Dr. McNamara be one of us.  May our careers and our lives reflect the humbleness, kindness, warmth, passion and success that she brought each Veteran and the field of psychology.  Thank you, Dr. McNamara for allowing us to be part of your life and for you to have so deeply influenced ours."

            The Bipartisan Congressional Budget Office (CBO):  On May 4, 2017 the American Health Care Act of 2017 [HR 1628] passed the U.S. House of Representatives.   CBO and the Joint Committee on Taxation (JCT) estimate that HR 1628 would reduce the cumulative federal deficit over the 2017-2026 period by $119 billion.  However, in 2018, 14 million more people would be uninsured under this legislation than under current law [ObamaCare (ACA)].  The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 23 million in 2026.  In 2026, an estimated 51 million people under the age of 65 (Medicare eligible) would be uninsured, compared with 28 million who would lack insurance that year under current law.

Over time, it would become more difficult for less healthy people (including people with preexisting medical conditions) in those states where wavers are sought from the Essential Health Benefits (EHB) requirement because their premiums would continue to increase rapidly.  Further, CBO and JCT estimate that services or benefits likely to be excluded from the EHBs in some states "include maternity care, mental health and substance abuse benefits, rehabilitative and habilitative services, and pediatric dental benefits.  In particular, out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars in a given year for the nongroup enrollees who would use those services.  Moreover, the ACA's ban on annual and lifetime limits on covered benefits would no longer apply to health benefits not defined as essential in a state."  "One day I'll know, how far I'll go."  Aloha,

Pat DeLeon, former APA President – Hawaii Psychological Association – June, 2017

 

Sent from my iPhone

HPA - June column

“I’VE BEEN STANDING AT THE EDGE OF THE WATER”

            The Importance of Focusing Upon the Bigger Picture:  Generating tremendous enthusiasm from our public service colleagues, then-interim CEO Cynthia Belar and President Tony Puente established the APA Office of Military and Veterans Health Policy, appointing long-time staffer Heather O’Beirne Kelly as its first director.  The VA is the largest employer of psychologists and leads the way in developing cost-effective, integrated, interdisciplinary health care initiatives; telehealth (tele-psychology), and quality internship and most recently post-doctoral training opportunities.  As always, there remain many areas for psychology to provide visionary leadership and innovative clinical services.  The Secretary of the VA reports that even today, 20 Veterans commit suicide daily and as the special edition of the Division 18 journal Psychological Services highlighted, under the editorship of Lisa Kearney, Jack Tsai, and Thomas O’Toole, the issue of Veterans’ homelessness remains a national tragedy.  One of Heather’s personal priorities is to educate and excite our next generation of colleagues regarding their societal responsibility to become personally engaged in order to bring the best of psychological knowledge to focus upon the nation’s societal priorities.

            This spring Heather invited mental health psychology and nursing graduate students and faculty at USUHS to attend a special presentation/Congressional briefing in the House of Representatives entitled “Veterans Health Research: A Showcase of Advancements.”  Medical and clinical psychology graduate student Omni Cassidy:  “I attended the Veterans Health Research briefing on Capitol Hill, which showcased groundbreaking technological advances in medical and prosthetic research for military Veterans.  The briefing was hosted by the Friends of VA Medical Care and Health Research (FOVA) whose executive committee includes a number of organization representatives, including APA’s Heather Kelly, Director of Military and Veterans Health Policy.  The showcase highlighted four outstanding projects.

            “Dr. Ann Spungen from the Bronx VA Medical Center discussed the ReWalk exoskeleton, an exoskeleton suit that provides powered hip and knee motion to help those with spinal cord injuries to stand and walk.  Dr. Leigh Hochberg from the Providence VA Medical Center discussed his research project, BrainGate, which is a system that uses brain electrodes to identify neural signals that help a user control the movement of electronic or robotic devices.  Dr. Gary Goldish from the Minneapolis VA Healthcare System has worked with engineers and Veterans to develop a standing wheelchair prototype that allows individuals to move from a traditional seated position to an upright standing position in order to increase function, mobility, and reach.  Lastly, and the one I found particularly fascinating, was Dr. Dustin Tyler from the Louis Stokes Cleveland VA Medical Center.  He discussed his work on developing sense of touch for those with prosthetic limbs.  Through an electronic nervous interface connected to the prosthetic limb that his team developed, sensors can measure the pressure applied to the prosthetic limb and send electrical signals to other parts of the arm and then to the brain allowing the user to sense what he/she is touching.

            “The most incredible and noteworthy portion of the briefing were the showcases of the devices and the testimonies from Veterans themselves who’s quality of life has been significantly improved through these technologies.  Through tear-stained eyes, one Veteran user of Dr. Tyler’s ‘sensing’ prosthetic hand expressed his immense gratitude for the opportunity to feel the sensation of squeezing a piece of fruit – something many might take for granted.  And, most importantly, his new ability to pick up his granddaughter and actually feel her in his hand, a sensation he hasn’t felt in a long time and one he was not sure he would be able to do again.  These projects, and many more through the VA, highlighted the enormous impact research funding has on the lives of those who have risked their lives for the freedoms we experience every day.”  Thanks to the vision and dedication of Robert Zeiss and his successor Ken Jones, the VA Office of Academic Affiliations currently supports approximately 440 post-doctoral positions annually, which allows the next generation of psychologists to actively engage in interdisciplinary, collaborative research and practice initiatives and thereby move the nation’s rehabilitation efforts into the 21 century – in many ways, these post-doctoral opportunities are implementing the vision of former APA President Jack Wiggins and then-VA Secretary Anthony Principi.

            The Best of Public Service:  This spring the VA Psychology Leadership conference celebrated its 20^th anniversary in San Antonio – formerly known as the Dallas conference having been established in 1998 with the strong support of Russell Lemle and APA’s Randy Phelps.  Over the years, many Hawaii colleagues have attended.  APA President Tony Puente, on the 125^th anniversary of APA, presented his friend and colleague Kathy McNamara with a Presidential Citation.  “She has served the profession of psychology in countless ways from being in the leadership of the AVAPL, the Department of Veterans Affairs, the National Academies of Practice and the American Psychological Association including serving on its Board of Directors….  To the Veterans and their families, she is known as Dr. Mc.  To the Veterans on the Island of Moloka’i she is known as the Mother Teresa of Moloka’i.  She has not only touched the minds and hearts of the Veterans and their families but also the people of Hawaii….  APA and AVAPL are so proud to have Dr. McNamara be one of us.  May our careers and our lives reflect the humbleness, kindness, warmth, passion and success that she brought each Veteran and the field of psychology.  Thank you, Dr. McNamara for allowing us to be part of your life and for you to have so deeply influenced ours.”

            The Bipartisan Congressional Budget Office (CBO):  On May 4, 2017 the American Health Care Act of 2017 [HR 1628] passed the U.S. House of Representatives.   CBO and the Joint Committee on Taxation (JCT) estimate that HR 1628 would reduce the cumulative federal deficit over the 2017-2026 period by $119 billion.  However, in 2018, 14 million more people would be uninsured under this legislation than under current law [ObamaCare (ACA)].  The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 23 million in 2026.  In 2026, an estimated 51 million people under the age of 65 (Medicare eligible) would be uninsured, compared with 28 million who would lack insurance that year under current law.

Over time, it would become more difficult for less healthy people (including people with preexisting medical conditions) in those states where wavers are sought from the Essential Health Benefits (EHB) requirement because their premiums would continue to increase rapidly.  Further, CBO and JCT estimate that services or benefits likely to be excluded from the EHBs in some states “include maternity care, mental health and substance abuse benefits, rehabilitative and habilitative services, and pediatric dental benefits.  In particular, out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars in a given year for the nongroup enrollees who would use those services.  Moreover, the ACA’s ban on annual and lifetime limits on covered benefits would no longer apply to health benefits not defined as essential in a state.”  “One day I’ll know, how far I’ll go.”  Aloha,

Pat DeLeon, former APA President – Hawaii Psychological Association – June, 2017

 

“YOU SEE THAT MOUNTAIN OVER THERE?”

To Repeal and Replace Obama Care (ACA)?  The initially proposed House of Representatives "repeal and replace Obama Care" legislation (The American Health Care Act of 2017 [H.R. 1628]) was estimated by the non-partisan Congressional Budget Office (CBO) to result in an additional 14 million individuals being uninsured, which would bring the number of uninsured Americans to 21 million in 2020 and 24 million in 2026.  In 2026, an estimated 52 million people under age 65 would be uninsured, compared with 28 million who would lack insurance that year under current law (the Affordable Care Act).  That effort lacked sufficient support and the highly anticipated vote was postponed on March 24, 2017.  Subsequently, a revised bill passed the House on May 4, by a vote of 217 to 213 without any Democratic support.  Interestingly, this was done prior to receiving an updated CBO impact statement.

The APA voiced its disappointment, resulting in APA President Tony Puente calling the legislation: "Significantly worse than the version considered last month.  The bill now opens the door to health plans once again charging exorbitant premiums to the tens of millions of Americans with pre-existing conditions."  The U.S. Senate is in the beginning stages of developing its recommendations – having to reconcile dramatically different, strongly held views among its members.  For those concerned about mental/behavioral health and substance use services, the critical issue is whether the "essential services" provision of the current law are retained and to what extent the Congress might provide the various state Governors with sufficient flexibility to essentially eliminate the progress made over the past decades in enacting federal mental health parity legislation.

This ongoing national debate on health care reform is occurring within the context that the United States continues to spend more on health care than any other industrialized nation and without expected comparable health outcomes.  Dean Art Kellermann of the USUHS School of Medicine reports that the National Academy of Medicine (formally, the IOM) estimates that we waste $750 billion per year on "unnecessary or inefficient services, excessive administrative costs, high prices, healthcare fraud and missed opportunities for prevention."  Those primarily in private practice should appreciate that a significant number of health policy experts are increasingly coming to the conclusion that as a nation we are steadily approaching the enactment of a comprehensive "single payer" system under which government would play a major role in determining what is considered "quality health care" and what percentage of the economy will ultimately be allocated to these services.  Since 1948, the World Health Organization (WHO) has taken the proactive policy position: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."  Without question, health care is a highly complex and evolving endeavor – with behavioral health often underappreciated.

            State-Based Insurance Exchanges:  The decision to establish state-based insurance exchanges, as envisioned by the ACA, was a major policy and operational commitment by 16 states and the District of Columbia.  Last year the Milbank Memorial Fund sponsored a gathering of many of the original leaders of these exchanges to reflect upon the "lessons learned" and implications for future health system reform efforts by state policymakers.  What should be the role of state government in assuring that their health system delivers on the goals of improved population health, efficient care, and a better patient experience of care?  How to develop and maintain the capacities to implement agreed upon policy decisions?

            The ACA provided three options for a state-based exchange's legal structure: public agency, quasi-governmental agency, or nonprofit organization, with each model being represented.  Upon reflection, the directors expressed an overwhelming feeling of privilege and gratitude on being chosen to lead their state's historic efforts at building a state-based exchange.  At the same time, many reported being challenged by the level of scrutiny, media attention, and political divisiveness that accompanied their every move.  They emphasized the importance of having national and state political backing, both to support the launch of the new exchange and to build the broad public support needed to enroll those eligible for coverage.  Retired US Navy nurse Coral Andrews, who was our Hawaii director, was particularly touched that President Obama personally joined one of their conference calls, lending moral and political support.

            While all involved were deeply grateful for the opportunity to serve as director, they acknowledged that this was a very intense, 24/7responsibility.  That only a relatively small number of the original directors remain in the role today reflects the demands of the position and the changing political support for this reform.  For future state-based major health system reform efforts it will be important to remember that those recruited for these positions will need strong support from their state's leaders.  Regardless of the political context and the policy positions adopted, certain capacities are needed to develop and implement major health reforms: clearly defined leadership, governance, roles, and mechanisms; staff capacity; and federal resources and assistance from other sources.  Leadership was especially challenging because of what was described as working in a fishbowl-type environment, where they often faced a contentious political environment.  Their strategy for dealing with this was to strive for bipartisan support and actively engage stakeholders.

All agreed that it was absolutely necessary to have a great relationship with and support from the Governor's office.  It was important to secure the Governor's leadership to "prioritize operational practically over political opportunity."  Having a strong advisory process was also viewed as critical and all agreed that the exchange structure must have "clear accountability with a single point of authority."  Similarly, a clear and effective partnership with the Medicaid program, without being swallowed or subsumed by it, was necessary.  Developing sufficient data to demonstrate progress to legislators and other stakeholders was extremely helpful.  Not surprisingly, recruiting qualified and committed staff was a major challenge for all of the directors.  Both public-sector and private-sector expertise was critical.  The biggest recruiting challenge all of the exchanges faced was finding skilled IT professionals.  Relying on a public-private partnership model requires a clearly articulated and shared vision to enable its success.  Partnership models must align accountability and responsibility to optimize success.  For all of us, the challenges and opportunities ahead are unprecedented.

            Integrated Interdisciplinary Care:  One of former APA President Susan McDaniel's personal priorities was preparing psychology for the evolving challenges occurring within the nation's health care environment.  Integrated and interdisciplinary team-based care is one of the foundations of the ACA.  Earlier this year, APA announced the development of an exciting curriculum for an Interprofessional Seminar on Integrated Primary Care, co-chaired by Jeff Goodie and Ron Rozensky.  Fundamental change can be unsettling for many; however, visionaries such as Susan are laying an impressive foundation for the next generation of colleagues across the nation.  "Oh, play me some mountain music."  Aloha,

Pat DeLeon, former APA President – Division 42 – May, 2017

 

Sent from my iPhone

Div 42 May column

“YOU SEE THAT MOUNTAIN OVER THERE?”

            To Repeal and Replace Obama Care (ACA)?  The initially proposed House of Representatives “repeal and replace Obama Care” legislation (The American Health Care Act of 2017 [H.R. 1628]) was estimated by the non-partisan Congressional Budget Office (CBO) to result in an additional 14 million individuals being uninsured, which would bring the number of uninsured Americans to 21 million in 2020 and 24 million in 2026.  In 2026, an estimated 52 million people under age 65 would be uninsured, compared with 28 million who would lack insurance that year under current law (the Affordable Care Act).  That effort lacked sufficient support and the highly anticipated vote was postponed on March 24, 2017.  Subsequently, a revised bill passed the House on May 4, by a vote of 217 to 213 without any Democratic support.  Interestingly, this was done prior to receiving an updated CBO impact statement.

The APA voiced its disappointment, resulting in APA President Tony Puente calling the legislation: “Significantly worse than the version considered last month.  The bill now opens the door to health plans once again charging exorbitant premiums to the tens of millions of Americans with pre-existing conditions.”  The U.S. Senate is in the beginning stages of developing its recommendations – having to reconcile dramatically different, strongly held views among its members.  For those concerned about mental/behavioral health and substance use services, the critical issue is whether the “essential services” provision of the current law are retained and to what extent the Congress might provide the various state Governors with sufficient flexibility to essentially eliminate the progress made over the past decades in enacting federal mental health parity legislation.

This ongoing national debate on health care reform is occurring within the context that the United States continues to spend more on health care than any other industrialized nation and without expected comparable health outcomes.  Dean Art Kellermann of the USUHS School of Medicine reports that the National Academy of Medicine (formally, the IOM) estimates that we waste $750 billion per year on “unnecessary or inefficient services, excessive administrative costs, high prices, healthcare fraud and missed opportunities for prevention.”  Those primarily in private practice should appreciate that a significant number of health policy experts are increasingly coming to the conclusion that as a nation we are steadily approaching the enactment of a comprehensive “single payer” system under which government would play a major role in determining what is considered “quality health care” and what percentage of the economy will ultimately be allocated to these services.  Since 1948, the World Health Organization (WHO) has taken the proactive policy position: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”  Without question, health care is a highly complex and evolving endeavor – with behavioral health often underappreciated.

            State-Based Insurance Exchanges:  The decision to establish state-based insurance exchanges, as envisioned by the ACA, was a major policy and operational commitment by 16 states and the District of Columbia.  Last year the Milbank Memorial Fund sponsored a gathering of many of the original leaders of these exchanges to reflect upon the “lessons learned” and implications for future health system reform efforts by state policymakers.  What should be the role of state government in assuring that their health system delivers on the goals of improved population health, efficient care, and a better patient experience of care?  How to develop and maintain the capacities to implement agreed upon policy decisions?

            The ACA provided three options for a state-based exchange’s legal structure: public agency, quasi-governmental agency, or nonprofit organization, with each model being represented.  Upon reflection, the directors expressed an overwhelming feeling of privilege and gratitude on being chosen to lead their state’s historic efforts at building a state-based exchange.  At the same time, many reported being challenged by the level of scrutiny, media attention, and political divisiveness that accompanied their every move.  They emphasized the importance of having national and state political backing, both to support the launch of the new exchange and to build the broad public support needed to enroll those eligible for coverage.  Retired US Navy nurse Coral Andrews, who was our Hawaii director, was particularly touched that President Obama personally joined one of their conference calls, lending moral and political support.

            While all involved were deeply grateful for the opportunity to serve as director, they acknowledged that this was a very intense, 24/7 responsibility.  That only a relatively small number of the original directors remain in the role today reflects the demands of the position and the changing political support for this reform.  For future state-based major health system reform efforts it will be important to remember that those recruited for these positions will need strong support from their state’s leaders.  Regardless of the political context and the policy positions adopted, certain capacities are needed to develop and implement major health reforms: clearly defined leadership, governance, roles, and mechanisms; staff capacity; and federal resources and assistance from other sources.  Leadership was especially challenging because of what was described as working in a fishbowl-type environment, where they often faced a contentious political environment.  Their strategy for dealing with this was to strive for bipartisan support and actively engage stakeholders.

All agreed that it was absolutely necessary to have a great relationship with and support from the Governor’s office.  It was important to secure the Governor’s leadership to “prioritize operational practically over political opportunity.”  Having a strong advisory process was also viewed as critical and all agreed that the exchange structure must have “clear accountability with a single point of authority.”  Similarly, a clear and effective partnership with the Medicaid program, without being swallowed or subsumed by it, was necessary.  Developing sufficient data to demonstrate progress to legislators and other stakeholders was extremely helpful.  Not surprisingly, recruiting qualified and committed staff was a major challenge for all of the directors.  Both public-sector and private-sector expertise was critical.  The biggest recruiting challenge all of the exchanges faced was finding skilled IT professionals.  Relying on a public-private partnership model requires a clearly articulated and shared vision to enable its success.  Partnership models must align accountability and responsibility to optimize success.  For all of us, the challenges and opportunities ahead are unprecedented.

            Integrated Interdisciplinary Care:  One of former APA President Susan McDaniel’s personal priorities was preparing psychology for the evolving challenges occurring within the nation’s health care environment.  Integrated and interdisciplinary team-based care is one of the foundations of the ACA.  Earlier this year, APA announced the development of an exciting curriculum for an Interprofessional Seminar on Integrated Primary Care, co-chaired by Jeff Goodie and Ron Rozensky.  Fundamental change can be unsettling for many; however, visionaries such as Susan are laying an impressive foundation for the next generation of colleagues across the nation.  “Oh, play me some mountain music.”  Aloha,

Pat DeLeon, former APA President – Division 42 – May, 2017