Division 29 May, 2015 column

I SAW HER AGAIN LAST NIGHT….

            The Very Best of APA:  The annual APA Practice Directorate State Leadership Conference (SLC) continues to be the highlight of my APA year.  This spring 530 colleagues, including an impressive number of early career psychologists and first time attendees, were treated to another spectacular event.  New models of service delivery, the importance of integrated and patient-centered care; and focusing upon developing effective business plans, while simultaneously providing “value-add” were highlighted.  The Illinois Psychological Association’s recent prescriptive authority success, thanks in large part to the dedication and persistence of Beth Rom-Rymer, brought new life to the RxP movement with a number of states reporting their membership being re-energized.  Ann Compton, former White House correspondent for ABC News presented a fascinating perspective on the inner workings of the Oval Office, when Hillary would finally announce, and the unique perspectives of the First Ladies.  This was also the 10^th anniversary of David Ballard’s visionary Psychologically Healthy Workplace and Organizational Excellence Awards ceremony, which actively engages psychology with the best of the business community at both the local and national level.  Under Norman Anderson’s leadership, APA itself was recently designated as one of the “Best Places to Work” by the Washington Post.  As always, the enthusiasm and excitement of the audience was palpable.

            The theme for this year’s conference was Practice Innovation and Practice Directorate Executive Director Katherine Nordal challenged those present to step up and become visionary leaders.  “Innovation involves new ideas and processes, change, upheaval and transformation.  To be innovators we need to shake off some old ways of thinking about traditional practice models.  We also need to shake off the negative attitudes some of our colleagues have about what’s happening in health care.  The world is changing and health care is moving ahead – with or without psychology.  Whether we move forward will be up to us!  We need to think differently about our professional roles and the way we provide services.  Too many psychologists are stuck in the traditional 50-minute therapy box.  And that box is way too confining.  We need to think creatively… how we practice… where we practice… and what we practice.

            “How can psychologists participate in the evolving system in ways that are good for us, our profession and our patients?  What effects will reforms in health care systems, financing and technology, have on us?  And, how do we, as leaders in our profession, support our members as these changes unfold?  We need to see and understand the bigger picture – the health care environment in which psychology lives.  Psychology should be the discipline that defines and expands the mental health quality measures available for Medicare and other public and private payers as these measures become more widely required.

“Clinical practice guidelines provide an example of our asserting a leadership role.  Historically, psychology has not been at the table.  That has enabled others to control the process, and payers have used their guidelines to determine what they will and will not pay for.  That will change as APA finalizes three initial guidelines – for PTSD, depression and obesity.  Guidelines developed by other disciplines often ignore the rich psychological science that informs good practice.  APA guidelines will identify the most effective psychological treatments for these disorders, regardless of the discipline providing the care.  Our guidelines development process is innovative.  APA’s panels are multidisciplinary.  One of our cutting-edge, best practices is including community members on each panel to represent the patient perspective.

“You’ll need a dose of courage to face the resistance you’re going to encounter back home.  There will be times when your colleagues push back at your efforts at innovation.  Sometimes you’ll hear your colleagues complain, ‘We shouldn’t change the way we’ve always done it.’  Or, ‘That’s not how I was trained.’  When you get that push back, what 3-word message are you going to give back to them?  ‘Shake it off.’  You are the leaders with the focused vision and vigilance needed to influence a challenging, changing health care system.  You are the leaders who will shape a vibrant future for professional psychology.”

The Administration’s Vision:  At a recent HRSA national Advisory meeting, the acting administrator discussed the Accountable Care Act’s vision for improving access to quality care; fostering a more diverse workforce emphasizing team-based, interdisciplinary care; developing healthy communities (i.e., a population-based focus); and giving a priority to prevention ,while addressing historical health disparities.  This is Katherine’s charge.

            A Very Special Personal Journey:  “The APA Congressional Science Fellowship program had a profound impact on my life and my career, and I am profoundly grateful for the experience.  At the most recent APA Council of Representatives meeting, former Congressman Brian Baird gave a talk at the plenary session and commented on the importance of the Fellowship for both the profession of psychology and for Congress itself.  You might recall that I was the first psychologist to be a Robert Wood Johnson (RWJ) Health Policy Fellow, and this predictably led to ‘Potomac Fever.’  I loved working on the personal staff of Senator Tom Daschle, and cherish the time I spent with Tom (in both South Dakota and DC) and being mentored by Rima Cohen, his health policy legislative assistant.  Of course, the two-month Institute of Medicine (IOM) orientation helped too (e.g., our half-day lecture about and tour of HHS was given by then Secretary Lou Sullivan).  I wrote lots of speeches, drafted legislation, met with constituents, attended committee hearings, and was intimately involved with the reauthorization of funding for the National Health Service Corps.  Bob Frank was the second psychologist picked as an RWJ Fellow; I’m sure his time working for Senator Jeff Bingaman (D-NM) at least partially was responsible for his current position as President of the University of New Mexico.

“Realizing that I could never go back to running a neuropsychology lab, I resigned a tenured full professorship at the Marshall University School of Medicine, determined to reshape my life as a health policy maven.  I applied for both the APA Congressional Science Fellowship and the MPH program at Harvard.  I was accepted for both, but opted to stay in DC and continue to learn about the fascinating world of health policy.  Ted Kennedy, Jay Rockefeller and Pete Stark all offered me jobs on their personal staff, but Congressman John Conyers then chaired the House Government Operations Committee, and I accepted a position on his committee staff, in part because of my interest in promoting a Canadian style single payer health care system for the United States, something Congressman Conyers passionately supported.  In addition, after a year working in the Senate, I wanted to learn more about the House of Representatives.

            “While spending two years on the Hill, I had an opportunity to get actively involved with APA activities and operations (Fellows are invited to participate in almost all relevant APA conferences, meetings, events and summits).  This eventually led to my active participation in APA governance and presidency of three divisions (12, 46, and 52) as well as participation for several terms on the Council of Representatives.  During this second year working for the Congress, my former Dean at Marshall became the Dean of the School of Medicine at the University of Missouri.  Although a thoracic surgeon, this Dean was very psychologically minded, and he was determined to bring me back to the Academy.  He offered me an opportunity to direct the Missouri Institute of Mental Health (MIMH), a policy, research and training ‘think tank’ with over 100 employees and a budget of about $6 million.  MIMH operated at the interface of the University of Missouri and the Missouri Department of Mental Health, and our mission was to serve anyone in Missouri with a mental illness, addiction or developmental disability.  The job required lots of time in Jefferson City (the state capital) as well as tracking state legislative policy.  It was a job that wouldn’t come around again, so I accepted the Dean’s offer and happily spent the next 20 years running the Institute.  I never went back to being a neuropsychologist… but I never regretted making the shift from direct patient care to being a ‘policy wonk.’

            “I simply couldn’t have done the job at MIMH – and it would never have been offered – had I not spent time on the Hill as a congressional science and health policy fellow.  I like to think I made a real difference during the two decades I spent in Missouri, and I’ve had opportunities to introduce literally thousands of students to health policy issues, both in Missouri and while serving as an Associate Dean at the California School of Professional Psychology (CSPP).  I also make sure the medical students I’m now teaching at the American University of Antigua know something about how health policy is shaped and how profoundly their professional lives will be affected by what happens in the halls of Congress and in state legislatures.  (A fortuitous and entirely unexpected benefit of being a former APA/AAAS Fellow was being invited to Canberra to testify before a subcommittee of the Australian Parliament about my experiences working on the Hill.)  Our 40^th Congressional Science Fellowship anniversary celebration at our last convention was truly memorable” [Danny Wedding].

            Change Is Inescapable; Although It Does Take Time:  As Katherine so apply notes, a number of our colleagues appear to be intractably resistant to change.  Apparently, however, this fundamental orientation is not limited to the discipline of psychology.  In reading about Rear Admiral Grace Hopper, who was a pioneering computer specialist, and who retired in 1986 as the Navy’s oldest serving officer (having served for 42 years), I smiled learning: “In general, applied mathematicians were looked down on by their colleagues in pure mathematics.  There was a widespread belief that ‘you turned to applied mathematics if you found the going too hard in pure mathematics.’”  Thank goodness for colleagues like former Division and APA President Ron Fox who continues to press for change, now meeting almost monthly with APA’s Heather Kelly strategizing about how to get psychologists -- who are themselves veterans -- to insist that they should continue to have access to the services of prescribing psychologists within the VA, as they did while on active duty.

Former USAF Prescribing Psychologist Elaine Foster recently wrote her own elected official: “After graduating from the DoD Psychopharmacology Demonstration Project (PDP) I served as a prescribing psychologist in the Air Force for over 20 years.  I continued to serve our active duty military after retiring, again as a prescribing psychologist under contract with the Air Force.  During that time, I prescribed for our veterans when we had space available at our military clinic….  If I walked across the hospital parking lot to our annexed VA clinic, I could no longer prescribe to that same patient I’d been prescribing to while he or she was active duty.  The current VA restrictions are illogical….  Because New Mexico recognizes prescribing psychologists, I can now prescribe to our veterans, but only in New Mexico, and only through a third party contractor….  This just does not make sense and is a clear waste of federal funds.”  It makes me feel so good to know….   “It always seems impossible until it’s done.”  Aloha,

Pat DeLeon, former APA President – Division 29 – May, 2015

 

I SAW HER AGAIN LAST NIGHT….

 The Very Best of APA:  The annual APA Practice Directorate State Leadership Conference (SLC) continues to be the highlight of my APA year.  This spring 530 colleagues, including an impressive number of early career psychologists and first time attendees, were treated to another spectacular event.  New models of service delivery, the importance of integrated and patient-centered care; and focusing upon developing effective business plans, while simultaneously providing "value-add" were highlighted.  The Illinois Psychological Association's recent prescriptive authority success, thanks in large part to the dedication and persistence of Beth Rom-Rymer, brought new life to the RxP movement with a number of states reporting their membership being re-energized.  Ann Compton, former White House correspondent for ABC News presented a fascinating perspective on the inner workings of the Oval Office, when Hillary would finally announce, and the unique perspectives of the First Ladies.  This was also the 10^th anniversary of David Ballard's visionary Psychologically Healthy Workplace and Organizational Excellence Awards ceremony, which actively engages psychology with the best of the business community at both the local and national level.  Under Norman Anderson's leadership, APA itself was recently designated as one of the "Best Places to Work" by the Washington Post.  As always, the enthusiasm and excitement of the audience was palpable.

            The theme for this year's conference was Practice Innovation and Practice Directorate Executive Director Katherine Nordal challenged those present to step up and become visionary leaders.  "Innovation involves new ideas and processes, change, upheaval and transformation.  To be innovators we need to shake off some old ways of thinking about traditional practice models.  We also need to shake off the negative attitudes some of our colleagues have about what's happening in health care.  The world is changing and health care is moving ahead – with or without psychology.  Whether we move forward will be up to us!  We need to think differently about our professional roles and the way we provide services.  Too many psychologists are stuck in the traditional 50-minute therapy box.  And that box is way too confining.  We need to think creatively… how we practice… where we practice… and what we practice.

            "How can psychologists participate in the evolving system in ways that are good for us, our profession and our patients?  What effects will reforms in health care systems, financing and technology, have on us?  And, how do we, as leaders in our profession, support our members as these changes unfold?  We need to see and understand the bigger picture – the health care environment in which psychology lives.  Psychology should be the discipline that defines and expands the mental health quality measures available for Medicare and other public and private payers as these measures become more widely required.

"Clinical practice guidelines provide an example of our asserting a leadership role.  Historically, psychology has not been at the table.  That has enabled others to control the process, and payers have used their guidelines to determine what they will and will not pay for.  That will change as APA finalizes three initial guidelines – for PTSD, depression and obesity.  Guidelines developed by other disciplines often ignore the rich psychological science that informs good practice.  APA guidelines will identify the most effective psychological treatments for these disorders, regardless of the discipline providing the care.  Our guidelines development process is innovative.  APA's panels are multidisciplinary.  One of our cutting-edge, best practices is including community members on each panel to represent the patient perspective.

"You'll need a dose of courage to face the resistance you're going to encounter back home.  There will be times when your colleagues push back at your efforts at innovation.  Sometimes you'll hear your colleagues complain, 'We shouldn't change the way we've always done it.'  Or, 'That's not how I was trained.'  When you get that push back, what 3-word message are you going to give back to them?  'Shake it off.'  You are the leaders with the focused vision and vigilance needed to influence a challenging, changing health care system.  You are the leaders who will shape a vibrant future for professional psychology."

The Administration's Vision:  At a recent HRSA national Advisory meeting, the acting administrator discussed the Accountable Care Act's vision for improving access to quality care; fostering a more diverse workforce emphasizing team-based, interdisciplinary care; developing healthy communities (i.e., a population-based focus); and giving a priority to prevention ,while addressing historical health disparities.  This is Katherine's charge.

            A Very Special Personal Journey:  "The APA Congressional Science Fellowship program had a profound impact on my life and my career, and I am profoundly grateful for the experience.  At the most recent APA Council of Representatives meeting, former Congressman Brian Baird gave a talk at the plenary session and commented on the importance of the Fellowship for both the profession of psychology and for Congress itself.  You might recall that I was the first psychologist to be a Robert Wood Johnson (RWJ) Health Policy Fellow, and this predictably led to 'Potomac Fever.'  I loved working on the personal staff of Senator Tom Daschle, and cherish the time I spent with Tom (in both South Dakota and DC) and being mentored by Rima Cohen, his health policy legislative assistant.  Of course, the two-month Institute of Medicine (IOM) orientation helped too (e.g., our half-day lecture about and tour of HHS was given by then Secretary Lou Sullivan).  I wrote lots of speeches, drafted legislation, met with constituents, attended committee hearings, and was intimately involved with the reauthorization of funding for the National Health Service Corps.  Bob Frank was the second psychologist picked as an RWJ Fellow; I'm sure his time working for Senator Jeff Bingaman (D-NM) at least partially was responsible for his current position as President of the University of New Mexico.

"Realizing that I could never go back to running a neuropsychology lab, I resigned a tenured full professorship at the Marshall University School of Medicine, determined to reshape my life as a health policy maven.  I applied for both the APA Congressional Science Fellowship and the MPH program at Harvard.  I was accepted for both, but opted to stay in DC and continue to learn about the fascinating world of health policy.  Ted Kennedy, Jay Rockefeller and Pete Stark all offered me jobs on their personal staff, but Congressman John Conyers then chaired the House Government Operations Committee, and I accepted a position on his committee staff, in part because of my interest in promoting a Canadian style single payer health care system for the United States, something Congressman Conyers passionately supported.  In addition, after a year working in the Senate, I wanted to learn more about the House of Representatives.

            "While spending two years on the Hill, I had an opportunity to get actively involved with APA activities and operations (Fellows are invited to participate in almost all relevant APA conferences, meetings, events and summits).  This eventually led to my active participation in APA governance and presidency of three divisions (12, 46, and 52) as well as participation for several terms on the Council of Representatives.  During this second year working for the Congress, my former Dean at Marshall became the Dean of the School of Medicine at the University of Missouri.  Although a thoracic surgeon, this Dean was very psychologically minded, and he was determined to bring me back to the Academy.  He offered me an opportunity to direct the Missouri Institute of Mental Health (MIMH), a policy, research and training 'think tank' with over 100 employees and a budget of about $6 million.  MIMH operated at the interface of the University of Missouri and the Missouri Department of Mental Health, and our mission was to serve anyone in Missouri with a mental illness, addiction or developmental disability.  The job required lots of time in Jefferson City (the state capital) as well as tracking state legislative policy.  It was a job that wouldn't come around again, so I accepted the Dean's offer and happily spent the next 20 years running the Institute.  I never went back to being a neuropsychologist… but I never regretted making the shift from direct patient care to being a 'policy wonk.'

            "I simply couldn't have done the job at MIMH – and it would never have been offered – had I not spent time on the Hill as a congressional science and health policy fellow.  I like to think I made a real difference during the two decades I spent in Missouri, and I've had opportunities to introduce literally thousands of students to health policy issues, both in Missouri and while serving as an Associate Dean at the California School of Professional Psychology (CSPP).  I also make sure the medical students I'm now teaching at the American University of Antigua know something about how health policy is shaped and how profoundly their professional lives will be affected by what happens in the halls of Congress and in state legislatures.  (A fortuitous and entirely unexpected benefit of being a former APA/AAAS Fellow was being invited to Canberra to testify before a subcommittee of the Australian Parliament about my experiences working on the Hill.)  Our 40^th Congressional Science Fellowship anniversary celebration at our last convention was truly memorable" [Danny Wedding].

            Change Is Inescapable; Although It Does Take Time:  As Katherine so apply notes, a number of our colleagues appear to be intractably resistant to change.  Apparently, however, this fundamental orientation is not limited to the discipline of psychology.  In reading about Rear Admiral Grace Hopper, who was a pioneering computer specialist, and who retired in 1986 as the Navy's oldest serving officer (having served for 42 years), I smiled learning: "In general, applied mathematicians were looked down on by their colleagues in pure mathematics.  There was a widespread belief that 'you turned to applied mathematics if you found the going too hard in pure mathematics.'"  Thank goodness for colleagues like former Division and APA President Ron Fox who continues to press for change, now meeting almost monthly with APA's Heather Kelly strategizing about how to get psychologists -- who are themselves veterans -- to insist that they should continue to have access to the services of prescribing psychologists within the VA, as they did while on active duty.

Former USAF Prescribing Psychologist Elaine Foster recently wrote her own elected official: "After graduating from the DoD Psychopharmacology Demonstration Project (PDP) I served as a prescribing psychologist in the Air Force for over 20 years.  I continued to serve our active duty military after retiring, again as a prescribing psychologist under contract with the Air Force.  During that time, I prescribed for our veterans when we had space available at our military clinic….  If I walked across the hospital parking lot to our annexed VA clinic, I could no longer prescribe to that same patient I'd been prescribing to while he or she was active duty.  The current VA restrictions are illogical….  Because New Mexico recognizes prescribing psychologists, I can now prescribe to our veterans, but only in New Mexico, and only through a third party contractor….  This just does not make sense and is a clear waste of federal funds."  It makes me feel so good to know….   "It always seems impossible until it's done."  Aloha,

Pat DeLeon, former APA President – Division 29 – May, 2015

 

THE INEVITABLE WINDS OF CHANGE

 From a public policy/political perspective, one can sense that the U.S. Congress is steadily returning to the days of bipartisanship, collaboration, and focusing upon meaningful accomplishments.  Recently, a number of congressional committees have recommended bipartisan bills; the most directly relevant to psychology is the Medicare "Doc Fix" legislation which has been a high priority for APA over the past several years, notwithstanding that it will add $141 billion to the projected federal deficit over the next decade.  The potentially highly emotionally charged "No Child Left Behind" reauthorization was unanimously endorsed by the Senate HELP Committee, while efforts to reform civil-asset forfeiture laws have gained strong bipartisan support within the Senate Judiciary Committee.  Although initially tied to the Attorney General's confirmation deliberations, the far reaching Sex-Trafficking legislation was ultimately sent to the President after a 99-0 Senate vote.  Similarly, this spring the Senate Commerce Committee has been exploring telehealth issues, again on a bipartisan basis.  These efforts would simply not happen without the strong encouragement of the leadership of both political parties.

            The APA State Leadership Conference (SLC):  The theme for this year's exciting APA State Leadership Conference (SLC) was Practice Innovationand it was the 10^th anniversary of David Ballard's visionary Psychologically Healthy Workplace and Organizational Excellence awards presentations.  Katherine Nordal stressed that: "Innovation involves new ideas and processes, change, upheaval and transformation.  To be innovators we need to shake off some old ways of thinking about traditional practice models.  We also need to shake off the negative attitudes some of our colleagues have about what's happening in health care.  This world is changing.  Everyone in this room knows it.  And health care is moving ahead – with or without psychology.  Whether we move forward will be up to us!  We need to think differently about our professional roles and the way we provide services.  Too many psychologists are stuck in the traditional 50-minute therapy box.  And that box is way too confining.  We need to think creatively about where psychology can best influence our evolving health care system… how we practice… where we practice… and what we practice."

            Katherine recently addressed our interdisciplinary health policy class at USUHS and, as she did at SLC, urged our next generation to see and understand the bigger picture – the health care environment in which psychology (and nursing) lives.  "We've developed a new registry to help fix the problem of low success rates with claims-based reporting, and to protect psychologists' Medicare payments.  Our Practice Organization was the first and only mental health organization to develop a registry.  Unlike other registries, our APAPO RQRSPRO focuses on mental and behavioral health measures.  We rolled out the registry in December and already have almost 1,200 registrants.  We have long-term aspirations.  We're laying the groundwork for a qualified clinical data registry.  Such a registry would give psychologists more choices of quality measures that better reflect the work that we do.  Psychology should be the discipline that defines and expands the mental health quality measures available for Medicare and other public and private payers as these measures become more widely required."

            I was particularly pleased to see her continuing emphasis upon engaging psychology with Medicaid, which is one of the foundations of President Obama's Patient Protection and Affordable Care Act (ACA).  The Congressional Budget Office (CBO) estimates that the ACA will reduce the number of uninsured Americans by 32 million.  Medicaid, which is a state administered program, is the largest single payer for mental health services in the nation, and as Katherine pointed out with Arkansas's recent success, has the potential for reimbursing the services of psychology's interns.  Getting psychologists to seek recognition under Medicaid has been a struggle given its traditional lower reimbursement rates; however, those with vision could appreciate its long term significance even prior to the enactment of the ACA.

            Most fittingly, Katherine also expressed all of psychology's appreciation for the successful efforts of the Illinois Psychological Association and Beth Rom-Rymer in particular.  "I want to share an example of a state that did a great job with collaborating and building partnerships.  That state is Illinois, gaining prescriptive authority for qualified psychologists.  And yes, it happened in the state that's home to the American Medical Association!  Hats off to Dr. Beth Rom-Rymer, who led the charge with her colleagues in Illinois.  It was a big win – the culmination of several years of tireless advocacy and a hard-fought legislative battle.  Our Illinois leaders demonstrated amazing skill in laying the groundwork for bringing medicine to the negotiating table and gaining support from a variety of organizations and groups – stakeholders like federally qualified health centers, prisons and the sheriff's association.  This win in Illinois has reinvigorated our profession's quest for prescriptive authority.  Idaho, Hawaii, New Jersey, North Dakota and Nebraska are engaged in legislative activity this year, and they're getting results."

            Integrating Behavioral Health Into Primary Care:  The California Technology Assessment Forum (CTAF) recently addressed the comparative clinical effectiveness and value of integrated behavioral health care.  "Despite a long history of treating physical health conditions separately from behavioral health, the two are inextricably linked.  Up to 70% of physician visits are for issues with a behavioral health component.  A similar proportion of adults with behavioral health conditions have one or more physical health issues….  Depression and anxiety in particular are common in primary care settings but are often inadequately identified and treated, leading to a worsening of behavioral conditions and/or increased difficulty managing physical health conditions."

            As Katherine consistently emphasizes, CTAF also noted that no single approach to integration will work for all communities; rather, integration should be designed for a particular set of local or statewide circumstances.  "In sum, there is a very large body of literature on the integration of mental health into primary care.  Studies of different models of integration across wildly varying delivery systems demonstrate with great consistency that integrated care improves depression and anxiety outcomes, although the absolute benefits are only small to modest.  Furthermore, integrated care improves patient quality of life and satisfaction with care."

            A Personal Reflection:  A number of years ago, former APA President Stan Graham shared his thoughts about the prospect of having to decide what to do with all of the awards and plaques he had received over the decades.  Perhaps send some of them to David Baker at the University of Akron's Psychology Achieves for posterity?  When they visit, our two grandchildren love to play in our closed-off roof dormer room.  The competition for that limited space is exactly what Stan described.  What to do with the Honorary Degree that former APA President Ron Levant bestowed upon me at Nova Southeastern University, or the impressive APA plaques and those from the State Associations which I visited during the past four decades?  How about the autographed photographs with our psychology colleagues who have been elected to the U.S. House of Representatives or the meeting we arranged with then First Lady Hillary Clinton to provide APA with the opportunity to talk about her National Health Insurance proposal?  Fond memories.  However....  The Inevitable Winds Of Change.  Aloha,

Pat DeLeon, former APA President – Division 42 – May, 2015

 

Division 42 May, 2015 column

THE INEVITABLE WINDS OF CHANGE

            From a public policy/political perspective, one can sense that the U.S. Congress is steadily returning to the days of bipartisanship, collaboration, and focusing upon meaningful accomplishments.  Recently, a number of congressional committees have recommended bipartisan bills; the most directly relevant to psychology is the Medicare “Doc Fix” legislation which has been a high priority for APA over the past several years, notwithstanding that it will add $141 billion to the projected federal deficit over the next decade.  The potentially highly emotionally charged “No Child Left Behind” reauthorization was unanimously endorsed by the Senate HELP Committee, while efforts to reform civil-asset forfeiture laws have gained strong bipartisan support within the Senate Judiciary Committee.  Although initially tied to the Attorney General’s confirmation deliberations, the far reaching Sex-Trafficking legislation was ultimately sent to the President after a 99-0 Senate vote.  Similarly, this spring the Senate Commerce Committee has been exploring telehealth issues, again on a bipartisan basis.  These efforts would simply not happen without the strong encouragement of the leadership of both political parties.

            The APA State Leadership Conference (SLC):  The theme for this year’s exciting APA State Leadership Conference (SLC) was Practice Innovation and it was the 10^th anniversary of David Ballard’s visionary Psychologically Healthy Workplace and Organizational Excellence awards presentations.  Katherine Nordal stressed that: “Innovation involves new ideas and processes, change, upheaval and transformation.  To be innovators we need to shake off some old ways of thinking about traditional practice models.  We also need to shake off the negative attitudes some of our colleagues have about what’s happening in health care.  This world is changing.  Everyone in this room knows it.  And health care is moving ahead – with or without psychology.  Whether we move forward will be up to us!  We need to think differently about our professional roles and the way we provide services.  Too many psychologists are stuck in the traditional 50-minute therapy box.  And that box is way too confining.  We need to think creatively about where psychology can best influence our evolving health care system… how we practice… where we practice… and what we practice.”

            Katherine recently addressed our interdisciplinary health policy class at USUHS and, as she did at SLC, urged our next generation to see and understand the bigger picture – the health care environment in which psychology (and nursing) lives.  “We’ve developed a new registry to help fix the problem of low success rates with claims-based reporting, and to protect psychologists’ Medicare payments.  Our Practice Organization was the first and only mental health organization to develop a registry.  Unlike other registries, our APAPO RQRSPRO focuses on mental and behavioral health measures.  We rolled out the registry in December and already have almost 1,200 registrants.  We have long-term aspirations.  We’re laying the groundwork for a qualified clinical data registry.  Such a registry would give psychologists more choices of quality measures that better reflect the work that we do.  Psychology should be the discipline that defines and expands the mental health quality measures available for Medicare and other public and private payers as these measures become more widely required.”

            I was particularly pleased to see her continuing emphasis upon engaging psychology with Medicaid, which is one of the foundations of President Obama’s Patient Protection and Affordable Care Act (ACA).  The Congressional Budget Office (CBO) estimates that the ACA will reduce the number of uninsured Americans by 32 million.  Medicaid, which is a state administered program, is the largest single payer for mental health services in the nation, and as Katherine pointed out with Arkansas’s recent success, has the potential for reimbursing the services of psychology’s interns.  Getting psychologists to seek recognition under Medicaid has been a struggle given its traditional lower reimbursement rates; however, those with vision could appreciate its long term significance even prior to the enactment of the ACA.

            Most fittingly, Katherine also expressed all of psychology’s appreciation for the successful efforts of the Illinois Psychological Association and Beth Rom-Rymer in particular.  “I want to share an example of a state that did a great job with collaborating and building partnerships.  That state is Illinois, gaining prescriptive authority for qualified psychologists.  And yes, it happened in the state that’s home to the American Medical Association!  Hats off to Dr. Beth Rom-Rymer, who led the charge with her colleagues in Illinois.  It was a big win – the culmination of several years of tireless advocacy and a hard-fought legislative battle.  Our Illinois leaders demonstrated amazing skill in laying the groundwork for bringing medicine to the negotiating table and gaining support from a variety of organizations and groups – stakeholders like federally qualified health centers, prisons and the sheriff’s association.  This win in Illinois has reinvigorated our profession’s quest for prescriptive authority.  Idaho, Hawaii, New Jersey, North Dakota and Nebraska are engaged in legislative activity this year, and they’re getting results.”

            Integrating Behavioral Health Into Primary Care:  The California Technology Assessment Forum (CTAF) recently addressed the comparative clinical effectiveness and value of integrated behavioral health care.  “Despite a long history of treating physical health conditions separately from behavioral health, the two are inextricably linked.  Up to 70% of physician visits are for issues with a behavioral health component.  A similar proportion of adults with behavioral health conditions have one or more physical health issues….  Depression and anxiety in particular are common in primary care settings but are often inadequately identified and treated, leading to a worsening of behavioral conditions and/or increased difficulty managing physical health conditions.”

            As Katherine consistently emphasizes, CTAF also noted that no single approach to integration will work for all communities; rather, integration should be designed for a particular set of local or statewide circumstances.  “In sum, there is a very large body of literature on the integration of mental health into primary care.  Studies of different models of integration across wildly varying delivery systems demonstrate with great consistency that integrated care improves depression and anxiety outcomes, although the absolute benefits are only small to modest.  Furthermore, integrated care improves patient quality of life and satisfaction with care.”

            A Personal Reflection:  A number of years ago, former APA President Stan Graham shared his thoughts about the prospect of having to decide what to do with all of the awards and plaques he had received over the decades.  Perhaps send some of them to David Baker at the University of Akron’s Psychology Achieves for posterity?  When they visit, our two grandchildren love to play in our closed-off roof dormer room.  The competition for that limited space is exactly what Stan described.  What to do with the Honorary Degree that former APA President Ron Levant bestowed upon me at Nova Southeastern University, or the impressive APA plaques and those from the State Associations which I visited during the past four decades?  How about the autographed photographs with our psychology colleagues who have been elected to the U.S. House of Representatives or the meeting we arranged with then First Lady Hillary Clinton to provide APA with the opportunity to talk about her National Health Insurance proposal?  Fond memories.  However....  The Inevitable Winds Of Change.  Aloha,

Pat DeLeon, former APA President – Division 42 – May, 2015

 

THE FOUNDATION FOR AN EXPANDED VISION (RxP History)

 Federal Involvement:  On November 30, 1984, at the Hawaii Psychological Association (HPA) annual convention, U.S. Senator Daniel K. Inouye urged the membership to amend their state practice act to allow them to independently utilize drugs where appropriate so that their "clients will be well-served."  After the Senator's challenge, the HPA Executive Committee agreed to pursue legislation which would study the feasibility of obtaining this clinical responsibility.  At that time there was little enthusiasm for the proposal within the psychological community and extreme opposition within the psychiatric community.  During the 1989 legislative session, hearings were held on eight separate bills.  A House Resolution was enacted "Requesting the Center for Alternative Dispute Resolution to convene a series of roundtable discussions."  Thus, Hawaii became the first state in the nation in which the issue of psychologists prescribing (RxP) was seriously debated.  Interestingly, their RxP legislation was ultimately vetoed on July 10, 2007 – more than two decades after the Senator's address.  In the 2015 legislative session, renewed HPA and grassroots interest resulted in their RxP bill passing the House of Representatives on March 10, 2015, by a vote of 23 yes, 13 yes with reservations, and 15 no.

            During Congressional deliberations on the Fiscal Year 1989 Appropriations bill for the Department of Defense (DoD) [P.L. 100-463], Senator Inouye included language which directed the Department to establish a "demonstration pilot training project under which military psychologists may be trained and authorized to issue appropriate psychotropic medications under certain circumstances."  Organized psychiatry raised considerable objections.  The following year the conferees stated: "the Department cannot ignore direction from Congress and therefore should develop such a training program…."  A DoD Blue Ribbon Panel was established, with Russ Newman representing APA, and recommended a two year fellowship, combing didactic and practicum activity.  To begin on time, two psychologists were initially assigned to the Army Physician Assistant program at Ft. Sam Houston Texas.

The Walter Reed/Uniformed Services University of the Health Sciences training program (PDP) began in the summer of 1991, and was closely monitored by the American College of Neuropsychopharmacology (ACNP).  ACNP concluded: "All 10 graduates of the PDP filled critical needs, and they performed with excellence wherever they were placed."  On June 17, 1994, Navy Commander John Sexton and Lt. Commander Morgan Sammons became the first graduates.  RxP training has continued in various venues, particularly in the private sector.  DoD and USPHS credentialing policies have been issued.  The seminal contribution of the DoD initiative is to affirmatively demonstrate that psychologists could be trained to safely prescribe in a cost-effective manner.  Interestingly, individual psychologists had been prescribing within the VA and Indian Health Service (Floyd Jennings) during this time period; however, without any formal organized training.

            APA Governance:  In 1989, under the leadership of Norma Simon, the APA Board of Professional Affairs (BPA) held a special meeting to explore this intriguing phenomenon.  BPA recommended: "focused attention on the responsibility of preparing the profession to address… needs of the public for psychologically managed psychopharmacological interventions be made APA's highest priority."  In August 1990, the Council of Representatives established an ad hoc Task Force on Psychopharmacology, chaired by Michael Smyer.  Its report concluded that practitioners, with combined training in psychopharmacology and psychosocial treatments, "could be viewed as a new form of health care professional, expected to bring to health care delivery the best of both psychological and pharmacological knowledge.  Further, the proposed new providers had the potential to dramatically improve patient care and make important new advances in treatment."  In August 1995, Council formally endorsed RxP for appropriately trained psychologists as APA policy and called for the development of model legislation and a model curriculum.  Subsequent Councils adopted these (1996); called for a national examination (1997); and formal APA recognition of Designated Postdoctoral RxP Training programs (2009).  APAGS adopted its Resolution of Support in 1997.  Bob McGrath estimates today there are more than 1750 psychologists who have completed their post-doctoral psychopharmacology training.

            State Legislation:  In March 1993, Indiana and in December 1998, Guam passed psychology RxP authorization legislation, although neither has been implemented to date.  In March 2002, New Mexico and in May 2004, Louisiana passed RxP legislation with John Bolter signing the first civilian script on January 20, 2005.  Elaine LeVine was the first female civilian prescriber.  More than a decade later, Illinois enacted its RxP legislation which was signed into law on June 25, 2014.  What is unique to Illinois is the decision to legislatively address the specifics of the required training (including at the undergraduate level) and its openness to incorporating RxP training at the graduate level.  Previous policy discussions had focused exclusively upon post-doctoral training.

            Future Challenges:  Although military and USPHS prescribing psychologists have provided quality psychopharmacotherapy services for more than two decades, there has been continued resistance within the VA and the federal Bureau of Prisons.  Ron Fox, former APA President: "As of December 31, 2013 when I was chair of the APA Insurance Trust, I can attest to the fact that prescribing psychologists do NOT have to pay higher premiums for professional liability insurance as the Trust deemed an increase unnecessary; and, because the Trust policy provides insurance to cover expenses related to licensing board complaints, I know that there have been no complaints or actions taken by state licensing boards regarding prescribing abuses by appropriately trained psychologists."  Along with enacting additional state practice laws, future challenges will include expanding to Federally Qualified Community Health Centers, state and local mental health clinics, and the evolving Accountable Care Organizations and Patient-Centered Medical Homes envisioned under President Obama's Patient Protection and Affordable Care Act.  Aloha,

Pat DeLeon, former APA President – Division 12 – April, 2015

 

HERE COMES THE JUDGE

  Perhaps it is due to growing up in a family where both parents were lawyers.  Perhaps it was serving as the first chair of the APA ad hoc Committee on Legal Issues (COLI).  More likely, it was profoundly enjoying Laugh-In.  For whatever reason, like former Division President Andy Benjamin, I have always been impressed by the commonality of interest between psychology and the legal profession.  The needs of psychology's patients often parallel those of the attorney's clients.  In 2008, the first Veteran's court was established in Buffalo in an attempt to seriously address this interface.  Former Massachusetts Psychological Association President and APA President Ron Levant heralded this transformative movement.  At the national level, APA and ABA cosponsor impressive conferences.  Another former APA President Don Bersoff, the association's first General Council, noted that by 2013, APA had submitted 147 amicus briefs, 58 of which were filed in the U.S. Supreme Court.  Why don't we hear about more state psychological associations working collaboratively with their local state bar associations?

            The FY' 2016 budget for the HHS Administration for Community Living (ACL) proposes to prevent, detect, and respond to elder abuse, neglect, and exploitation.  As the population of older Americans increases, these problems continue to grow.  Yet, there is no single set of national elder abuse prevalence data.  A 2004 national survey of State Adult Protective Service programs showed a 16% increase in the number of elder abuse cases from an earlier 2000 study.  Estimates are that 84% of all elder abuse incidents go unreported.  The most recent data suggest that at least 10%, approximately 5 million older Americans, experience abuse each year, many in multiple forms.

            The Administration reports extensive negative effects of abuse, neglect, and exploitation on the health and independence of seniors.  Older victims of even modest forms of abuse have dramatically higher (300%) morbidity and mortality rates than non-abused older individuals.  Adverse health impacts include an increased likelihood of heart attacks, dementia, depression, chronic diseases and psychological distress.  As a result, a growing number of seniors access the healthcare system and are ultimately forced to leave their homes and communities prematurely.

ACL envisions building a foundation and establishing best practices for States to expand and improve the protection of elderly individuals living in their communities and in long-term care settings; increase the information and technical assistance available; protect the rights of older adults and prevent their exploitation; and reduce health-care fraud and abuse.  Its Ombudsman Program relies heavily upon volunteers who make up the bulk of those who resolve resident issues.  The landscape is changing as individuals in need of long-term care services and supports increasingly choose to live in community settings.  Fortunately there is a growing federal awareness of the uncharted area of abuse, neglect, and exploitation of older adults and persons with disabilities.  These challenges must be effectively addressed.  We would rhetorically ask: What better topic for a joint conference or dinner discussion between our local state psychological and bar associations?  Aloha,

Pat DeLeon, former APA President – Division 31 – March, 2015

UNITED WE STAND, DIVIDED….

 The Critical Nature of State Associations:  Early on in my career I worked for the State of Hawaii Division of Mental Health at a time when state employees were being unionized.  Dues were an "expense" that I never regretted; for with the union, our collective voice was heard.  A very small, but illustrative example: When the inpatient psychiatrist was going away for two weeks, he pinned a notice on the bulletin board that I was in charge.  Upon his return, I submitted a request for a small amount of additional pay.  The head of the Division (a physician) took the position that a non-physician could nothave been in charge.  The union representative successfully argued that I was, in fact, in charge -- "See the pin hole where the notice was posted."  Several years later, psychologist Joe Blaylock was appointed Head of the Division of Mental Health.  As individuals, we may sincerely believe that our expertise is beneficial and serves society well.  However, the reality is that organized medicine has, over many years, consistently opposed any expansion of the clinical practice of all non-physicians, including their ability to serve in administrative or policy setting positions.  Without developing a cohesive collective voice, the past will all too accurately continue to predict the future.

The enactment of President Obama's Patient Protection and Affordable Care Act (ACA) heralds the beginning of unprecedented change in our nation's health care environment.  Former APA Congressional Science Fellow Sandra Wilkniss points out that the ACA provides one of the largest expansions of mental health and substance use disorder coverage in a generation.   She has also urged psychology to appreciate the magnitude of transformation occurring as the nation's health care system moves steadily towardsintegrated, interdisciplinary care – and thus away from its historical reliance upon fee-for-service, independent practice.  Data-based gold standard "best practices" will be tomorrow's expectation.

            I sincerely appreciate the 25+ years that I have been able to be involved in the APA governance and particularly the opportunity during my Presidency in 2000 to visit a number of smaller rural state psychological associations.  Nationwide, there are over 46 million citizens living in rural America who face ongoing challenges in accessing health care.  Rural America is where psychology can truly make a demonstrable difference in the lives of so many Americans.  Rural residents have historically struggled with issues related to access to care, recruitment and retention of health care providers of all disciplines, and maintaining the economic viability of hospitals and health care providers in isolated rural communities.  Rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than their urban counterparts.  Interestingly, the goal of President Obama's "Improving Rural Health Care Initiative" is to build healthier rural populations and communities through evidence-based practices.  This is an important mission for which psychology and the other behavioral sciences can make a unique contribution.  Exciting opportunities exist for those with visionary leadership.

            A number of our colleagues do not seem to understand that as one of the nation's educated elite, they have a societal responsibility to become personally involved in effectively addressing society's most pressing needs.  Collectively, they do not seem to appreciate that through their own state psychological association, and at the federal level APA, they can have a profound impact upon the public policy/political process.  During my involvement within the APA governance, I came to deeply appreciate that our profession is only where it is today because of the efforts of the visionary leaders of the past.  Gene Shapiro, Nick Cummings, Suzanne Bennett Johnson, Bill McKeachie, and the late John Gardner (former Secretary of HEW under President Lyndon Johnson and President of Common Cause) to name just a few to whom we owe so much.  Today's challenge is for each of us to reach out to colleagues and convince them to join (and especially, to rejoin) the only collective voice they have – the Arkansas Psychological Association.  This is particularly true for our senior colleagues who thereby will have the opportunity to mentor the next generation.  During my early days with the Hawaii Government Employees Association (HGEA), I saw how effective this personalized approach can be.  This challenge is about the very future of the field in a dramatically changing world – it is not exclusively a practitioner, academic, or science issue.  It is about survival and addressing unprecedented change.  It is about setting achievable goals.  And it is, above all else, about taking advantage of new exciting opportunities.

            Telepsychology – A Future For Many:  The unprecedented advances occurring within the computer and technology fields continue to have a major impact upon all aspects of society including our economy, except, most health policy experts would proffer, the health care industry.  The ACA is dedicated to rapidly changing this in furtherance of targeting the critical health policy goal of accomplishing "the triple aim" -- i.e., improving the experience of care, improving the health of populations, and reducing the cost of health care.  Psychology is very fortunate that 2011 APA President Melba Vasquez possessed the vision to appreciate the significance of the advent of the era of Telemental Health/Telepsychology for the profession and for all of behavioral health.  Acknowledging the successes of pioneering colleagues within the Departments of Veterans Affairs (VA) and Defense (DoD) who have been particularly responsive to its exciting potential, she established in close collaboration with the Association of State and Provincial Psychology Boards (ASPPB) and the APA Insurance Trust (APAIT), a telehealth task force which systematically addressed a number of the complex issues surrounding utilizing this evolving technology.  In August, 2013 at our annual convention, Council passed their recommended Telepsychology Guidelines on the consent agenda.

Telemental health services were initiated within VA in 2004-2005, and under the leadership of Antonette Zeiss, the first psychologist to be appointed chief consultant for the Office of Mental Health Services, VA was soon leading the way for the nation.  In fiscal year 2013, more than 600,000 veterans accessed care using telehealth programs for a total of over 1.7 million episodes of care.  It is estimated that VA telehealth services are increasing by approximately 22% annually.  We are indeed most fortunate that one of the truly visionary leaders in this area is Steve DeMers, ASPPB Chief Executive Officer.  His colleagues Fred Millan and Janet Pippin Orwig have been working diligently with both nursing and medicine, as well as the Council of State Governments, to coordinate developing an innovative Telepsychology Licensure Compact.   The critical implementation steps will be at the state level until sufficient national consensus is ultimately developed justifying a federal approach.  Working out the details will become one of the Arkansas Psychological Association's priorities over the next several years.  "It ain't quite this simple, so I better explain just why you got to ride on the union train."  Aloha,

Pat DeLeon, former APA President – Arkansas Psychological Association – February, 2015