EXCITING OPPORTUNITES FOR THOSE WITH VISION

    During my tenure on Capitol Hill, one of the most interesting federal agencies, often overlooked by psychology, was the Centers for Disease Control and Prevention (CDC).  What psychology brings to society's most pressing needs often falls within its jurisdiction.  When Rodney Hammond was there, the Director proffered that: "child maltreatment is a serious public health problem with extensive short- and long-term health consequences.  Abused children often suffer physical injuries, including cuts, bruises, burns, and broken bones.  In addition, maltreatment causes stress that can disrupt early brain development, and extreme stress can harm the development of the nervous and immune systems.  As a result, children who are abused or neglected are at higher risk for health problems as adults, including alcoholism, depression, drug abuse, eating disorders, obesity, sexual promiscuity, smoking, suicide, and certain chronic disorders.  Fortunately, there is a growing body of evidence that documents the effectiveness of primary prevention strategies….  (I)ntegrating behavioral health approaches into primary care systems can be an important component of health reform (10/23/09)."

            The CDC Fiscal Year 2014 budget highlights several behavioral and psychological initiatives which should be of considerable interest to our state associations (SPAs).  CDC has a long history of working closely with public and private agencies to explore mutually shared programmatic interests.  Why not with SPAs?  This year, for example, in response the nation's epidemic of obesity: "CDC is currently in the process of collaborating with national groups, and in FY 13 entered into a Memorandum of Understanding (MOU) with the Culinary Institute of America to educate volume food service leaders on strategies to increase the number of healthy and tasty menu options for children and adults."  Addressing the issue of falls among older adults, CDC uses: "the public health model and focusing on primary prevention, CDC uses the best available scientific data to identify effective fall interventions and to determine the optimal strategies to promote widespread adoption of proven programs.  CDC develops, disseminates, and supports proven strategies that prevent older adult falls.  This is done through research, capacity building, dissemination, and implementation of evidence-based programs, and by developing resources to help healthcare providers incorporate fall prevention into clinical care."  Both of these priorities are fundamentally behavioral.

            "CDC's mission, simply put, is to keep Americans safe and healthy where they work, live, and play.  Our scientists and disease detectives work around the world to put proven prevention strategies to work, track diseases, research outbreaks, and respond to emergencies of all kinds.  CDC works with partners around the country and world… preventing the leading causes of disease, disability, and death."  The range of behavioral issues CDC addresses is impressive: gun violence, rape prevention and education, smoking, community transformation, racial and ethnic approaches to community health, preventing motor vehicle crashes, AIDS/HIV, teen pregnancy, Alzheimer's disease, and promoting breastfeeding to new mothers.  Focusing upon its success in addressing chronic diseases, which are the leading causes of death and disability in the nation, CDC notes the importance of environmental approaches to promote health and reinforce healthful behaviors.  Close to Rodney's heart, CDC described its enhanced capacity to collect child maltreatment mortality data and its efforts to engage parents, communities, and states in ensuring child well-being and preventing child maltreatment.  It's Core Violence and Injury Prevention Program provides support to states to prevent all forms of violence.

            SLC:  At this year's exciting State Leadership Conference (SLC), Katherine Nordal highlighted for the 500+ colleagues in attendance that: "The clock is ticking towards full implementation of the law [President Obama's Affordable Care Act (ACA)] andJanuary 1, 2014 is coming quickly.  ButJanuary 1^st is really just a mile maker in this marathon we call health care reform.  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us.  Many of our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  These are factors that create 'value-add' for psychologists on health care teams and in integrated, interdisciplinary systems of care.  No one else is fighting the battles for psychology… and don't expect them to."

            Hawaii:  Beth Giesting, Healthcare Transformation Coordinator for the State of Hawaii: "We were fortunate to get a State Innovations Planning grant.  Heading toward the half-way mark I can say we've made a lot of progress and learned a lot.  Among our lessons -- there's a lot of support in the health care community for this organized effort and general agreement on what needs to be done.  On the other hand, there is so much infrastructure that needs to be put in place, especially in HIT, before we can do a lot we need to do.  You won't be surprised to know that the most intractable problem that pops up everywhere concerns behavioral health – it is among the top issues for avoidable ER and inpatient use, a big unmet need for the VA, a major concern for the public safety system, in short supply and confusing of access for kids, adults, and the elderly.  Obviously, we need to do something about the behavioral health workforce shortages.  Also in our plan is trying to figure out ways to support expansion of FQCHCs and have them collaborate with the Native Hawaiian Health Centers to provide case management."  There are numerous opportunities for those with vision and who get involved.  Aloha,

 

Pat DeLeon, former APA President – Division31 – June, 2013

 

LEADING THE WAY IN UNCHARTERED WATERS

USUHS:  Since January, 2012 I have had the privilege of serving on the faculty of the Uniformed Services University of the Health Sciences (USUHS) and have been very impressed by the professionalism and dedication of the graduate students and faculty in nursing and psychology.  The Psychology Department hosts a weekly seminar exposing the broader university community to a wide range of behavioral expertise.  Steven Brewer's report: "Combat and Behavioral Health – The USUHS Medical and Clinical Psychology Department provided another informative seminar recently.  This time the topic was the behavioral health of soldiers and marines after a decade of combat.  The presenter was renowned military researcher Carl Castro, U.S. Army Colonel and the current director of the Military Operational Medicine Research Program at Fort Detrick, Maryland.  To provide perspective for his discussion, Col. Castro began by discussing the context of combat-related PTSD and how it differs from other types, perhaps due to the extensive training provided prior to deployment.  This prior training makes the traumatic event expected and not unanticipated.  The prior training may also allow reaction to occur 'automatically' and allow the person to not freeze.  The symptoms themselves may also be beneficial in the combat environment for survival of self and protection of others, especially when the environment will provide repeated exposure to the traumatic events, rather than a single instance.

            "The key points of Col. Castro's presentation were made through the Lessons Learned from a decade of combat.  The first Lesson Learned is 'Combat impacts the mental health and well-being of Soldiers and Marines.'  Service members in a Brigade Combat Team assessed at three months after returning from a year in Iraq had a three-fold increase of PTSD.  The risk increased proportionately with the increase of combat engagement and even perceived danger.  Even 12 months post-deployment saw a significant increase in angry and aggressive behaviors.  The second Lesson Learned is 'Not all Soldiers are at equal risk for mental health problems.'  The risk is greatest for those serving in direct combat, such as Infantry units, compared to those who serve in combat support (CS) or combat service support (CSS), such as Signal units.  While it is important to note that the CS and CSS service members do still see an increase in symptoms and mental health disorders during deployments, the risk increases directly with combat exposure.  Those who served in high combat were most likely to show symptoms of anxiety, depression, PTSD, and other mental health disorders.

            "The third Lesson Learned is 'Leadership is important for maintaining Soldier mental health.'  Soldiers with high perceptions of leadership were less likely to screen positive for a mental health problem compared to those with low perceptions of leadership.  In fact, the percentage of positive mental health problems was lower in High Combat/ High Leadership groups (17%) than it was in Low Combat/ Low Leadership groups (20%), indicating the importance of good leadership to mental health.  The fourth Lesson Learned is 'Mental health training works.'  For instance, Battlemind Training (BMT) is an evidence-based skill development model that uses examples relevant to service members, has a team focus, and builds on existing strengths.  Those who received BMT reported significantly fewer PTSD symptoms at three months post-deployment compared to those who received the standard stress education training.

            "The fifth Lesson Learned is 'Mental health 'resetting' following a year-long combat tour takes more than 12 months.'  Many units that deploy for 12 months are then authorized a 12-month 'dwell time' to reset before possibly deploying again.  However, the evidence shows that symptoms of depression, anxiety, and PTSD often increase over the 12-month period.  Service members have little time to deal with their mental health issues, as the dwell time includes many deployment related activities, including training and preparation for the next deployment.  The sixth Lesson Learned is 'Longer and multiple deployments are likely to lead to more mental health issues.'  Intuitively, it makes sense that symptoms do not get better by multiplying the trauma which caused the symptoms.  The evidence bears out this thought, for both 12- and 6-month deployments.  The last Lesson Learned is 'Every combat Soldier and Marine will face moral and ethical challenges.'  The combat arena is a difficult one for people to understand unless they have been there, and the decisions that must be made can be challenging to an individual's personal code of ethics.  The findings indicate Soldiers who screened positive for a mental health problem or who had high levels of anger were twice as likely to engage in unethical behavior on the battlefield compared to those Soldiers who screened negative or who had low levels of anger.  Soldiers with high levels of combat were more likely to engage in unethical behaviors than Soldiers with low levels of combat.

            "The next step is to use the Lessons Learned to improve the mental health of those who serve.  The primary means appears to be focusing on the junior leadership, including non-commissioned and commissioned officers.  We must also work on the recovery and return-to-duty both after and when mental health issues arise.  Relationship building among peers, mental health providers, and leaders is critical to improve the facilitation of mental health services.  Finally, the transition from the combat arena to home is difficult.  Some service members return to an active duty post; others, such as the Reservists, are transitioned to their civilian life with little time to make the conversion.  Families often suffer from confusion and a sense of helplessness when mental health symptoms appear.  As we move into the future, we must ensure we are providing the best care we can to those who have served 'in harm's way.'"

            "Retirement":  Prior to USUHS, I served with the late-U.S. Senator Daniel K. Inouye for 38+ years, retiring as his chief of staff.  One of the most interesting initiatives was the directive by the conferees on the Fiscal Year 1989 Appropriations bill that DoD establish a "demonstration pilot training project under which military psychologists may be trained and authorized to issue appropriate psychotropic medications under certain circumstances."  Morgan Sammons and John Sexton (both U.S. Navy) were the first to graduate from this program at the June 17, 1994 ceremony held at Walter Reed, attended by then APA President Bob Resnick.  These two trailblazing colleagues unequivocally demonstrated that psychologists can learn to safely and cost-effectively provide high quality psychopharmacological care.  Military psychologists should be proud of their historical accomplishment and now also affirmatively assist other colleagues in obtaining this important clinical responsibility within the VA, and throughout the civilian sector.

            The Civilian Sector:  During the past year significant progress has been made in two of our larger states.  In New Jersey, Bob McGrath reports: "The New Jersey RxP bill passed our Assembly on April 29, 2013 despite strong opposition from several of the medical societies.  Though they fielded five lobbyists on the day of the vote, they had no argument against the bill other than the usual claims that the training is insufficient and patients would be 'harmed,' without presenting a shred of data to support their position.  Next we move on to the Senate.  It's a remarkably expensive undertaking, and we can use any help we can get."

In Illinois, Beth Rom-Rymer: "We have had a remarkable 14 months.  On March 6, 2012, the Illinois State Senate Public Health Committee passed our RxP bill out of Committee by a vote of 6-4.  With our lobbyists, we made the critical decision to spend the next 12 months educating our psychologists and legislators around the state on RxP issues; training Illinois psychologists in becoming effective advocates for RxP; and reaching out to mental health associations, social service organizations, law enforcement agencies, hospitals, mental health centers, physician groups, etc. to educate about, and advocate for, RxP.  We have been very fortunate to work with strongly committed and dedicated legislative chief sponsors, including the Senate President ProTem Don Harmon.  On March 12, 2013, our RxP legislation passed out of the Senate Public Health Committee by the unanimous vote of 8-0 with one abstention.  On April 25th, we overwhelmingly passed out of the Senate by a vote of 37-10 with 4 abstentions.  On May 7th, our Senate bill was placed in the House Executive Committee.  Over the next several days, we were continually conferring with our lobbyists over the advisability of calling our bill.  We made the strategic decision that we wanted to take more time to work with our Representatives so that the vote would reflect an informed understanding of the issues.  We will be working very closely, over the next several months, with our legislators and all of our third party groups around the state.  We are very fortunate that although this legislative session has concluded on May 31st, we are in the first year of a two year sequence.  We are, therefore, able to build on all of our terrific accomplishments, to date, and focus on the House.  We are also in productive discussions with the Governor's Office.  We are looking toward achieving passage during our next legislative session in the spring of 2014."  From the littlest of Acorns, those with vision see mighty Oaks.  Aloha,

 

Pat DeLeon, former APA President – Division19 – June, 2013

THE RAPIDLY CHANGING HEALTH CARE ENVIRONMENT

As we begin to focus upon our forthcoming annual APA convention, to be held in Hawaii, we should reflect upon the challenge issued by Practice Directorate Executive Director Katherine Nordal at this year's exciting State Leadership Conference (SLC) to get personally involved in our state association's legislative efforts.  "The clock is ticking toward full implementation of the law [President Obama's landmark Patient Protection and Affordable Care Act (ACA)] and January 1, 2014 is coming quickly.  ButJanuary 1^st is really just a mile marker in this marathon we call health care reform.  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us.  The details of ACA implementation vary from state to state, and so do the key players….  I want to highlight an important new development within APA, the Center for Psychology and Health.  The Center includes a new Office of Health Care Financing, which will address challenges such as ongoing implementation of new psychotherapy billing codes and seeking new CPT (Current Procedural Terminology) codes that will adequately capture the work of psychologists in integrated care settings.  Dr. Randy Phelps is heading up this office….  Yes, the clock is ticking toward January 1, 2014.  But remember, we're not running a sprint.  Health care reform is a marathon – we're in it for the long haul.  New models of care and changes in health care financing won't take shape overnight.  We can't hope to finish the marathon called health care reform if we're not at the starting line.  Fortunately, many psychology leaders have embraced our call to action."  SLC and our annual conventions have always been the highlight of the psychology year for me – such collective energy, vision, and enthusiasm.  Katherine has a wonderful gift of vividly capturing the most critical agendas: This year, "Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  No one else is fighting the battles for psychology… and don't expect them to."  Last year, "If we're not at the table, it's because we're on the menu.  And I quite frankly don't want to be on anybody's plate to be eaten."

            Randy's Vision:  "APA launched its new Center for Psychology and Health under the direction of CEO Norman Anderson in January.  One component of that Center is a new Office of Health Care Financing (OHCF), which we are currently setting up and will be directed by me.  First, some background.  As Norman has indicated in a number of venues, the purpose of the new APA Center for Psychology and Health is to vigorously pursue Goal Two of APA's Strategic Plan: Expand psychology's role in advancing health.  The Center pulls together top leadership, staff, and major initiatives across all of APA to focus the association's efforts on four inter-related challenges outlined by Norman towards achieving this goal.  They are: 1) Workforce, education and training challenges; 2) Influencing how we are viewed by policy makers, the scientific community, other disciplines and the public; 3) Addressing how we view and define ourselves; and, 4) What Norman calls the 'getting included, getting paid' challenge.  There is, and has been, a tremendous amount of work by APA on each of these challenges, and we will keep the membership informed.

            "Specifically regarding the 'getting included, getting paid' challenge, hopefully you're aware of the ongoing advocacy by the APA Practice Organization to legislatively define psychologists as 'physicians' in Medicare, gain inclusion of psychologists in every state's Medicaid system, and legally challenge inappropriate insurance practices and parity violations.  The new OHCF was created to augment those efforts, and will work in close partnership with Katherine and APAPO, although it will be housed in APA's Executive Office.  Getting included as providers in all primary care and integrated care settings, playing a key role in inter-professional treatment teams, participating in Accountable Care Organizations (ACOs), etc., are all necessary, but not sufficient, steps to insuring our future.  For example, if you (or your institution) are not being reimbursed for your services in the existing fee-for-service (FFS) system or in the newer care delivery models, you are at risk of being replaced by those who are reimbursable, or by lower cost providers.

            "The AMA Strategy:  Our strategy is to directly target this issue in the most critical national venues where financing policies and mechanisms are translated into actual reimbursement realities.  The American Medical Association (AMA) is one of those venues, so a primary activity of the new OHCF for the immediate future is to coordinate and expand APA's involvement with the AMA.  Their processes play a very direct and powerful role in shaping this country's health care financing policies and provider reimbursement levels – in both the public sector and the private health care market.  The Center for Medicare and Medicaid Services (CMS) uses the AMA's recommendations to set the fees paid in Medicare.  And, these Medicare fees become the benchmark for reimbursements in other federal programs such as TriCare (DoD) and Medicaid and, very importantly, the commercial insurance market.

            "So how does the AMA influence the public and private reimbursement system throughout the country?  The AMA owns and runs the confidential and proprietary process through which all health care procedures in the U.S. are described and then assigned a billing code (which is then used for reimbursement in virtually all payment systems), known as the Current Procedural Terminology (CPT) system.  APA is a player at the AMA CPT Committee, and was represented there by Tony Puente from 1994-2008.  In 2009, Tony became the first psychologist elected as a voting member of its governing body, the AMA CPT Editorial Panel.  Since then, Neil Pliskin has represented APA at CPT.  The AMA also owns and controls the highly confidential process by which 'work values' are determined for all CPT codes; i.e., for all health care procedures from surgery to psychotherapy and beyond.  That committee is known as the Resource-Based Relative Value Update Committee or 'RUC.'  Jim Georgoulakis is the APA representative to the AMA RUC, and has held that seat for a decade and a half.

            "So the AMA defines the procedure codes used by all health care providers, including psychologists, and also assigns a valuation ('RVU') to each procedure.  CMS bases its fees on the RUV recommendations of the AMA, so this is where 'value' translates to reimbursement dollars.  Commercial carriers and other federal programs then use the CMS fee schedule as a benchmark in setting their rates.

            "APA's Game Plan:  As I noted, APA has been a player for many years at the AMA CPT and RUC through our volunteer representatives.  But with pressures to transform the health care system accelerated by President Obama's ACA, it is critical for APA to kick its CPT and RUC involvement up a notch to be at the table even more actively.  And while these processes are central to maintaining the existing fee-for-service (FFS) system in health care, the move to newer financing models such as 'bundling' and 'global payments' will still rely on current fees as the building blocks to value the contribution of individual team members.  So psychology cannot afford to neglect this arena for both the present and the future.

            "To that end, we are working very intensively at the CPT and RUC with colleagues Tony, Jim, and Neil on issues that affect both 1) mental health services by psychologists and 2) the delivery of psychological services in physical health and integrated care settings.  The immediate priorities of the OHCF in each of those two domains are:  Mental Health Codes -- * Complete the AMA RUC survey process for the three remaining CPT codes in the new mental health CPT code set that went into effect January 1^st for the entire public and private mental health system.  CMS is using an interim fee schedule, and will not release its final fees for all mental health codes until that survey work is completed.  * Work with the AMA and the other mental health societies to develop an 'extended service' psychotherapy code for trauma, PTSD, and other treatments that extend beyond 60 minute sessions, because there is no code available in the new mental health code set.  Codes for Integrated Care -- * Lobby CMS for permission to re-survey (through the RUC system) the existing Health and Behavior CPT codes, used for psychological treatments associated with physical disorders.  Those codes are currently valued at 30-40% below the comparable mental health codes.  * Participate in the AMA's ongoing development of reimbursement codes for care coordination, transitional care, team conferences, etc.  Psychologists are currently not reimbursable for these activities, and are not yet at the AMA table where they are being developed."

            Health Resources and Services Administration (HRSA):  Having finally completed deliberations on its very contentious Fiscal Year 2013 budget, the Administration recently submitted its request for Fiscal Year 2014.  Administrator Mary Wakefield, who has participated in Cynthia Belar's Education Directorate Advocacy Breakfast: "Thanks to ACA, HRSA has an even broader role.  Combined with first of its kind initiatives like the National HIV/AIDS strategy, HRSA's mandate continues to grow.  Working with our DHHS partners, HRSA is responsible for 50 individual provisions in the health care law.  These generally fall into three major categories.  * Expanding the primary care safety net for all Americans – especially those who are geographically isolated, economically disadvantaged or medically vulnerable – for example, through expansion of the Health Center program.  * Training the next generation of primary care professionals, while improving the diversity of the workforce and re-orienting it toward interdisciplinary, patient-centered care.  HRSA does this through targeted support to students and clinicians and grants to colleges, universities and other training institutions.  * Working with its partner agencies, HRSA is expected to greatly expand prevention and public health efforts to catch patients' health issues early – before they require major intervention; to improve health outcomes and quality of life; and to help contain health care costs in the years ahead.  Our FY 2014 budget request places a strong emphasis on investing in programs that improve access to health care in underserved areas and allows the Health Resources and Services Administration to take important steps towards implementing healthcare reform and improving healthcare access for underserved populations.  We are determined to work with our DHHS and other healthcare partners to assure the health of the Nation."

            As a result of the continuing diligent efforts by Cynthia Belar and Nina Levitt, the HRSA budget request includes $2,892,000 for the Graduate Psychology Education (GPE) program, which was the level provided in FY 2012 (with a slight increase in FY 2013).  This APA sponsored program funds accredited health profession schools, universities, and other public or private nonprofit entities to plan, develop, operate, or maintain doctoral psychology schools and programs and programs in mental and behavioral health practice to train psychologists to work with underserved populations.  The program is designed to foster an integrated and interprofessional approach to addressing access to behavioral health care for vulnerable and underserved populations.  Fifty-five percent of graduates were underrepresented minorities and/or from disadvantaged backgrounds and 29% report practicing in a medically underserved area.  In support of the program, HRSA noted that mental disorders rank in the top five chronic illnesses in the U.S. and that the National Alliance on Mental Illness reported approximately 6%, or one in 17 Americans suffers from a serious mental illness.  Serious mental illnesses cost society approximately $193.2 billion in lost earnings per year.  Individuals suffering from a serious mental illness earned at least 40% less than people in good mental health, confirming that mental disorders contribute to significant losses of human productivity.  Over the years, we have come to appreciate that the federal government is much more sympathetic to paying for clinical services rendered by practitioners when it has supported their training.

            The Office for the Advancement of Telehealth (OAT) would receive $11.5 million, which was also its level in FY 2012.  Funds would be provided for two grants under the Licensure Portability Grant Program, as well as associated technical assistance and evaluation activities.  OAT anticipates that 204 communities will have access to adult mental health services and 239 communities will have access to pediatric and adolescent mental services by FY 2014.  The OAT programs are viewed as an integral component of the overall DHHS Improve Rural Health Care Initiative to expand the use of telecommunications technologies that increase access to and improve the quality of health care provided to rural and underserved populations.  Telehealth programs strengthen partnerships among rural health care providers, recruit and retain rural health care professionals, and modernize the health care infrastructure in rural areas.

            Very Timely Steps -- Division 31:  "APA Division 31 and Division 42 received a CODAPAR grant to create a specific digest of the laws of each State, and then create State specific electronic health record (EHR) templates.  All APA member psychologists will have access to the laws and templates.  It should assist in the implementation of the ACA provisions that will require EHR use among integrated healthcare professionals.  Check the Division's website for the grant proposal and additional information.  To gain access, go directly to:http://www.apadivisions.org/division-31/membership/health-record-templates.aspx.  The State specific EHR templates comply with the laws of each jurisdiction.  The States have had an opportunity to have their digests and the templates reviewed through the volunteer efforts of their member experts on the ethics/law.  Each State's vetted materials are now posted at the Division 31 Community website so that all APA members will have access to these free resources [Andy Benjamin, Division 31 Past-President]."

            Intriguing Incremental Steps:  Those involved in shaping APA's Guidelines for the Practice of Telepsychology, which is a collaborative effort by APA governance entities, the Insurance Trust, and the Association of State and Provincial Psychology Boards (ASPPB), have taken notice of the parallel evolution of the notion of an "E. Passport" by ASPPB.  This would address a number of issues surrounding interjurisdictional telepsychology practice and ASPPB is currently seeking public comment on their preliminary proposal.  "The primary objective of every regulator within the field of occupational regulation should be public protection.  Regulators typically achieve public protection by establishing licensing standards, engaging in complaint resolution, and by facilitating education.  A central consideration in evaluating the effectiveness of any proposed Telepsychology standard, guideline, or regulatory language is its ability to ensure that the practice of psychology is done competently and at the minimum standard of acceptable and prevailing practice.  In essence, by asking, 'Will this solution to Telepsychology protect the recipients of the psychological services?'"  The ASPPB Telepsychology Task Force is considering the E. Passport proposal as such a mechanism to monitor and regulate interjurisdictional telepsychology practice.  This goes directly to the underlying issue of licensure mobility which, with the advent of technology and integrated health systems, must be effectively addressed in a timely manner ifpsychology is to remain competitive within the global health care environment.

            Clinical Pharmacy:  "Reciprocity of pharmacy licensure is possible across all the states, Puerto Rico, and the District of Columbia and is facilitated by a national licensure transfer process and a national jurisprudence exam.  There is no multi-state compact, however, as in nursing.  The National Association of Boards of Pharmacy (NABP) provides these national mobility resources as a service to member state boards of pharmacy and to licensees.  NABP also provides the Model Pharmacy Practice Act and updates it regularly.  The Model Act addresses key issues, including the regulatory framework for collaborative drug therapy management agreements between pharmacists and physicians, nurse practitioners, and other prescribers, Collaborative drug therapy management facilitates pharmacists' patient management activities which include the initiation, modification, and cessation of medication (June, 2011)."  Pharmacy's visionary approach proactively addresses the complex issues surrounding providing telehealth services by their profession.  Aloha,

Pat DeLeon, former APA President – Division 42 – June, 2013

 

A TIME OF CHANGE, CHALLENGES, OPPORTUNITIES

 As we excitedly observe from afar the evolving progress of our colleagues in New Jersey and Illinois, we should appreciate that historically where our profession has been able to have prescriptive authority (RxP) legislation enacted, it has been where a few have been sufficiently committed to made this their highest personal priority, demonstrated by never being "distracted" by other interesting events such as our annual APA conventions and state leadership conferences (SLCs).  The public policy/political process is a very personal one where success only comes with vision, persistence, and commitment.  As State Advocate Guru Mike Sullivan constantly reminds us, change is always the result of individual participation and that there are only a few who have been willing to become actively engaged.  Those who succeed have focused on society's real needs (i.e., envisioning a "higher agenda" beyond mere "turf issues").  Over the years we have also come to appreciate that substantive change always takes time; often far longer than one would initially predict, regardless of its ultimate benefit.  And, that change is very unsettling for many.

            State Leadership Conference (SLC):  During this year's extremely exciting APA State Leadership Conference (SLC), Practice Directorate Executive Director Katherine Nordal made clear to the over 500 attendees that unprecedented change is coming, particularly with the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA), and that it will be at the state and local level where the most critical implementation decisions will be made.  "The clock is ticking toward full implementation of the law and January 1, 2014is coming quickly.  But January 1^st is really just a mile marker in this marathon we call health care reform.  We're facing unchartered territory with health care reform and there's no universal roadmap to guide us.  The details of ACA implementation vary from state to state, and so do the key players.  There are challenges for the states.  A principal example is expansion of Medicaid.  Millions of consumers are expected to move into the Medicaid system as ACA is fully implemented.  We must pave the way for psychologists to provide services to the swelling ranks of Medicaid recipients.  To do that, we need to confront barriers to our participation and reimbursement.  Medicaid programs in 16 states do not recognize private sector psychologists as providers.  For those that do, many place conditions and restrictions on psychologists' participation.  One restriction involves requiring physician referral for psychological services.  And as of 2010, only 25 state Medicaid programs utilized health and behavior codes.  APA created these codes more than 10 years ago to facilitate our involvement in integrated systems of care and allow reimbursement for interventions that target physical disorders – such as diabetes, chronic pain, and cardiac disease.

            "One of the first steps in positioning for reform is for practitioners to recognize that they bring numerous professional skills and strengths to integrated care settings.  These are factors that create 'value-add' for psychologists on health care teams and in integrated, interdisciplinary systems of care.  And that's what many of our practitioners increasingly will need to promote: the value and quality they can contribute to emerging models of care.  We are a highly educated and talented discipline, and we need to identify and create opportunities to make others aware of the skills and strengths we can contribute to health care.  I believe that if we are not valued as a health profession, it will detract from our value in other practice arenas as well.  So regardless of how we feel about the current state of our health care system, psychology must take its seat at the table and contribute to the solutions needed to fix our ailing system.  No one else is fighting the battles for psychology… and don't expect them to.  We need to look at our advocacy broadly as taking advantage of any opportunity to help others understand and appreciate the value of psychology and psychological services.  It's not enough to have a good message.  We also need good messengers.  Health care reform is a marathon – we're in it for the long haul.  New models of care and changes in health care financing won't take shape overnight.  For two years in a row at SLC our theme has been health care reform, and we've focused on the critical need for psychology to get engaged.  We can't hope to finish the marathon called health care reform if we're not at the starting line.  Fortunately, many psychology leaders have embraced our call to action."  Katherine has always been a staunch supporter of prescriptive authority.  In our judgment, obtaining RxP is critical to psychology's future as an independent health care provider.

            Integrated Care:  One of the defining features of the ACA is its emphasis upon increasing access to team-based, interdisciplinary, integrated patient-centered primary care.  Accordingly, it will be interesting to see the extent to which visionary psychologists come to appreciate that the ongoing battles today between organized medicine and the Advanced Practice Registered Nurses (Doctors of Nursing Practice) are very much about psychology's future, especially at the state level.  It is estimated that the number of Nurse Practitioners will nearly double by 2025; from 128,000 in 2008 to 244,000.  A similar trend exists for Physician Assistants; where the number was 40,469 in 2000, increasing to 83,466 in 2010.  A thought provoking article in the New England Journal of Medicine notes: "In Virginia, after prolonged negotiations that engaged the Medical Society of Virginia and the Virginia Council of Nurse Practitioners, the state legislature unanimously enacted a 'compromise' struck by the two organizations in March, 2012.  The law stipulates that nurse practitioners must work as part of a patient-care team led and managed by a physician, and they must adhere to scope-of-practice limits as applied to them.  The law expands from four to six the number of nurse practitioners who can be supervised by a physician, and it recognizes telemedicine as a legal form of oversight when nurse practitioners practice in different locations.  The boards of medicine and nursing in Virginia jointly drafted regulations implementing the law.  The AMA promotes the Virginia law as a model that other states should consider, but the American Association of Nurse Practitioners believes the law places Virginia out of step with national trends."

Timely?  We would remind the readership that on June 17, 2011 proposed regulations for Community Mental Health Centers (CMHCs) seeking federal support (i.e., Medicare and Medicaid reimbursement) were promulgated that would require "a psychiatric evaluation, completed by a psychiatrist or psychologist with physician counter signature, that includes the medical history and severity of symptoms."  As a condition of participation, the "CMHC must designate a physician-led interdisciplinary team that is responsible, with the client, for directing, coordinating, and managing the care and services furnished for each client.  The interdisciplinary treatment team is composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and therapeutic needs of CMHC clients."  The envisioned physician-led interdisciplinary team would provide the care and services, with the CMHC designating a psychiatric registered nurse, clinical psychologist, or clinical social worker, who is a member of the interdisciplinary team, to coordinate the care and treatment decisions with each client, in order to ensure that each client's needs are assessed and that the active treatment plan is implemented as indicated.  Clearly the underlying policy issue being posed for psychology is: Whether our clinicians should be considered independent providers or allied health physician extenders?

Transformational Change is Necessary:  The various reports issued by the Institute of Medicine (IOM) over the years should alert psychology, as Katherine Nordal has emphasized at SLCs, that what we as psychologists and data-oriented behavioral scientists believe should be a priority for our nation's health care system is often unappreciated (or simply not understood) by those who establish clinical and programmatic priorities, and particularly the all-important reimbursement systems.  "Health care in America has experienced an explosion in knowledge, innovation, and capacity to manage previously fatal conditions.  Yet, paradoxically, it falls short on such fundamentals as quality, outcomes, cost, and equity.  Each action that could improve quality – developing knowledge, translating new information into medical evidence, applying the new evidence to patient care – is marred by significant shortcomings and inefficiencies that result in missed opportunities, waste, and harm to patients….  In short, the country needs health care that learns by avoiding past mistakes and adopting newfound successes….  The entrenched challenges of the U.S. health care system demand a transformed approach.  Left unchanged, health care will continue to underperform; cause unnecessary harm; and strain national, state, and family budgets.  The actions required to reverse this trend will be notable, substantial, sometimes disruptive – and absolutely necessary.  The imperatives are clear, but the changes are possible – and they offer the prospect for best care at lower cost for all Americans [IOM]."  We would suggest that psychology's maturing RxP quest and our active clinical participation in the evolving integrated models of care substantially reflect this underlying societal charge.

Divisional Visionaries:  The RxP evolution is transformational and will make a substantial different in the lives of many individual patients, as well as our health care system's definition of "quality care."  Psychology has a societal responsibility to address the critical psychosocial-cultural-economic gradient of care.  As Katherine proffers: If not psychology, who?  During the Illinois legislative hearings, former Division President Bob McGrath submitted  testimony:  "I am writing in support of awarding appropriately trained psychologists in Illinois the authority to prescribe.  Any decision about scope of practice for a profession requires balancing the goal of maximizing freedom of choice/access to care with that of public safety.  In this case, the empirical record clearly supports the proposed expansion in scope.

"First there is a clear shortage of specialty mental health prescribers.  No one can argue with this assertion.  Studies consistently demonstrate that 60-80% of all medications for mental disorders are prescribed by primary care physicians.  These physicians are dedicated, conscientious, and caring, and they have valiantly filled the gap created by the lack of appropriate  psychiatric services.  However, they are diagnosing and treating mental disorders with little or no formal training in the diagnosis of mental disorders or in alternatives to medication.  It is no surprise then to find they rely heavily on medications, even when such medications should not represent the first-line treatment.  The result is over-medication and unnecessary medication.  Allowing appropriately trained psychologists to prescribe would substantially increase the population of specialty mental health prescribers, increase the proportion of such prescribers who are familiar with circumstances in which alternatives to medication are superior, and reduce costs associated with using a physician as the primary prescriber.

"This argument only makes sense if prescribing psychologists are safe, and there the record is clear.  Psychologists will only be allowed to prescribe after having completed at least five years of graduate training in psychology, becoming licensed as a psychologist, completing an additional three years of medical training, and becoming licensed as a prescriber.  Consider that in five years a physician becomes licensed to prescribe over 4000 medications and participate in any medical procedure from childbirth to surgery.  In contrast, a psychologist who wants to prescribe spends three years learning approximately 100 medications (including their interactions with other drugs) and the small set of medical procedures relevant to their prescription (e.g., reading lab test results, performing and interpreting a physical examination).

"However, the case for psychologists as safe prescribers is not just logical; it is also data-based.  Psychologists have prescribed for more than 20 years in the U.S. military; they have written hundreds of thousands of prescriptions in two U.S. states where psychologists can prescribe (Louisiana and New Mexico); they have served as prescribers in the U.S. Public Health Service and Indian Health Service.  In all that time, not one complaint has ever been lodged against a prescribing psychologist.  What is particularly telling is that not one physician has ever complained about the performance of a prescribing psychologist to a licensing board.

"I am the Director of the M.S. Program in Clinical Psychopharmacology at Fairleigh Dickinson University.  Fairleigh Dickinson is one of three institutions designated by the American Psychological Association as meeting the association's guidelines for preparing psychologists to prescribe.  So far, Fairleigh Dickinson has graduated over 100 psychologists with a master's degree in clinical psychopharmacology.  We have graduates who have prescribed in the military, in the Public Health Service, in the Indian Health Service, and in the states where psychologists are currently authorized to prescribe….

"Psychologists are a highly trained, ethically bound profession.  We do not enter into the obligations of being a prescriber frivolously.  The fact that we have designed a curriculum that requires three additional years of medical training after completion of the doctorate reflects a profession that perceives the role of the prescriber with great caution.  Allowing psychologists to prescribe in Illinois will improve access to care without reducing public safety.  I hope you will look beyond the emotional appeals of its opponents, and recognize it is the logical choice."

            Reflections:  RxP:  Jerry Strauss reported on the September, 2008 Louis Stokes VA Medical Center Psychology Service first annual all day conference open to VA and community psychologists titled "The RxP Movement in Psychology and Implications for Treating Patients with HIV and Tobacco Abuse."  Participants included former Division President Morgan Sammons and APA's Randy Phelps.  "The conference was well attended by VA psychologists, psychology postdoctoral fellows and interns, and community psychologists; most of whom are very interested in the prescriptive authority movement for psychologists.  This event may be the spring board for initiating a Psychopharmacology Training Program at the Cleveland VA.  Stay tuned."  A review of the feedback subsequently received from the trainees and postdocs was quite informative.  A number felt that: "Many of the sessions focused on the diagnoses and situations where psychologists with prescription privileges could play a vital role.  The speakers presented support for psychologists receiving prescription privileges and showed how prescription privileges for psychologists would lead to fully integrated care."  And also, "I felt the sessions that spoke about prescription privileges were one sided.  I felt like I was at a sales pitch for prescription privileges in that only the pros were presented.  It would have been nice to hear both the pros and cons.  The cons seemed to arise from the audience, not the presenters."

Retirement:  Floyd Jennings is one of the first recognized prescribing psychologists, his expertise resulting in formal recognition in the Indian Health Service (IHS) Santa Fe hospital by-laws in the 1980s.  "My hunch, albeit mere speculation, is that the quality of life post-retirement for psychologists is related to the degree to which investment in professional activities became the principal and deciding focus of personal identity for the person.  That is, for persons – like myself – who invested far too much in professional activities to the detriment of development of personal areas of interest, retirement is a death sentence in the very near term; for one asks, either consciously or unconsciously, 'Is this all there is?'  Thus, speaking solely for myself, therefore, I had decided to 'work' in some fashion until I infarct and expire.  My mind continues to be active, even more so than in the past; and I write more, and think more about policy and long-range issues than short-term, tactical matters.  To be sure, I am building in far more time for travel and those experiences for which I have longed; but nonetheless, continue to function in an employed fashion (the first such opportunity in decades) and the county appears in no hurry to discharge me.  One wag said, 'Why?'  You are now vested and we might as well continue to get some use from you…!"  Aloha,

Pat DeLeon, former APA President – Division 55 – May, 2013

 

EVOLVING PROFESSIONS – INTERESTING TIMES:

The 30^th Annual APA State Leadership Conference (SLC):  "Countdown to Health Care Reform," as always, was a truly outstanding event.  From my public policy/political perspective, I was particularly pleased with the extent to which those fortunate to attend the conference learned firsthand the intricacies of working with the media at both the local and national level.  Former Hawaii Psychological Association (HPA) President June Ching, for example, described her impressive efforts over the years to be "helpful" to our local print, radio, and television colleagues, while always being mindful of her unique expertise.  Arthur Evans, Jr., Commissioner of the Department of Behavioral Health and Intellectual disAbility Services for the City of Philadelphia, and Robin Henderson of the Central Oregon Health Council described their visionary efforts to "bend the cost curve," while ensuring that beneficiaries received gold-standard care; i.e., demonstrating that psychology's involvement would bring "added value" to the overall quality of life of their neighbors.  David Ballard's exemplary Psychologically Healthy Workplace Awards Ceremony once again highlighted the broad impact of psychology in improving daily lives throughout America.

The presentation on the APA/ASPPB/APIT joint Telepsychology Taskforce demonstrated our profession's responsiveness to the unprecedented challenges occurring within the nation's health care environment.  "The Task Force for the Development of Telepsychology Guidelines has completed its work on the "Guidelines for the Practice of Telepsychology."  The APA Board of Directors will be asked at their June 2013 meeting to recommend that the APA Council of Representatives at its meeting in August 2013 adopt as APA policy these Guidelines.  This joint effort has been funded for one additional year (2013) to allow the Task Force to continue its collaborative work to advance model regulatory language and provide guidance on risk management practices (Joan Freud)."  On a related note, ASPPB is circulating its draft "E.Passport proposal" for public comment.  This will be a mechanism developed by ASPPB (concurrent to the Telepsychology Task Force work) to facilitate interjurisdictional practice for those providing telepsychology services.  Each of the 500-plus state psychology leaders present at SLC will undoubtedly have his/her own highlight.  SLC is a one-of-a-kind leadership and advocacy training event, which in my judgment is only surpassed by our annual convention (this year being held in Honolulu) in its importance to our professional community.

            A former APA Congressional Science Fellow and now Executive Director of the Practice Directorate, Katherine Nordal in her Keynote Address passionately laid out for the audience the importance of being personally involved and actively engaged in the public policy/political process over the long haul.  "At this time last year, the future of the Affordable Care Act (ACA) seemed uncertain.  Since then, we've had a Supreme Court decision that upheld the ACA and the November reelection of President Barack Obama.  The Affordable Care Act has survived, and implementation of the largest expansion of the health care safety net will proceed.  The clock is ticking toward full implementation of the law and January 1, 2014 is coming quickly.  But January 1^st is really just a mile maker in this marathon we call health care reform.  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us.  The details of ACA implementation vary from state to state, and so do the key players.

            "All of you are painfully aware of the difficult health care environment in which we find ourselves these days:  * Ever increasing demands for cost containment, declining levels of reimbursement and limits on service delivery.  * Greater regulatory requirements.  And, * Increasing competition in the psychotherapy marketplace, particularly due to growing numbers of masters-trained mental health providers.  Fee-for-service is being replaced by alternative reimbursement mechanisms and marketplace and regulatory developments are encouraging more collaborative and integrated practice models.  I see professional psychology facing challenges on three levels:  First, there are challenges on the federal level where for starters, there are plenty of unfamiliar faces on Capitol Hill – a total of 94 new House and Senate members in the 113^th Congress.  There are challenges for the states.  A principle example is expansion of Medicaid.  Millions of consumers are expected to move into the Medicaid system as the ACA is fully implemented.  Medicaid programs in 16 states do not recognize private sector psychologists as providers.  For those that do, many place conditions and restrictions on psychologists' participation.  For example, requiring physician referral for psychological services.  As of 2010, only 25 state Medicaid programs utilized health and behavior codes.  In addition to challenges at the federal and state levels, there are challenges for individual practitioners, regardless of practice setting.  One of the major ongoing challenges facing many practitioners is the need to adapt to new and emerging systems of care.  Looking to the future, viable practice options will vary from one psychologist to another.

            "Let's focus on what's happening to address the challenges – beginning with what psychology brings to the table.  One of the first steps in positioning for reform is for practitioners to recognize that they bring numerous professional skills and strengths to integrated care settings, including:  * Conducting thorough psychological assessments.  * Understanding environmental factors such as family and community systems.  * Designing, monitoring and evaluating interventions.  * Promoting patient responsibility, resilience and recovery.  * Applying behavioral principles to modify health-risk behaviors and attending to interpersonal barriers to behavior change.  And,  * Understanding group dynamics and facilitating teamwork.  These are factors that create 'value-add' for psychologists on health care teams and in integrated, interdisciplinary systems of care.  And that's what many of our practitioners increasingly will need to promote: the value and quality they can contribute to emerging models of care.  We are a highly educated and talented discipline, and we need to identify and create opportunities to make others aware of the skills and strengths we can contribute to health care.  I believe that if we are not valued as a health profession, it will detract from our value in other practice arenas as well.  So regardless of how we feel about the current state of our health care system, psychology must take its seat at the table and contribute to the solutions needed to fix our ailing system.  Psychology will be valued to the extent that we bring our knowledge to bear on the grand challenges of our society.  And believe you me, health care is a grand challenge.

            "I can sum up in two words what we encourage state leaders to focus on as the countdown to health care reform proceeds: Advocacy and Education.  On the advocacy front, we must step up to the plate and insist that psychologists and the psychological and behavioral services we deliver be included in emerging models of care and payment mechanisms.  No one else is fighting the battles for psychology… and don't expect them to.  We need to look at our advocacy broadly as taking advantage of any opportunity to help others understand and appreciate the value of psychology and psychological services.  It's not enough to have a good message.  We also need good messengers.  Education involves both public education and outreach, along with psychologist education and training needed to prepare the profession for the new practice models that will evolve with health care reform.  The skill sets needed for a psychology practice that predominately involves psychotherapy are not necessarily sufficient for practice in integrated care settings.  Yes, the clock is ticking towardJanuary 1, 2014.  But remember, we're not running a sprint.  Health care reform is a marathon – we're in it for the long haul.  New models of care and changes in health care financing won't take shape overnight.  We can't afford to be left out of health care again (i.e., Medicare) and then have to spend decades playing catch-up.  We can't hope to finish the marathon called health care reform if we're not at the starting line.  Fortunately, many psychology leaders have embraced our call to action."

            Advances Within Professional Nursing:  This Spring I had the opportunity to attend two national/international nursing conferences addressing how their profession is responding to our ever-changing health care environment.  The American Association of Colleges of Nursing (AACN) 2013 Spring Annual Meeting was entitled "Guiding Change: Technology in Nursing Higher Education."  Not surprisingly, there was a focus on exploring challenges inherent in the increasingly technology-dependent environment of nursing higher education, as well as the utility and effectiveness of simulation in nursing education and research-based suggestions for the future.  The importance of public policy/political advocacy remained a consistent theme.  The Hawai'i State Center for Nursing held its annual Pacific Institute of Nursing conference, "Partnership with Parity: The New Paradigm."  Two of their speakers described particularly interesting developments for non-physician clinical practice, within the policy context of the 2010 Institute of Medicine (IOM) report "The Future of Nursing: Leading Change, Advancing Health."  The IOM noted that with more than three million members, the nursing profession is the largest segment of the nation's health care workforce.  And recommended that * Nurses should practice to the fullest extent of their education and training.  * Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.  * Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.  And, * Effective workforce planning and policy making require better data collection and information infrastructure.

            The first recommendation of the IOM was to "Remove scope-of-practice barriers.  Advanced practice registered nurses should be able to practice to the full extent of their education and training."  Perhaps most intriguing was the call for the Federal Trade Commission and the Antitrust Division of the Department of Justice to review existing and proposed state regulations concerning advanced practice registered nurses (APRNs) to identify those that have anticompetitive effects without contributing to the health and safety of the public.  States with unduly restrictive regulations should be urged to amend them to allow APRNs to provide care to patients in all circumstances in which they are qualified to do so.

Attorney Barbara Safreit reported that the National Governors Association (NGA) had recently released a policy document specifically addressing this issue, "The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care."  Highlights include: research suggests that Nurse Practitioners (NP) can perform many primary care services as well as physicians do and achieve equal or higher patient satisfaction rates among their patients (including time spent with patients, prescribing accuracy, and the provision of preventive education).  State laws and regulations governing NPs revealed wide variation among the states with respect to rules governing scope of practice, including the extent to which states allow NPs to prescribe drugs, to practice independently of physician oversight and to bill insurers and Medicaid under their own provider identifier.  "To better meet the nation's current and growing need for primary care providers, states may want to consider easing their current scope of practice restrictions, as well as their reimbursement policies, as a way of encouraging and incentivizing greater NP involvement in the provision of primary care….  None of the studies in NGA's literature review raise concerns about the quality of care offered by NPs."

            Cathy Rick, Chief Nursing Services Officer for the Department of Veterans Affairs (VA), described the extraordinary progressive changes in the newest VHA Nursing Handbook, which, in essence, will now provide VA advanced practice nurses with the authority for independent practice, regardless of individual state licensure limitations, unless an individual VA facility limits their scope within that facility.  This visionary document has been "cleared" by the relevant legal authorities who will be affirmatively assisting hesitant states in appreciating the federal government's supremacy powers within federal facilities.  The handbook notes that research and evidence-based practice have demonstrated the significant and synergistic relationships between delivery of nursing care, patient and resident outcomes, and staff satisfaction as well as process effectiveness and efficiency.  It recognizes that nursing care is complex and that paradigms have shifted (and will continue to shift).  VHA nursing care delivery will be agile, innovative, and supportive of the Veteran as the driver of their individual healthcare.  The basic tenets of VHA nursing are aligned with the ANA Standards of Practice and achieved through evidence-based practice, defined elements of practice, and professional development.  Two key underlying components are that the patient owns and drives their care based on the information available and nursing interventions are based on the best available evidence and accepted standards of practice.  Specifically the Nursing Handbook states:

"Clinical nursing practice varies widely among the States.  To ensure safe and appropriate health care to the nation's Veterans, VA has standardized the elements of practice, within VA, for clinical nursing practice other than the prescribing of controlled substances, without regard to individual State Practice Acts.  This ensures a consistent standard of nursing care throughout VA's national health care system….  Under the Federal Controlled Substances Act… a health care practitioner may prescribe controlled substances only if the practitioner's State license authorizes such prescribing.  Accordingly, APRNs, including NPs, may prescribe controlled substances within VA only if they are authorized to do so by their State of licensure or registration and comply with the limitations and restrictions on that prescribing authority.  Where VA establishes elements of nursing practice that are more expansive or otherwise inconsistent with State practice standards, VA's practice standards control.  VA nurses must follow the VA nursing practice standards established in VA rules, regulations, and policies."  Without question this is a most impressive development for our nursing colleagues.  The readership should recall that the AACN announced that in October, 2004 their member schools voted to endorse moving the current level of preparation necessary for advanced nursing practice from the master's degree to the doctorate-level (i.e., the Doctor of Nursing Practice (DNP)) by the year 2015.  Psychology could learn a lot from our nursing colleagues – we are living in "changing times."

Exciting Opportunities To Contribute:  One of the most rewarding aspects of being in a university environment is the constant exposure to new ideas and challenges.  Steve Brewer recently presented a colloquium on his fascinating research at the Uniformed Services University of the Health Sciences (USUHS).  "There is very little research examining the effects of combat deployment on the driving abilities of post-deployment service members.  However, there is evidence that service members have an increased risk of being involved in a vehicular accident within the first six months of returning from a combat deployment.  Specifically, within the first six months post-deployment there was a 13% increase that all service members (regardless of age/rank) would be in a vehicular accident.  Junior enlisted (E1-E4) had a 22% increase and 18-21 year olds had a 25% increase.  Also, the number of deployments increased the likelihood of being at-fault in an accident.  One deployment meant a 12% increase; two deployments meant a 27% increase; and three or more deployments meant a 36% increase in the likelihood of being at-fault in a vehicular accident.  There is also research that describes the effects of PTSD and TBI on cognitive abilities, many of which are required for the safe operation of a motorized vehicle.  In order to study the effects of combat deployment on driving abilities, we at the USUHS Ettenhofer Laboratory for Neurocognitive Research ran a pilot study in cooperation with the University of Virginia.  We used a virtual reality driving simulator (VRDS) that was designed with multiple testing scenarios.  The participants' driving abilities were measured through motor tests and cognitive tests.  The findings and feedback from the participants of this pilot study will be used to improve the operational scenarios.  These improved scenarios will eventually be used to examine the effects of deployment and other variables to establish the safe and unsafe driving characteristics of participants.  Scenarios will also be utilized for rehabilitative purposes to assist with improving unsafe driving abilities into safe ones.  Such a process could be included in post-deployment training to decrease the incidence of vehicular accidents."

           Interesting Life Journeys:  Having retired from the U.S. Senate staff after 38+ years, I have become quite interested in learning what colleagues that I have worked closely with over the decades are now doing post-psychology or in expanded roles.  Long time VA psychologist visionary Rod Baker has "retired" authoring, co-authoring, and editing three books on the history of psychology in the VA and has just published his fourth book,More Stories from VA Psychology.  This latest publication, like a previous one, features career stories written by retired and current psychology leaders whose careers span 61 of the 66 years of VA psychology history that was established in 1946.  The career stories add an entertaining first person perspective that expands the reader's understanding of the formal history of VA psychology.  Moreover, I recently learned that Rod has a broader writing activity that includes five published articles on the history of the Old West.  And, I just finished reading his very enjoyable historical fiction novel, The Rune Master Saga, set in 9^thcentury Norway.  Highly recommended – his clinical and developmental perspectives are definitely present.  The sequel should be equally intriguing.  See his Author page onAmazon.com to learn how Rod became interested in writing fiction.

            Kay Daub, Professor of Nursing at the University of Hawaii at Hilo, recently became actively involved in hospice care programs on the Big Island of Hawaii.  "Several months ago, I had the opportunity to read a bit about End of Life care and what it means to patients who are dying.  I had always been very interested in death and dying, but somehow as way leads on to way, I began my nursing career in telemetry and ICU.  Though many cases involved end of life care, my focus had been cure no matter what.  So many ethical dilemmas surround the end of life, as I suppose so many ethical dilemmas surround the beginning of life.  How does one wrap their head around the concept of comfort care, and let go of the notion of cure no matter how painful, cold, futile, or lonely?  I have now taken on this interest and have pursued caring for patients at the end of life; this is in addition to my current busy academic career that removes me from the 'bedside.'  What a gift this has been.  It is a challenge to go beyond the comfort zone of avoiding communication about a difficult subject.  The elephant in the room, what is on my patient's mind; how do I talk about death, active death?  I have started meeting the patient and family where they are.  I have gotten to hear lovely and sometimes not so lovely stories of memories over a life span.  I have even heard a patient talking to someone who died before him.  My focus is on comfort rather than cure.  My nursing has become more holistic, much more patient and family centered.  There is a lesson to be had.  Death is our greatest teacher.  It does teach us how to live.  Death can come at any time in one's life, how wonderful to end with great comfort and reflection."

            Reflecting upon the exponential growth and expanding influence of professional psychology over the past four-plus decades, trailblazer Gene Shapiro recently commented: "We need another 'dirty dozen' to fight for the role of tomorrow's providers."  As Katherine noted: "No one else is fighting the battles for psychology… and don't expect them to."  Aloha, 

Pat DeLeon, former APA President – Division 29 – May, 2013

INSPIRATIONAL VISION

    It is difficult to believe that four decades ago, I embarked upon what would become a most fascinating journey, on the very first day of the infamous Watergate hearings.  I retired from the U.S. Senate staff with wonderful memories and a deep feeling of accomplishment.  Our nation's Capital is an unforgettable place; rich in history and tradition, and for those who decide to become engaged in the public policy/political process, providing a once in a lifetime opportunity to "make a real difference" in the lives of our nation's citizens.  It is simply an awesome experience that I would recommend to every colleague; an opportunity to truly "give psychology away" in the finest sense.  When I arrived in Washington, DC, professional psychology was, in retrospect, in its infancy – especially in becoming involved in the public policy/political arena.  Practice legends Ted Blau, Nick Cummings, Max Siegal, Logan Wright, and Ray Fowler had not yet begun thinking about running for APA President.  What today we might consider specialized professional divisions (e.g., Divisions 38, 41, 42, 55, etc.) simply did not exist.  In the mid-1970s, we were collectively just beginning to appreciate our potential role as generic health care providers, beyond being "merely" mental health specialists in small private practices and community mental health centers.

In the early 1970s, the profession was fortunate to have committed visionaries at both the state and national level.  In New Jersey, Gene Shapiro, Bob Weitz, Marv Metsky, and Stan Moldawsky were paving the way for psychology's ultimate recognition as a licensed independent profession.  Those seeking to advance our professional agenda had little expectation that APA, which was historically heavily influenced by academic psychology, would be the appropriate vehicle for guiding professional psychology's (r)evolution.  Consequently, much of the creative energy over the next several decades would be strategically expended outside of APA as California's Nick Cummings and the late Rogers Wright, along with their "dirty dozen" colleagues, pressed for (dare we say "lobbied for") psychology's statutory recognition.  Future APA President Jack Wiggins (envisioning and naming the National Register), Gene, and Carl Zimet worked with the APA Board of Directors and the American Board of Professional Psychology to establish this vibrant entity, chaired by Carl, outside of APA's governance.  The professional school movement and specialized post-doctoral educational initiatives (e.g., rehabilitation psychology and psychology and the law) would come.  Reflecting, I expect that it is probably impossible for today's early career psychologists to truly appreciate yesterday's seemingly turbulent and yet vibrant environment.  So many really do owe so much to so few.

In the midst of what must be considered a period of extraordinarily exciting professional growth, our esteemed colleague Alfred M. Wellner strived to operationalize what he, a gifted visionary, could readily see needed to be accomplished.  He was clearly an individual who was ahead of his time.  He appreciated that if the profession of psychology were ever to fulfill its clinical potential, it would have to position itself for those who established federal (and state) health policy standards in a logical and transparent manner.  He understood that psychology would have to address the vexing questions: "Who are we?" and "How can we assure the public (and those who ultimately pay for our services) that we are who we say we are?"  At the time, Gene and Jack were focusing upon independent recognition under the Department of Defense CHAMPUS program, where these fundamental questions had to be answered for non-psychologist administrators.   Al soon came to experience that as a discipline, psychologists are wonderfully talented in developing rationales for why something cannot be done or exploring ad infinitum why what has been proposed must be modified.  In spite of these seemingly insurmountable challenges Al persisted and even invited me to participate in reviewing resumes for potential inclusion in his envisioned National Register of Health Care Providers in Psychology.  Several states had not yet passed licensing laws so the Register served as the resource for insurance carriers and others to identify qualified psychologists eligible for reimbursement.  Should those with PhD's be differentiated from those with EdD's?  Was a doctorate in clinical substantially different than one in counseling or educational psychology?  What about licensed masters level psychologists?  There were no simple answers; yet Al pressed on – proclaiming decisions had to be made and always in an open and judicious manner.  The Register was serving a critical need of the time providing an objective listing of those who should be deemed "psychologists" for the purpose of receiving reimbursement for their clinical services.  And, its Psychologists' Legal Consultation Plan brought to life the crucial interface of psychology and the law for many practitioners.  Alfred M. Wellner was a visionary who was decades ahead of his time.  Mahalo.

With the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA), our nation has finally taken the position that all Americans will have access to timely healthcare, particularly patient-centered, gold standard (i.e., data driven) primary care.  Putting this in perspective, this has been a policy agenda for nearly every President since Franklin D. Roosevelt, regardless of political affiliation.  By 2014, almost all of the provisions of ACA will have been implemented and the healthcare environment for psychology's practitioners and training institutions will have undergone unprecedented change.  The extraordinary advances occurring today within the computer and communications fields call out for some form of national licensure and national scope of practice for each of the health professions.  There is increasing evidence that the quality of telehealth services are comparable to, and often significantly more cost-effective, than traditional face-to-face provider relationships based upon geographical availability, especially with the younger technology-savvy generation.  Under the leadership of Al's successor, Judy Hall, the Register has been proactively positioning itself to address this professional and societal need, working closely with the leadership of the various state licensing boards and now being recognized, or in the process of being recognized, in 46 jurisdictions in the U.S. and Canada as a vehicle for licensure mobility.  Similarly, the Register's leadership has been highly cognizant of the unique and pressing needs of our early career psychologists for obtaining quality and relevant continuing education experiences.

The Register was established at a time when psychology was just beginning to seek federal statutory and regulatory recognition.  Over the years, we successfully obtained inclusion under CHAMPUS (now TRICARE), the Federal Employees' Health Benefit Program, the Federal Workers Compensation Act, the Federal Criminal Code, various provisions of Medicare; and such training initiatives as the Indian Education Act Fellowship program, the National Health Service Corps Scholarship Program, and the Individual Federal Insured Loan Program.  Recognition was obtained under various provisions of the Social Security Disability Benefits Act, not to mention eligibility for the U.S. Public Health Service Regular Corps which is the sole requirement for being appointed U.S. Public Health Service Surgeon General.  This was also the era when Nick and his colleagues participated in the Colorado Medicare study Senate Finance Committee hearings, exploring to what extent psychological services were "safe, effective, and appropriate" pursuant to the U.S. Office of Technology Assessment finding that only 10 to 20 percent of all medical procedures had been shown by controlled tests to be beneficial.  Today there are of course many new legislative challenges; for example, obtaining inclusion under the Medicare Graduate Medical Education (GME) program, Medicaid (which is the foundation for the ACA's beneficiary expansion efforts), and express recognition under the Accountable Care Organization and Medical Home provisions of ACA.

At this year's 2013 outstanding APA State Leadership conference, Practice Directorate ED Katherine Nordal reflected upon the radically changing healthcare environment: "At this time last year, the future of the Affordable Care Act (ACA) seemed uncertain.  The ACA has survived, and implementation of the largest expansion of the health care safety net will proceed.  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us.  The details of ACA implementation vary from state to state, and so do the key players.  I see professional psychology facing challenges on three levels: First, there are challenges on the federal level.  Beyond the federal level, there are challenges for the states.  A principle example is expansion of Medicaid as ACA is fully implemented.  And, there are challenges for individual practitioners regardless of practice setting.  Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  I believe that if we are not valued as a health profession, it will detract from our value in other practice arenas as well. So regardless of how we feel about the current state of our health care system, psychology must take its seat at the table and contribute to the solutions needed to fix our ailing system.

"No one else is fighting the battles for psychology… and don't expect them to.  Health care reform is a marathon – we're in it for the long haul.  New models of care and changes in health care financing won't take shape overnight.   We can't afford to be left out of health care again [i.e., Medicare] and then have to spend decades playing catch-up.  We can't hope to finish the marathon called health care reform if we're not at the starting line.  Fortunately, many psychology leaders have embraced our call to action."  We need another "dirty dozen" to fight for the role of tomorrow's providers.  Aloha,

Pat DeLeon, former APA President – National Register – April, 2013