THE NATION’S EVER-EVOLVING HEALTHCARE ENVIRONMENT
It is important to appreciate that substantive change always takes time and further, that those who study the evolving currents within our nation’s healthcare environment often develop an intuitive sense of how the future will evolve. Nearly two decades ago, the Institute for the Future, supported by the Robert Wood Johnson Foundation, prognosticated what the future of health and health care would be within the decade (i.e., in 2010). Many of their predictions hold true today. It was expected that the nation’s population will be older and more ethnically and racially diverse. The burden of disease would shift towards chronic illnesses that stem from our behaviors. Whereas the health care industry had lagged behind other industries in implementing information technologies, this will become a prime catalyst of change. The emergence of new health care providers will also create change. Physicians were described as experiencing little real change in the way they practiced medicine “since the invention of the telephone.” “Our health behaviors… influence up to 50 percent of our health status. Although we do not anticipate radical improvements in these health behaviors… the emphasis… on prevention will help us to begin to decrease these harmful behaviors.” Perhaps most significantly, “(O)ver the next decade, our view of health will be expanded to encompass mental, social, and spiritual well-being.” “Understanding the role of mental factors in health and disease may be the most important contribution of an expanded view of health.”
The Agency for Healthcare Research and Quality (AHRQ): At our Uniformed Services University health policy class, Arlene Bierman, Director of the AHRQ Center for Evidence and Practice Improvement, described their exciting efforts to bring up-to-date research findings to the attention of policy makers, practitioners and their professional organizations. Primary care is complex and dynamic in nature, often requiring a team-based approach to meet the needs of patients with behavioral health issues. AHRQ created the Academy for Integrating Behavioral Health and Primary Care as a national resource for healthcare professionals interested in behavioral health and primary care integration. The Academy organizes the knowledge base and research, while providing expert insight on why and how to integrate effectively on a meaningful scale. The Academy Web Portal [https://integrationacademy.ahrq.gov] offers definitions, measures, strategies, lessons learned, and other practical tips for application to the field of integration. Its website features several products for clinicians, researchers, and quality improvement teams such as a lexicon, playbook [https://integrationacademy.ahrq.gov/products/playbook/about-playbook], and resources on opioid use disorder and substance abuse. All of AHRQ’s materials are in the public domain and therefore available free of charge.
Divisional Fellows Demonstrating Exceptional Vision: Former Division 42 President (1990) Michael Enright truly appreciated the implications of the changing tides within healthcare. “This is your old pal Ranger Mike checking in from my hacienda in central Mexico. It seems like a lifetime ago that you and I put in the resolution to the Council of Representatives of the APA to create Division 55 of the association -- to endorse prescriptive authority for our colleagues in psychology. As you know, I took a different trail and been practicing as an APRN for the past 20 years. Madre de Dios – ‘What a long strange trip it’s been.’ I still have the official hospital badge that my nurse supervisors fashioned for me that introduced me as ‘Dr. Enright, Student Nurse.’ Although it is sometimes awkward to explain my dual credentialing, I am so happy that I chose this route for attaining prescribing authority.
“I continue to question the wisdom of our profession in requiring a doctoral level practitioner to earn another Master’s degree in order to demonstrate the competency required for prescriptive authority. You recall our many discussions and debates regarding the wisdom of this strategy during the 1990s. In retrospect, I am concerned that this onerous requirement has unintentionally stifled our dream of universal prescriptive authority for psychology. In contrast to the current limited practice of prescribing psychologists, my nurse credential allows me to access a full, unlimited formulary of medications for my patients. In Wyoming, advance practice nurses have the same authority as physicians when writing a prescription. My license also allows me to follow my patients to other states should they need medication when traveling. You might be surprised how often this is necessary. I have ‘called’ medication for my patients to every state in the union, but Texas, over the course of my career. I do not regret taking the direct route to prescriptive authority and am very thankful to my nursing colleagues for having helped me with the initial training. Notwithstanding my aforementioned critique, I am proud, as I’m sure you are, of my colleagues in the states that have passed prescriptive authority legislation for psychologists (including neighboring Idaho).
“These days you will find me in my office in Wyoming where I continue to practice part time with my primary care partners in our rural multidisciplinary clinic. Today, we are even more inclusive and have added a nutritionist, a podiatrist, a biofeedback office, and yes, even a very progressive chiropractor to our team. Practicing as a psychologist and as a nurse practitioner no longer feels like such an anomaly. When I am not in the office I am usually wandering up a trout stream in the high country above the Red Desert or rambling through a barranca in the Sierra Madre. These peaceful days afford me the time to reflect on how thankful I am to have had the honor of advancing the scope of practice for our profession with wonderful colleagues, especially former President Jack Wiggins with his rural vision. Thank you!”
Another one of psychology’s truly unsung visionaries, Randy Phelps, has made a tremendous difference over the past quarter-of-a-century for all of the profession, and especially for our practitioners in private or public service. “I am retiring as APA’s senior advisor for health care financing on December 31st, the day before my birthday. I was recruited by Russ Newman in 1994 to assist efforts to get mental health coverage – and psychology -- into the Clinton health care plan, and agreed to close my Houston practice and come aboard for a 2-year stint. I like to joke that I’m now on my 25th year of a 2-year APA contract, and we are still working on access to mental health care for all Americans.
“Over my 25 years at APA, I have had the good fortune to be involved in so many things of great importance to psychology, and to the public we serve. Often, these works were behind the scenes, and not apparent to our members, but were nevertheless critical to the future of our profession. There are many accomplishments I’m proud of. In the late 1990s, I led the creation of the Health and Behavior billing codes for delivering psychological services to those with physical disorders. This was APA’s first attempt to get psychologists more fully into integrated care, something we are unfortunately still struggling with today. The Health and Behavior CPT codes were designated to eliminate the problem of having to assign the patient a psychiatric diagnosis just to use psychological methods to help someone with a physical illness like diabetes, for example.
“I began my career in the public sector and am still dedicated to that work. I created the APA’s Veteran’s Affairs portfolio 20 years ago, including serving on the VA’s Committee on Serious Mental Illness, and working with the VA Central Office, many Veterans Service Organizations, and VA’s own psychology organizations. I was a co-founder of the annual VA Psychology Leadership Conference, now in its 21st year, and was one of the architects of the Congressional deal that moved psychology into the professional pay category in VA. And it was through this work that I met my wife, Dr. Barbara Van Dahlen, the founder of Give an Hour, which gives free mental health care to service members, Veterans, and their families.
“In recent years, I left my decade-long position as Deputy Executive Director of the APA Practice Directorate and APA Practice Organization, to lead a small team of staff and volunteer psychologists charged with insuring our profession’s value and reimbursement levels within the healthcare system. We represent psychology inside the quasi-regulatory system run by Medicare and the AMA’s CPT and RUV systems. This has been the most challenging and difficult work I have done in my 40 years as a psychologist, made even harder by confidentiality agreements that prevent our work from coming to light until 1-2 years later. I am proud that over the past five years our team won increases in national payment levels for the psychotherapy codes, and more recently, increases beginning in 2019 for most psychologists who provide psychological and neuropsychological testing.
“This past year for APA’s 125th anniversary I was honored with an invitation to write the history of professional practice over the last 25 years. That article, co-authored with my colleagues James Bray and Lisa Kearney, was published in a special edition of the American Psychologist. Much of the profession’s journey that we describe in the article is my own journey as well.
“Through it all I’ve had the pleasure of working with the best and brightest of our discipline. There are far too many to name here, but you know who you are, and I am indebted to each of you. Despite being a Texan, I’m not actually riding off into the sunset. In fact, I will be devoting all of my energy to Give an Hour. Although I will no longer be in a position to make strategy and policy decisions at APA, I am looking forward to watching what our next generation of psychologists will do. Indeed, I will have a front row seat, since our oldest daughter is on her way to becoming one of us.” Aloha,
Pat DeLeon, former APA President – Division 42 – November, 2018
