At the end of last year, the White House released a report entitled Reforming America's Healthcare System Through Choice and Competition, authored by the Secretaries of the Departments of Health and Human Services, Treasury, and Labor. "As health care spending continues to rise, Americans are not receiving the commensurate benefit of living longer, healthier lives. Health care bills are too complex, choices are too restrained, and the insurance premiums and out-of-pocket costs are climbing faster than wages and tax revenue. Health care markets could work more efficiently and Americans could receive more effective, high-value care if we remove and revise certain federal and state regulations and policies that inhibit choice and competition…. Reduced competition among clinicians leads to higher prices for health care services, reduces choice, and negatively impacts overall health care quality and the efficient allocation of resources. Government policies have suppressed competition by reducing the available supply of providers and restricting the range of services that they can offer. This report recommends policies that will broaden providers' scope of practice [SOP] while improving workforce mobility, including telehealth, to encourage innovation and to allow providers more easily to meet patients' needs."
Several salient conclusions include that government rules restrict competition if they keep healthcare providers from practicing to the "top of their license" – i.e., to the full extent of their abilities; given their education, training, skills, and experience -- consistent with the relevant standards of care. This includes restrictions on the appropriate use of telehealth technologies and the range of services providers can provide. Oftentimes, SOP restrictions limit provider entry and ability to practice in ways that do not address demonstrable or substantial risks to consumer health and safety. Further, there is a risk that healthcare professionals with overlapping skill sets will seek these restrictions as they view SOP restrictions as an easy, state-sanctioned opportunity to insulate themselves from competition. For example, the report found that Advanced Practice Registered Nurses, Physician Assistants, Pharmacists, Optometrists, and Dental Hygienists can safely and effectively provide some of the same services as physicians, in addition to providing complementary services, citing the Institute of Medicine (IOM) and the Federal Trade Commission (FTC). Interestingly, this extends to physician supervision and collaborative practice regulations, which can be unreasonably restrictive. One specific recommendation: "States should consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their license, utilizing their full skill set."
The report further addressed the related issues of licensure mobility and telehealth; both of which are highly relevant to psychology's practitioners and their vision for the future. State-based licensing requirements, by definition, inhibit provider mobility and often inhibit delivery of services across state lines by making it more difficult for qualified practitioners, who are licensed in one state to work in another state, even though most complete nationally certified education and training programs and sit for national qualifying exams. Appropriate standards of care do not differ from state to state; yet, the process of obtaining a license in another state is often slow, burdensome, and costly. There is little economic justification for this and it can inhibit the efficient development and use of telehealth, as well as in-person services. The report further noted that Interstate Compacts and model laws can mitigate the effects of state-licensing requirements. The compact approach has only recently been proposed, with nursing enacting the first in 1999.
Telehealth is described as a significant innovation in healthcare services with mental health highlighted as an example of its usefulness. It increases the virtual supply of providers and extends their reach to new locations, promoting beneficial competition, reducing transportation expenses, and improving access to quality care and long-term quality outcomes. Nevertheless, a variety of regulatory barriers keep telehealth from reaching its full potential. Two specific recommendations: States should consider adopting licensure compacts or model laws that improve licensure mobility by allowing healthcare providers to more easily practice in multiple states, thereby creating additional opportunities for telehealth practice. And, States generally should consider allowing individual providers and payers to mutually determine whether and when it is safe and appropriate to provide telehealth services, including where there has not been a prior person-to-person visit.
For psychology, the key to the future is the vision of Steve DeMers, retired CEO, Mariann Burnetti-Atwell, current CEO, and the Board of the Association of State and Provincial Psychology Boards (ASPPB). In 2015, ASPPB developed, with input from all major psychology stakeholders and some consumer organizations, and then approved PSYPACT (Psychology Interjurisdictional Compact) to provide for the legal and ethical practice of psychology across jurisdictions. PSYPACT will allow psychologists with an E.Passport certificate from a compact state to electronically provide psychological services into another compact state without having to get licensed in the remote state. It will also allow psychologists in a compact state with an IPC (interjurisdiction practice certificate) to physically go into another state to provide temporary in person, face-to-face psychological services without having to get licensed in that state. Individual psychologists in any compact state would apply for an E.Passport and/or IPC as a prerequisite to being able to practice under the authority of this compact. PSYPACT will vet all psychologists who apply for the E.Passport and/or IPC to make sure they have the requisite education, training, experience and do not have prior discipline, child abuse or criminal history.
PSYPACT will have the effect of increasing access to care for patients, increasing continuity of treatment if a patient moves out of state, decreasing licensure barriers for psychologists to practice, while ensuring the public is protected. Where there are conflicts of law between states (i.e., duty to warn laws), PSYPACT will help ensure both the psychologist and the patient will understand which laws govern the psychological interaction. To date, seven states (Arizona, Utah, Nevada, Colorado, Nebraska, Missouri, and Illinois) have adopted PSYPACT. So far in the 2019 legislative session, North Dakota (NDHB 1343), New Mexico (NMSB 141), New Hampshire (NHHB 484) and Georgia (GAHB 26) have all introduced PSYPACT legislation. We are anticipating that the District of Columbia and Pennsylvania will introduce legislation soon. In Texas, PSYPACT is part of the Texas sunset legislation which will hopefully be introduced in the near future. Psychologists in the above states are encouraged to contact their legislators to support PSYPACT legislation. ASPPB has heard from several other states which have expressed an interest in pursuing PSYPACT legislation. For more information, please contact Alex Siegel at asiegel@asppb.org). The words of Steve Ragusea should be taken to heart by those who wish to ignore the changing healthcare environment: "Based on inflation, the amount I get paid through most third party payers today is one third less than I was getting in 1980."
APA's Vision for the Future: "I recently attended the first meeting of APA's inaugural Advocacy Coordinating Committee as the sole student among fourteen members led by exceptional co-chairs former APA President Tony Puente and former APA Recording Secretary Jennifer Kelly. We received in-person support from another former President Jessica Daniel, President Rosie Bingham, and President-elect Sandy Shullman. Having the recent, current, and future APA Presidential trio in the room was inspiring. CEO Arthur Evans and Deputy CEO Jim Diaz-Granados spoke at the meeting, several key staff sat alongside us for the entire two days, and the Board of Directors joined us for dinner following the first day of the meeting. I was particularly pleased to learn the recommendations of Bob Frank who has served as a Robert Wood Johnson Fellow and President of the University of New Mexico.
"Joining this committee is my next step following what seems like years of involvement with APA Divisions, including serving as an APAGS Board representative and convention programming co-chair for Division 55. By sharing my experiences and perspective, I hope to help others see the value of student involvement in advocacy and for students to see a path to leadership roles. Visionary leader Ron Fox once said that as beneficiaries of the shared resources of higher education, we have an ethical obligation to engage in advocacy. The goal of this advocacy, as outlined in the mission statement in APA's newly drafted strategic plan, is 'to benefit society and improve lives.' The Committee is key to advancing APA towards fulfilling this mission (Joanna Sells, graduate student Uniformed Services University)." Aloha,
Pat DeLeon, former APA President – Division 42 – February, 2019
Sent from my iPhone
Wednesday, February 20, 2019
Tuesday, February 19, 2019
ALOHA - D42 column
WITH THE WHITE HOUSE EMBRACING HEALTHCARE TECHNOLOGY
At the end of last year, the White House released a report entitled Reforming America’s Healthcare System Through Choice and Competition, authored by the Secretaries of the Departments of Health and Human Services, Treasury, and Labor. “As health care spending continues to rise, Americans are not receiving the commensurate benefit of living longer, healthier lives. Health care bills are too complex, choices are too restrained, and the insurance premiums and out-of-pocket costs are climbing faster than wages and tax revenue. Health care markets could work more efficiently and Americans could receive more effective, high-value care if we remove and revise certain federal and state regulations and policies that inhibit choice and competition…. Reduced competition among clinicians leads to higher prices for health care services, reduces choice, and negatively impacts overall health care quality and the efficient allocation of resources. Government policies have suppressed competition by reducing the available supply of providers and restricting the range of services that they can offer. This report recommends policies that will broaden providers’ scope of practice [SOP] while improving workforce mobility, including telehealth, to encourage innovation and to allow providers more easily to meet patients’ needs.”
Several salient conclusions include that government rules restrict competition if they keep healthcare providers from practicing to the “top of their license” – i.e., to the full extent of their abilities; given their education, training, skills, and experience -- consistent with the relevant standards of care. This includes restrictions on the appropriate use of telehealth technologies and the range of services providers can provide. Oftentimes, SOP restrictions limit provider entry and ability to practice in ways that do not address demonstrable or substantial risks to consumer health and safety. Further, there is a risk that healthcare professionals with overlapping skill sets will seek these restrictions as they view SOP restrictions as an easy, state-sanctioned opportunity to insulate themselves from competition. For example, the report found that Advanced Practice Registered Nurses, Physician Assistants, Pharmacists, Optometrists, and Dental Hygienists can safely and effectively provide some of the same services as physicians, in addition to providing complementary services, citing the Institute of Medicine (IOM) and the Federal Trade Commission (FTC). Interestingly, this extends to physician supervision and collaborative practice regulations, which can be unreasonably restrictive. One specific recommendation: “States should consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their license, utilizing their full skill set.”
The report further addressed the related issues of licensure mobility and telehealth; both of which are highly relevant to psychology’s practitioners and their vision for the future. State-based licensing requirements, by definition, inhibit provider mobility and often inhibit delivery of services across state lines by making it more difficult for qualified practitioners, who are licensed in one state to work in another state, even though most complete nationally certified education and training programs and sit for national qualifying exams. Appropriate standards of care do not differ from state to state; yet, the process of obtaining a license in another state is often slow, burdensome, and costly. There is little economic justification for this and it can inhibit the efficient development and use of telehealth, as well as in-person services. The report further noted that Interstate Compacts and model laws can mitigate the effects of state-licensing requirements. The compact approach has only recently been proposed, with nursing enacting the first in 1999.
Telehealth is described as a significant innovation in healthcare services with mental health highlighted as an example of its usefulness. It increases the virtual supply of providers and extends their reach to new locations, promoting beneficial competition, reducing transportation expenses, and improving access to quality care and long-term quality outcomes. Nevertheless, a variety of regulatory barriers keep telehealth from reaching its full potential. Two specific recommendations: States should consider adopting licensure compacts or model laws that improve licensure mobility by allowing healthcare providers to more easily practice in multiple states, thereby creating additional opportunities for telehealth practice. And, States generally should consider allowing individual providers and payers to mutually determine whether and when it is safe and appropriate to provide telehealth services, including where there has not been a prior person-to-person visit.
For psychology, the key to the future is the vision of Steve DeMers, retired CEO, Mariann Burnetti-Atwell, current CEO, and the Board of the Association of State and Provincial Psychology Boards (ASPPB). In 2015, ASPPB developed, with input from all major psychology stakeholders and some consumer organizations, and then approved PSYPACT (Psychology Interjurisdictional Compact) to provide for the legal and ethical practice of psychology across jurisdictions. PSYPACT will allow psychologists with an E.Passport certificate from a compact state to electronically provide psychological services into another compact state without having to get licensed in the remote state. It will also allow psychologists in a compact state with an IPC (interjurisdiction practice certificate) to physically go into another state to provide temporary in person, face-to-face psychological services without having to get licensed in that state. Individual psychologists in any compact state would apply for an E.Passport and/or IPC as a prerequisite to being able to practice under the authority of this compact. PSYPACT will vet all psychologists who apply for the E.Passport and/or IPC to make sure they have the requisite education, training, experience and do not have prior discipline, child abuse or criminal history.
PSYPACT will have the effect of increasing access to care for patients, increasing continuity of treatment if a patient moves out of state, decreasing licensure barriers for psychologists to practice, while ensuring the public is protected. Where there are conflicts of law between states (i.e., duty to warn laws), PSYPACT will help ensure both the psychologist and the patient will understand which laws govern the psychological interaction. To date, seven states (Arizona, Utah, Nevada, Colorado, Nebraska, Missouri, and Illinois) have adopted PSYPACT. So far in the 2019 legislative session, North Dakota (NDHB 1343), New Mexico (NMSB 141), New Hampshire (NHHB 484) and Georgia (GAHB 26) have all introduced PSYPACT legislation. We are anticipating that the District of Columbia and Pennsylvania will introduce legislation soon. In Texas, PSYPACT is part of the Texas sunset legislation which will hopefully be introduced in the near future. Psychologists in the above states are encouraged to contact their legislators to support PSYPACT legislation. ASPPB has heard from several other states which have expressed an interest in pursuing PSYPACT legislation. For more information, please contact Alex Siegel at asiegel@asppb.org). The words of Steve Ragusea should be taken to heart by those who wish to ignore the changing healthcare environment: “Based on inflation, the amount I get paid through most third party payers today is one third less than I was getting in 1980.”
APA’s Vision for the Future: “I recently attended the first meeting of APA’s inaugural Advocacy Coordinating Committee as the sole student among fourteen members led by exceptional co-chairs former APA President Tony Puente and former APA Recording Secretary Jennifer Kelly. We received in-person support from another former President Jessica Daniel, President Rosie Bingham, and President-elect Sandy Shullman. Having the recent, current, and future APA Presidential trio in the room was inspiring. CEO Arthur Evans and Deputy CEO Jim Diaz-Granados spoke at the meeting, several key staff sat alongside us for the entire two days, and the Board of Directors joined us for dinner following the first day of the meeting. I was particularly pleased to learn the recommendations of Bob Frank who has served as a Robert Wood Johnson Fellow and President of the University of New Mexico.
“Joining this committee is my next step following what seems like years of involvement with APA Divisions, including serving as an APAGS Board representative and convention programming co-chair for Division 55. By sharing my experiences and perspective, I hope to help others see the value of student involvement in advocacy and for students to see a path to leadership roles. Visionary leader Ron Fox once said that as beneficiaries of the shared resources of higher education, we have an ethical obligation to engage in advocacy. The goal of this advocacy, as outlined in the mission statement in APA’s newly drafted strategic plan, is ‘to benefit society and improve lives.’ The Committee is key to advancing APA towards fulfilling this mission (Joanna Sells, graduate student Uniformed Services University).” Aloha,
Pat DeLeon, former APA President – Division 42 – February, 2019
Thursday, February 7, 2019
COME GATHER ‘ROUND PEOPLE WHERE EVER YOU ROAM
Colleagues with Exceptional Vision: One of the advantages of being personally involved within the governance of APA, at either the national or state level, is that, over time, one becomes exposed to the wide range of professional issues which each of the nation's health care professions must eventually address. The recent announcement by Walmart, for example, that they were establishing a mental health clinic within one of their Texas facilities is reminiscent of the intensive discussions within optometry and ophthalmology when it was becoming increasingly evident that consumers would soon be able to obtain their eye examinations and purchase glasses at major shopping malls, rather than having to rely upon visits to "mom and pop" eye specialists. Those concerned about the change frequently presented a "public health hazard" allegation; that is, that the quality of care would be compromised, as if the locus of care was a significant issue. Others, including the Federal Trade Commission (FTC), raised the underlying issue of potential "restraint of trade." Today, consumers have considerable choice in deciding where and by whom they wish to receive their eye care.
Russell Petrella, a long-time colleague and APA member, is President and CEO of Beacon Health Options, a Boston-based behavioral health services company which is running the Walmart clinic. Consumers will be able to walk in, call, or make an appointment online to see a licensed mental health professional about daily problems in living; such as anxiety, depression, grief, social and family relationships, and stress. On-site clinicians will provide assessments and develop mutually agreed upon treatment plans. Russ: "Our goal is to increase access, reduce stigma and mainstream behavioral health services." We would rhetorically ask: If psychology is serious about addressing the adverse consequences of the historical stigma surrounding receiving mental health care -- What better way than to normalize behavioral health services, as is the case today with eye and dental care?
This fall I had the opportunity to attend the 127th annual meeting of AMSUS (The Society of Federal Health Professionals); titled The Future of Healthcare is Now. One of the most intriguing presentations addressed the enthusiastic embracement of telehealth by the Department of Veterans Affairs (VA). Their 2018 data noted approximately 2.29+ million episodes of care via telehealth, which were received by more than 782,000 Veterans at 900 sites of care. There was a reported satisfaction rate of 88-90% with slightly less than one percent receiving care in their home or at a non-VA location. This latter finding is expected to significantly increase in the coming year, pursuant to recently enacted expansive legislation.
Earlier this year, The Psychology Times focused upon the efforts of Tiffany Jennings who is the Louisiana Psychological Association (LPA) Rural Health Coordinator for APA and the Chair of the LPA Rural and TeleHealth Services Committee. One of her goals is to: "Develop an ongoing community where those in rural areas, or who serve rural populations, can collaborate with each other…. Telemedicine has been gaining more ground in treatment, particularly for those in rural areas where treatment services may be limited, or non-existent. University Health in Shreveport was highlighted in the local media highlighting the advantages of telemedicine – such as cost, reduced transportation burden – and that telemedicine can be as effective as traditional in-person treatment."
Within both the VA and the Department of Defense (DOD), mental health specialists have been particularly supportive of utilizing this ever-improving technology. Ray Folen, former Chief of the Department of Psychology at Tripler Army Medical Center (TAMC) in Honolulu and now Executive Director of the Hawaii Psychological Association (HPA), has been providing telehealth services since the mid-1990's. "As a U.S. Army tertiary care facility in the middle of the Pacific, we were responsible for providing health care in a catchment area that covered 50 percent of the earth's surface, most of it water. Telehealth was not just an option for us, it was an absolute necessity. In many situations it was the only way we could get behavioral health services to our servicemen and their families located in remote Pacific areas. In the beginning, the only viable 'teleconferencing' tools available were videophones, which had less than one percent of the '4G' bandwidth we have now. The technology was challenging but it worked and, over time, the bandwidth, infrastructure and equipment improved as did our skills and understanding of distance therapy. By 2015, we had ten full-time and many part-time tele-psychologists providing needed services to thousands of service members and their families located throughout the Pacific, Asia and the continental U.S.
"The technology and infrastructure are now readily available, treatment outcomes are reported to be equivalent to face-to-face therapy (our data found, in some instances, that telehealth was superior to face-to-face), insurance companies are now reimbursing for telehealth services, many state and federal telehealth regulations have been written, state interjurisdictional agreements are being established, and safety and liability issues are being addressed. Patient satisfaction with telehealth is high and it provides access to care that patients located in remote areas, or who are home bound, would not otherwise receive. Why, then, are more of our colleagues not embracing this technology and receiving the appropriate and necessary training?"
Marlene Maheu has long been on the cutting-edge of psychology's gradual evolution towards effectively utilizing telehealth technology. "Despite the promise of technology for increasing access, reducing overhead costs and delivering higher quality assessment/care, many psychologists are unaware of the legal and ethical issues needed for telepsychology. To shed light on this inconsistency, we have now published two studies of psychologists' attitudes and beliefs related to telepsychology. In our 2000 study, only approximately one third of the respondents surveyed reported awareness of laws of relevance to behavioral telehealth or online counseling, as it was called at the time. In our 2017 study, the number of clinicians who believed that current laws are relevant to telehealth increased to two thirds. In other words, approximately one third of psychologists still believe that current laws did not apply to telehealth.
"The problem is that they are incorrect. All current state law and ethical codes apply to telepsychology, whether or not the state has interpreted existing regulations for the use of technology it then falls on the clinician to know how issues such as privacy and confidentiality apply to video conferencing, suggesting apps, posting on Facebook, practicing over state lines, billing through PayPal, and/or using artificial intelligence in practice management.
"Our research also showed that willingness to use technology in the clinical arena varied with age of the respondent. Not too surprisingly, psychologists who were 65+ years old (digital immigrants) were the least likely to use technology in their practices. However, psychologists in the youngest subgroup of survey respondents were the next least likely group to use technology. The reluctance of younger psychologists (digital natives) to adopt technology for clinical services seems counterintuitive; except when one considers the origins of telehealth. As a grassroots effort that started with clinicians creatively seeking solutions for clients/patients who couldn't access needed care, the cauldron for forging telehealth practice was not the laboratory or university. Rather, it was in the heart of the clinician trying to assist a Hawaiian islander who couldn't find help for her ADHD child, it was with psychologists serving the rural farmer who realized that his son suicided. Telehealth was borne of the creative powers of the clinicians who sat with prisoners convicted to life sentences in the midst of undiagnosed and untreated bipolar disorder. Given the grassroots origins of telehealth, one factor contributing to the slow adoption rate found in our survey was hypothesized as being as being related to slow faculty acceptance of telehealth. Although few studies have reported on faculty adoption related to telepsychology, a poster paper presentation we saw back in 2013 showed very slow internship adoption rates for telehealth. Another factor explaining the low adoption rate of telehealth technologies by the younger psychologists may be the tendency for these psychologists to start their careers by working for established groups rather than in private practice, where fewer authorities need to approve service delivery mechanisms.
"As faculty members and internship directors become more acquainted with the evidence-base in support of telepsychology, graduates may learn more about the strong evidence base and be inspired to seek placements and employment in more telehealth-supportive environments. The immediate need for graduate school training as well as professional certification is evident. Of particular concern when looking at the need for professional telepsychology training is the growing number of licensed professionals who choose to work for online employers, many of whom fail to offer technological processes for complying with basic legal and ethical mandates." For those interested in pursuing these issues and especially their ramifications for training and practice, we would suggest attending various presentations Marlene will be making at our annual APA conventions.
Over the years, we have come to especially appreciate the contributions of those involved with the Association of State and Provincial Psychology Boards (ASPPB). ASPPB recently reported that by the end of 2018: "Seven states (Arizona, Utah, Nevada, Nebraska, Colorado, Missouri, and Illinois) had adopted the Psychology Interjurisdictional Compact (PSYPACT). PSYPACT will allow those psychologists who possess an E.Passport as part of PSYPACT to provide electronic services across state lines into another compact state without having to be licensed in that state. For the 2019 legislative session, North Dakota has introduced legislation (NDHB 1343) and New Hampshire and New Mexico have prefiled PSYPACT legislation. We are anticipating that Georgia, Pennsylvania, and the District of Columbia will follow and introduce a PSYPACT bill. In Texas, PSYPACT is part of the Texas sunset legislation which will hopefully be introduced in the near future. In addition, ASPPB has heard from several other states which have expressed an interest in pursuing PSYPACT legislation (Alex Siegel, asiegel@asppb.org)."
The Maturing Psychopharmacology (RxP) Agenda: Steve and Anthony Ragusea: "For the last five years, the Florida Psychological Association (FPA) has been quietly pursuing RxP legislation. Our RxP committee has diligently done its groundwork, consulting with membership, lobbyists, gathering letters of support, and meeting with our legislators. It has been exciting to watch our legislative efforts make gradual but definitely steady progress over time. As with all such legislation, the path to success is often slow and uneven as things move forward step by step. But, we have been relentless in keeping our eyes on the prize of securing RxP for Florida psychologists and the patients we serve.
"We now have two primary sponsors; Representative Cary Pigman has been our House sponsor for over a year. Rep. Pigman is a board-certified emergency room physician with military experience who, in the past, has successfully increased scope of practice for other health professions. He understands the need for psychologists who can safely prescribe psychoactive medications and he has already been of enormous assistance. He has not yet submitted his bills for the current legislative session, but he will soon do so and he has assured us our legislation will be included in his submission. In addition, we now have a Senate sponsor in Senator Jeff Brandes! We're very excited to have him representing our bill, which has already been introduced in the Senate as SB304. Senator Brandes has just publicly announced that, 'Florida is facing a mental-health epidemic. Five States and the U.S. Military allow certain psychologists to prescribe once they receive specialized training. Expanding scope of practice must be an option as we seek to address this crisis.' We are grateful to both Senator Brandes and Representative Pigman for their enthusiastic support. We even were featured on National Public Radio (NPR). Soon, we expect the usual stale, ancient arguments to emerge from organized medicine that have been tried for over half a century. Despite the fact that they always eventually fail, organized medicine always insists on a fight. Things are about to get very interesting in Florida!" "For the times they are a'changin'!" Aloha, (Bob Dylan).
Pat DeLeon, former APA President – Division 29 – February, 2019
Russell Petrella, a long-time colleague and APA member, is President and CEO of Beacon Health Options, a Boston-based behavioral health services company which is running the Walmart clinic. Consumers will be able to walk in, call, or make an appointment online to see a licensed mental health professional about daily problems in living; such as anxiety, depression, grief, social and family relationships, and stress. On-site clinicians will provide assessments and develop mutually agreed upon treatment plans. Russ: "Our goal is to increase access, reduce stigma and mainstream behavioral health services." We would rhetorically ask: If psychology is serious about addressing the adverse consequences of the historical stigma surrounding receiving mental health care -- What better way than to normalize behavioral health services, as is the case today with eye and dental care?
This fall I had the opportunity to attend the 127th annual meeting of AMSUS (The Society of Federal Health Professionals); titled The Future of Healthcare is Now. One of the most intriguing presentations addressed the enthusiastic embracement of telehealth by the Department of Veterans Affairs (VA). Their 2018 data noted approximately 2.29+ million episodes of care via telehealth, which were received by more than 782,000 Veterans at 900 sites of care. There was a reported satisfaction rate of 88-90% with slightly less than one percent receiving care in their home or at a non-VA location. This latter finding is expected to significantly increase in the coming year, pursuant to recently enacted expansive legislation.
Earlier this year, The Psychology Times focused upon the efforts of Tiffany Jennings who is the Louisiana Psychological Association (LPA) Rural Health Coordinator for APA and the Chair of the LPA Rural and TeleHealth Services Committee. One of her goals is to: "Develop an ongoing community where those in rural areas, or who serve rural populations, can collaborate with each other…. Telemedicine has been gaining more ground in treatment, particularly for those in rural areas where treatment services may be limited, or non-existent. University Health in Shreveport was highlighted in the local media highlighting the advantages of telemedicine – such as cost, reduced transportation burden – and that telemedicine can be as effective as traditional in-person treatment."
Within both the VA and the Department of Defense (DOD), mental health specialists have been particularly supportive of utilizing this ever-improving technology. Ray Folen, former Chief of the Department of Psychology at Tripler Army Medical Center (TAMC) in Honolulu and now Executive Director of the Hawaii Psychological Association (HPA), has been providing telehealth services since the mid-1990's. "As a U.S. Army tertiary care facility in the middle of the Pacific, we were responsible for providing health care in a catchment area that covered 50 percent of the earth's surface, most of it water. Telehealth was not just an option for us, it was an absolute necessity. In many situations it was the only way we could get behavioral health services to our servicemen and their families located in remote Pacific areas. In the beginning, the only viable 'teleconferencing' tools available were videophones, which had less than one percent of the '4G' bandwidth we have now. The technology was challenging but it worked and, over time, the bandwidth, infrastructure and equipment improved as did our skills and understanding of distance therapy. By 2015, we had ten full-time and many part-time tele-psychologists providing needed services to thousands of service members and their families located throughout the Pacific, Asia and the continental U.S.
"The technology and infrastructure are now readily available, treatment outcomes are reported to be equivalent to face-to-face therapy (our data found, in some instances, that telehealth was superior to face-to-face), insurance companies are now reimbursing for telehealth services, many state and federal telehealth regulations have been written, state interjurisdictional agreements are being established, and safety and liability issues are being addressed. Patient satisfaction with telehealth is high and it provides access to care that patients located in remote areas, or who are home bound, would not otherwise receive. Why, then, are more of our colleagues not embracing this technology and receiving the appropriate and necessary training?"
Marlene Maheu has long been on the cutting-edge of psychology's gradual evolution towards effectively utilizing telehealth technology. "Despite the promise of technology for increasing access, reducing overhead costs and delivering higher quality assessment/care, many psychologists are unaware of the legal and ethical issues needed for telepsychology. To shed light on this inconsistency, we have now published two studies of psychologists' attitudes and beliefs related to telepsychology. In our 2000 study, only approximately one third of the respondents surveyed reported awareness of laws of relevance to behavioral telehealth or online counseling, as it was called at the time. In our 2017 study, the number of clinicians who believed that current laws are relevant to telehealth increased to two thirds. In other words, approximately one third of psychologists still believe that current laws did not apply to telehealth.
"The problem is that they are incorrect. All current state law and ethical codes apply to telepsychology, whether or not the state has interpreted existing regulations for the use of technology it then falls on the clinician to know how issues such as privacy and confidentiality apply to video conferencing, suggesting apps, posting on Facebook, practicing over state lines, billing through PayPal, and/or using artificial intelligence in practice management.
"Our research also showed that willingness to use technology in the clinical arena varied with age of the respondent. Not too surprisingly, psychologists who were 65+ years old (digital immigrants) were the least likely to use technology in their practices. However, psychologists in the youngest subgroup of survey respondents were the next least likely group to use technology. The reluctance of younger psychologists (digital natives) to adopt technology for clinical services seems counterintuitive; except when one considers the origins of telehealth. As a grassroots effort that started with clinicians creatively seeking solutions for clients/patients who couldn't access needed care, the cauldron for forging telehealth practice was not the laboratory or university. Rather, it was in the heart of the clinician trying to assist a Hawaiian islander who couldn't find help for her ADHD child, it was with psychologists serving the rural farmer who realized that his son suicided. Telehealth was borne of the creative powers of the clinicians who sat with prisoners convicted to life sentences in the midst of undiagnosed and untreated bipolar disorder. Given the grassroots origins of telehealth, one factor contributing to the slow adoption rate found in our survey was hypothesized as being as being related to slow faculty acceptance of telehealth. Although few studies have reported on faculty adoption related to telepsychology, a poster paper presentation we saw back in 2013 showed very slow internship adoption rates for telehealth. Another factor explaining the low adoption rate of telehealth technologies by the younger psychologists may be the tendency for these psychologists to start their careers by working for established groups rather than in private practice, where fewer authorities need to approve service delivery mechanisms.
"As faculty members and internship directors become more acquainted with the evidence-base in support of telepsychology, graduates may learn more about the strong evidence base and be inspired to seek placements and employment in more telehealth-supportive environments. The immediate need for graduate school training as well as professional certification is evident. Of particular concern when looking at the need for professional telepsychology training is the growing number of licensed professionals who choose to work for online employers, many of whom fail to offer technological processes for complying with basic legal and ethical mandates." For those interested in pursuing these issues and especially their ramifications for training and practice, we would suggest attending various presentations Marlene will be making at our annual APA conventions.
Over the years, we have come to especially appreciate the contributions of those involved with the Association of State and Provincial Psychology Boards (ASPPB). ASPPB recently reported that by the end of 2018: "Seven states (Arizona, Utah, Nevada, Nebraska, Colorado, Missouri, and Illinois) had adopted the Psychology Interjurisdictional Compact (PSYPACT). PSYPACT will allow those psychologists who possess an E.Passport as part of PSYPACT to provide electronic services across state lines into another compact state without having to be licensed in that state. For the 2019 legislative session, North Dakota has introduced legislation (NDHB 1343) and New Hampshire and New Mexico have prefiled PSYPACT legislation. We are anticipating that Georgia, Pennsylvania, and the District of Columbia will follow and introduce a PSYPACT bill. In Texas, PSYPACT is part of the Texas sunset legislation which will hopefully be introduced in the near future. In addition, ASPPB has heard from several other states which have expressed an interest in pursuing PSYPACT legislation (Alex Siegel, asiegel@asppb.org)."
The Maturing Psychopharmacology (RxP) Agenda: Steve and Anthony Ragusea: "For the last five years, the Florida Psychological Association (FPA) has been quietly pursuing RxP legislation. Our RxP committee has diligently done its groundwork, consulting with membership, lobbyists, gathering letters of support, and meeting with our legislators. It has been exciting to watch our legislative efforts make gradual but definitely steady progress over time. As with all such legislation, the path to success is often slow and uneven as things move forward step by step. But, we have been relentless in keeping our eyes on the prize of securing RxP for Florida psychologists and the patients we serve.
"We now have two primary sponsors; Representative Cary Pigman has been our House sponsor for over a year. Rep. Pigman is a board-certified emergency room physician with military experience who, in the past, has successfully increased scope of practice for other health professions. He understands the need for psychologists who can safely prescribe psychoactive medications and he has already been of enormous assistance. He has not yet submitted his bills for the current legislative session, but he will soon do so and he has assured us our legislation will be included in his submission. In addition, we now have a Senate sponsor in Senator Jeff Brandes! We're very excited to have him representing our bill, which has already been introduced in the Senate as SB304. Senator Brandes has just publicly announced that, 'Florida is facing a mental-health epidemic. Five States and the U.S. Military allow certain psychologists to prescribe once they receive specialized training. Expanding scope of practice must be an option as we seek to address this crisis.' We are grateful to both Senator Brandes and Representative Pigman for their enthusiastic support. We even were featured on National Public Radio (NPR). Soon, we expect the usual stale, ancient arguments to emerge from organized medicine that have been tried for over half a century. Despite the fact that they always eventually fail, organized medicine always insists on a fight. Things are about to get very interesting in Florida!" "For the times they are a'changin'!" Aloha, (Bob Dylan).
Pat DeLeon, former APA President – Division 29 – February, 2019
Wednesday, February 6, 2019
Division 29 February coolumn
“COME GATHER ‘ROUND PEOPLE WHERE EVER YOU ROAM”
Colleagues with Exceptional Vision: One of the advantages of being personally involved within the governance of APA, at either the national or state level, is that, over time, one becomes exposed to the wide range of professional issues which each of the nation’s health care professions must eventually address. The recent announcement by Walmart, for example, that they were establishing a mental health clinic within one of their Texas facilities is reminiscent of the intensive discussions within optometry and ophthalmology when it was becoming increasingly evident that consumers would soon be able to obtain their eye examinations and purchase glasses at major shopping malls, rather than having to rely upon visits to “mom and pop” eye specialists. Those concerned about the change frequently presented a “public health hazard” allegation; that is, that the quality of care would be compromised, as if the locus of care was a significant issue. Others, including the Federal Trade Commission (FTC), raised the underlying issue of potential “restraint of trade.” Today, consumers have considerable choice in deciding where and by whom they wish to receive their eye care.
Russell Petrella, a long-time colleague and APA member, is President and CEO of Beacon Health Options, a Boston-based behavioral health services company which is running the Walmart clinic. Consumers will be able to walk in, call, or make an appointment online to see a licensed mental health professional about daily problems in living; such as anxiety, depression, grief, social and family relationships, and stress. On-site clinicians will provide assessments and develop mutually agreed upon treatment plans. Russ: “Our goal is to increase access, reduce stigma and mainstream behavioral health services.” We would rhetorically ask: If psychology is serious about addressing the adverse consequences of the historical stigma surrounding receiving mental health care -- What better way than to normalize behavioral health services, as is the case today with eye and dental care?
This fall I had the opportunity to attend the 127th annual meeting of AMSUS (The Society of Federal Health Professionals); titled The Future of Healthcare is Now. One of the most intriguing presentations addressed the enthusiastic embracement of telehealth by the Department of Veterans Affairs (VA). Their 2018 data noted approximately 2.29+ million episodes of care via telehealth, which were received by more than 782,000 Veterans at 900 sites of care. There was a reported satisfaction rate of 88-90% with slightly less than one percent receiving care in their home or at a non-VA location. This latter finding is expected to significantly increase in the coming year, pursuant to recently enacted expansive legislation.
Earlier this year, The Psychology Times focused upon the efforts of Tiffany Jennings who is the Louisiana Psychological Association (LPA) Rural Health Coordinator for APA and the Chair of the LPA Rural and TeleHealth Services Committee. One of her goals is to: “Develop an ongoing community where those in rural areas, or who serve rural populations, can collaborate with each other…. Telemedicine has been gaining more ground in treatment, particularly for those in rural areas where treatment services may be limited, or non-existent. University Health in Shreveport was highlighted in the local media highlighting the advantages of telemedicine – such as cost, reduced transportation burden – and that telemedicine can be as effective as traditional in-person treatment.”
Within both the VA and the Department of Defense (DOD), mental health specialists have been particularly supportive of utilizing this ever-improving technology. Ray Folen, former Chief of the Department of Psychology at Tripler Army Medical Center (TAMC) in Honolulu and now Executive Director of the Hawaii Psychological Association (HPA), has been providing telehealth services since the mid-1990’s. “As a U.S. Army tertiary care facility in the middle of the Pacific, we were responsible for providing health care in a catchment area that covered 50 percent of the earth’s surface, most of it water. Telehealth was not just an option for us, it was an absolute necessity. In many situations it was the only way we could get behavioral health services to our servicemen and their families located in remote Pacific areas. In the beginning, the only viable ‘teleconferencing’ tools available were videophones, which had less than one percent of the ‘4G’ bandwidth we have now. The technology was challenging but it worked and, over time, the bandwidth, infrastructure and equipment improved as did our skills and understanding of distance therapy. By 2015, we had ten full-time and many part-time tele-psychologists providing needed services to thousands of service members and their families located throughout the Pacific, Asia and the continental U.S.
“The technology and infrastructure are now readily available, treatment outcomes are reported to be equivalent to face-to-face therapy (our data found, in some instances, that telehealth was superior to face-to-face), insurance companies are now reimbursing for telehealth services, many state and federal telehealth regulations have been written, state interjurisdictional agreements are being established, and safety and liability issues are being addressed. Patient satisfaction with telehealth is high and it provides access to care that patients located in remote areas, or who are home bound, would not otherwise receive. Why, then, are more of our colleagues not embracing this technology and receiving the appropriate and necessary training?”
Marlene Maheu has long been on the cutting-edge of psychology’s gradual evolution towards effectively utilizing telehealth technology. “Despite the promise of technology for increasing access, reducing overhead costs and delivering higher quality assessment/care, many psychologists are unaware of the legal and ethical issues needed for telepsychology. To shed light on this inconsistency, we have now published two studies of psychologists’ attitudes and beliefs related to telepsychology. In our 2000 study, only approximately one third of the respondents surveyed reported awareness of laws of relevance to behavioral telehealth or online counseling, as it was called at the time. In our 2017 study, the number of clinicians who believed that current laws are relevant to telehealth increased to two thirds. In other words, approximately one third of psychologists still believe that current laws did not apply to telehealth.
“The problem is that they are incorrect. All current state law and ethical codes apply to telepsychology, whether or not the state has interpreted existing regulations for the use of technology it then falls on the clinician to know how issues such as privacy and confidentiality apply to video conferencing, suggesting apps, posting on Facebook, practicing over state lines, billing through PayPal, and/or using artificial intelligence in practice management.
“Our research also showed that willingness to use technology in the clinical arena varied with age of the respondent. Not too surprisingly, psychologists who were 65+ years old (digital immigrants) were the least likely to use technology in their practices. However, psychologists in the youngest subgroup of survey respondents were the next least likely group to use technology. The reluctance of younger psychologists (digital natives) to adopt technology for clinical services seems counterintuitive; except when one considers the origins of telehealth. As a grassroots effort that started with clinicians creatively seeking solutions for clients/patients who couldn’t access needed care, the cauldron for forging telehealth practice was not the laboratory or university. Rather, it was in the heart of the clinician trying to assist a Hawaiian islander who couldn’t find help for her ADHD child, it was with psychologists serving the rural farmer who realized that his son suicided. Telehealth was borne of the creative powers of the clinicians who sat with prisoners convicted to life sentences in the midst of undiagnosed and untreated bipolar disorder. Given the grassroots origins of telehealth, one factor contributing to the slow adoption rate found in our survey was hypothesized as being as being related to slow faculty acceptance of telehealth. Although few studies have reported on faculty adoption related to telepsychology, a poster paper presentation we saw back in 2013 showed very slow internship adoption rates for telehealth. Another factor explaining the low adoption rate of telehealth technologies by the younger psychologists may be the tendency for these psychologists to start their careers by working for established groups rather than in private practice, where fewer authorities need to approve service delivery mechanisms.
“As faculty members and internship directors become more acquainted with the evidence-base in support of telepsychology, graduates may learn more about the strong evidence base and be inspired to seek placements and employment in more telehealth-supportive environments. The immediate need for graduate school training as well as professional certification is evident. Of particular concern when looking at the need for professional telepsychology training is the growing number of licensed professionals who choose to work for online employers, many of whom fail to offer technological processes for complying with basic legal and ethical mandates.” For those interested in pursuing these issues and especially their ramifications for training and practice, we would suggest attending various presentations Marlene will be making at our annual APA conventions.
Over the years, we have come to especially appreciate the contributions of those involved with the Association of State and Provincial Psychology Boards (ASPPB). ASPPB recently reported that by the end of 2018: “Seven states (Arizona, Utah, Nevada, Nebraska, Colorado, Missouri, and Illinois) had adopted the Psychology Interjurisdictional Compact (PSYPACT). PSYPACT will allow those psychologists who possess an E.Passport as part of PSYPACT to provide electronic services across state lines into another compact state without having to be licensed in that state. For the 2019 legislative session, North Dakota has introduced legislation (NDHB 1343) and New Hampshire and New Mexico have prefiled PSYPACT legislation. We are anticipating that Georgia, Pennsylvania, and the District of Columbia will follow and introduce a PSYPACT bill. In Texas, PSYPACT is part of the Texas sunset legislation which will hopefully be introduced in the near future. In addition, ASPPB has heard from several other states which have expressed an interest in pursuing PSYPACT legislation (Alex Siegel, asiegel@asppb.org).”
The Maturing Psychopharmacology (RxP) Agenda: Steve and Anthony Ragusea: “For the last five years, the Florida Psychological Association (FPA) has been quietly pursuing RxP legislation. Our RxP committee has diligently done its groundwork, consulting with membership, lobbyists, gathering letters of support, and meeting with our legislators. It has been exciting to watch our legislative efforts make gradual but definitely steady progress over time. As with all such legislation, the path to success is often slow and uneven as things move forward step by step. But, we have been relentless in keeping our eyes on the prize of securing RxP for Florida psychologists and the patients we serve.
“We now have two primary sponsors; Representative Cary Pigman has been our House sponsor for over a year. Rep. Pigman is a board-certified emergency room physician with military experience who, in the past, has successfully increased scope of practice for other health professions. He understands the need for psychologists who can safely prescribe psychoactive medications and he has already been of enormous assistance. He has not yet submitted his bills for the current legislative session, but he will soon do so and he has assured us our legislation will be included in his submission. In addition, we now have a Senate sponsor in Senator Jeff Brandes! We’re very excited to have him representing our bill, which has already been introduced in the Senate as SB304. Senator Brandes has just publicly announced that, ‘Florida is facing a mental-health epidemic. Five States and the U.S. Military allow certain psychologists to prescribe once they receive specialized training. Expanding scope of practice must be an option as we seek to address this crisis.’ We are grateful to both Senator Brandes and Representative Pigman for their enthusiastic support. We even were featured on National Public Radio (NPR). Soon, we expect the usual stale, ancient arguments to emerge from organized medicine that have been tried for over half a century. Despite the fact that they always eventually fail, organized medicine always insists on a fight. Things are about to get very interesting in Florida!” “For the times they are a’changin’!” Aloha, (Bob Dylan).
Pat DeLeon, former APA President – Division 29 – February, 2019
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