THE STEADY EVOLUTION OF THE PRESIDENT’S VISION

            Who Are Providers?  Over the next decade our nation will experience the systematic implementation of the Patient Protection and Affordable Care Act (PPACA), President Obama's landmark health care reform legislation.  Practitioners, administrators, and health policy experts of all disciplines will eventually come to appreciate the importance of addressing the considerable flexibility provided in the law for the States and the Administration to craft effective local responses to broader national priorities, such as dramatically increasing access to primary care.  The emotional political rhetoric being expressed in the House of Representatives calling for an immediate repeal of "Obama Care" is most unfortunate, as it makes historically bipartisan technical corrections to any complex legislation much more difficult to achieve.  Nevertheless, as was the case with the highly controversial Medicare and Medicaid legislation proposed by President Lyndon Johnson as a key component of his Great Society vision, we are confident that ultimately President Obama's initiative will similarly stand the test of time.

            The Senate Appropriations Committee FY'11 recommendations for the Health Resources and Services Administration (HRSA) would have provided $40 million to begin the newly authorized Medical Home demonstration program, which would include community health teams and community-based collaborative care networks.  Under these authorities, funds would be used for the creation and support of interdisciplinary patient care teams, assistance to low-income individuals to access care, case management, benefit enrollment, and other assistance.  Funding would also have been available to initiate Accountable Care Organizations (ACOs) within which providers and hospitals would be encouraged to join together to form groups covering at least 5,000 patients each, which would be accountable for cost, quality, and overall care.  Health policy experts have suggested that these ACOs would essentially be Health Maintenance Organizations (HMOs), which were the vision of President Richard Nixon.

            A careful review of the actual statutory language for both the Medical Home and Accountable Care Organization initiatives reveals that a functional/programmatic rather than structural/discipline approach was adopted by the Congress, providing the Secretary of Health and Human Services (HHS) with broad authority to issue implementing regulations.  For example, although "physician services" will be provided, who is a "physician" and who will administer the local entity is not specified.  For rural America, with its historical shortage of health care practitioners of all disciplines, this flexibility is particularly significant.  For those psychologists and other non-physicians who appreciate the importance of the underlying movement towards interdisciplinary and integrated care, this Congressional approach provides the opportunity (and necessity) for active engagement at both the local and national legislative and administrative levels.

            Since the definitions of "medical home" and "ACO" are not agreed to, either in statute or within the national health policy community, there undoubtedly will be an extended debate around which entities will ultimately qualify for such designation and specifically, if non-physician providers (e.g., nurse practitioners) or non-physician provider-led practices, may qualify.  Most likely the answer will depend upon a number of factors, including relevant statutory definitions, the financing setting (e.g., Medicaid), promulgation of relevant regulations or guidance; and in some cases, state practice acts.  We should expect that how the underlying issues are resolved for Medical Homes and Accountable Care Organizations will be similar, given the many shared legislative goals of these two models.

The Medicare Shared Savings Program (MSSP), established by PPACA Sec. 3022, allows for the inclusion of non-physician providers, by reference to existing definitions.  Section 3502 of PPACA establishes a grant program to create health teams that provide support to primary care providers and provides capitated payments to these providers.  It defines "primary care" as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health needs, developing a sustained partnership with patients, and practicing in the context of family and community."  Similarly, Sec. 5405 defines a "primary care provider" as "a clinician who provides integrated, accessible health care services and who is accountable for addressing a large majority of personal health care needs, including providing preventive and health promotion services for men, women, and children of all ages, developing a sustained partnership with patients, and practicing in the context of family and community, as recognized by a State licensing or regulatory authority."  Another section of PPACA states: "TREATMENT OF QUALIFIED DIRECT PRIMARY CARE MEDICAL HOME PLANS. – The Secretary of Health and Human Services shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home plan that meets criteria established by the Secretary, so long as the qualified health plan meets all requirements that are otherwise applicable and the services covered by the medical home plan are coordinated with the entity offering the qualified health plan."  We should expect that non-governmental accrediting agencies will soon begin addressing this important policy void.  Typically, such entities have provided significant flexibility given the differing conditions which exist across our nation, particularly in rural America, and the broad range of input which they receive from concerned community stakeholders.

Research To Practice:  Last year theInstitute of Medicine (IOM) released its sixth report in the Learning Health System series, highlighting its workshop on Clinical Data As The Basic Staple Of Health Learning: Creating And Protecting A Public Good.  The underlying IOM goal is to have 90 percent of clinical decisions supported by accurate, timely, and up-to-date clinical information and reflect the best available evidence by 2020.  Those sensitive to the personalized nature of health policy will appreciate that many of participants in the IOM discussions have served, or serve, within the Bush and Obama Administrations.  Today the U.S. per capita health care costs are nearly double that of comparable nations.  "Care that is important is often not delivered.  Care that is delivered is often not important.  In part, this is due to our failure to apply the evidence we have about the medical care that is most effective."

Throughout the IOM report there was the distinct call for broader public engagement, especially to build the necessary trust to achieve the IOM vision.  Public policy and public awareness lag behind the technical, organizational, and legal capacity for reliable safeguarding of individual privacy and data security in mining clinical data by new technologies.  It was felt that there is a fundamental conflict between whether health care data should be viewed as a public good or a private commodity.  This relates directly to underlying privacy concerns often espoused by organized psychology and the fear by patients of discrimination.  "In many respects, the greatest challenge associated with establishing a medical care data system to serve the public interest lies in the fact that such data largely reside in the private sector, where commercial interests and other factors inhibit sharing."  Ultimately advancing the notion of clinical data as a public good is essential to a healthcare system that learns.  The utility of clinical data was viewed a transformative agent for our nation's health care system, especially as technology becomes increasingly sophisticated.

A modern evidence and value-driven healthcare system must have the capacity to learn and adapt – to track performance in real-time and generate and apply information for future improvements in safety, quality, and value of care received.  Today, there are enormously misaligned incentives which have evolved from an obsolete reimbursement system.  Research must become a normative part of health care, in which every intervention with a patient is seen as an opportunity to learn.  In essence, it is time to adopt an entirely new paradigm.  Taking a broader perspective, it is possible to integrate data taken on socioeconomic, environmental, biomedical, and genetic factors; individual health status and health behaviors; biomedical and genetic factors, as well as on resource use, outcomes, financing, and expenditures.  These data are stored in a variety of electronic silos and data bases and, under appropriate policy conditions, can be meaningfully aggregated and integrated.  Change is coming – about half of primary care physicians report that their patients have arrived with research from the Internet. Yet changing the culture of providers to collect data in high-quality ways remains dramatically difficult.

To effectively change behavior, we must directly address incentives and realize that the existing incentive structure discourages information sharing, giving greater weight to possible errors in protecting privacy relative to errors in failing to use existing information to improve public and individual health.  To build public support, the value of sharing clinical information must be demonstrated.  The public must come to appreciate the significance to them of the National Academy of Sciences' estimate that 25 percent of developmental disabilities (i.e., cerebral palsy, autism, and mental retardation) are caused by environmental factors.  And, the American Cancer Society's estimate that one-third of cancer deaths could be prevented through lifestyle and environmental changes.  Effectively utilizing clinical data will make a real difference in the lives of many citizens and is critical to the well functioning of integrated primary care.  Will psychology take a leadership role in educating society?  The three major challenges for the 21^st century are culture, communication, and collaboration.

The common workshop themes which emerged were: * Clarity on the basic principles of clinical data stewardship; * Incentives for real-time use of clinical data in evidence development; * Transparency to the patient when data are applied for research; * Addressing the market failure for expanding electronic health records (EHR); * Personal records and portals that center patients in the learning process; * Coordinated EHR user organization evidence development work; * The business case for expanded data sharing in a distributed network; * Assuring publicly funded data are used for the public benefit; * Broader semantic strategies for data mining; * And, Public engagement in evidence development strategies.

In submitting the FY'12 budget request for the National Institutes of Health (NIH) the Director: "This budget request for a $31.987 billion total program level reflects an effort, amid economic uncertainty and fiscal constraint, to fulfill the President's unwavering commitment to international leadership in science and progress in biomedical research.  The requested funding will enhance NIH's ability to support research that prolongs life, reduces disability, and strengthens the economy….  (E)nhancing the evidence base for health care decisions:  NIH will support rigorous studies for assessing the effectiveness of new therapies and health care interventions within populations and for individuals.  Research in comparative effectiveness and personalized medicine is essential to the fulfillment of the agency's mission and will enhance the evidence base for decision making in clinical practice.  For example, NIH will fund a Health Maintenance Organization Research Network Collaboratory.  This landmark initiative will bring together HMOs caring for more than 13 million patients for the purpose of accelerating research in the high priority areas of epidemiological studies, clinical trials, and electronic-health-record-enabled health care delivery."

The Robert Wood Johnson Foundation(RWJ) recently announced a highly relevant grant program seeking to build the evidence for and strengthen the use of regulatory, legal, and policy solutions to improve public health and help citizens live healthier lives.  This would include identifying those laws and legal practices which unintentionally harm health.  As always, we live in "interesting times."  Aloha,

 

Pat DeLeon, former APA President – Division 42 – March, 2011

 

ALOHA – MAKING A REAL DIFFERENCE

            The Health Policy Process:  Early in the Obama Administration Mary Wakefield, Administrator of the Health Resources and Services Administration (HRSA), visited Hawaii in order to get a first hand view of our unique health care needs, particularly on the neighbor islands.  Captain Jacqueline Rychnovsky, Senator Inouye's Department of Defense (DoD) Nurse Fellow, and Beth Giesting, CEO of the Hawai'i Primary Care Association, accompanied Mary, who also gave a wonderfully insightful talk at the APA Education Directorate policy breakfast during our recent San Diego convention.  Beth was recently appointed to the Negotiated Rulemaking Committee and Process for HRSA.  Her January report:

            "One of the results of the Affordable Care Act and its early investment in the primary care delivery system ($11 billion more for community health centers over five years and an emphasis on patient-centeredprimary care services) is the need to ensure the credibility of the federal designation process.  This is the process that assesses the needs vs. the primary care resources of a defined community:  * Any community that wants to compete for federal community health center funding or be designated a federally-qualified health center must be designated as a Medically Underserved Area or Population (MUA/P).  * Any community that wants to take advantage of National Health Service Corps resources must be designated a Health Professional Shortage Area (HPSA).  * Any clinician or medical group that wants to become a Rural Health Clinic and reap the benefits of enhanced Medicare and Medicaid payments must be in a designated Health Professional Shortage Area.  And, * Besides the CHC and NHSC programs, there are dozens of other federal programs that have come to rely on federal designations for eligibility or prioritization of resources.

            "The rules now in use for HPSAs and MUA/Ps date back to the 1970s.  Proposed changes to the criteria for designations were introduced in 1998 and 2008, each time setting off an avalanche of questions, concerns, and opposition.  This time, HRSA is employing a process to bring together a wide array of stakeholders to work together on a negotiated draft of the proposed rules.  Participants in this process include representatives from Primary Care Associations (including the Hawai'i Primary Care Association), the National Association of Community Health Centers, Safety Net Clinics, state Primary Care Offices, the National Association of Rural Health Clinics, the Association of State and Territorial Health Officers, Rural Hospitals, Native American and Alaskan health organizations, and public health and health data experts, among others.

            "To-date, the group has agreed that we need to maintain the distinction between areas where the provider to population ratio is too low (HPSA or MUA) and areas where there may appear to be an adequate number of providers but barriers to access exist for some of the area residents (MUP).  We are also working with the principle that organizations like community health centers that continue to serve a significant underserved population will not be de-designated based on the results of new rules.  Since there is so much to consider in this process, our committee has created subgroups.  One is considering the availability and ramifications of data on populations, providers, and health status while another is working on the many issues around identifying special populations and barriers to care.  We are scheduling 3-day meetings for each of the next three months so that we can make recommendations and allow for impact testing to help inform HRSA's ultimate decisions for the new designation rules."

            A Personal Perspective:  Lt. Col.Maureen Charles, this year's DoD Nurse Fellow:  "I have served in the US Air Force Nurse Corps for over twenty years.  During this time I have performed in various capacities to include working as a clinical nurse on medical/surgical; labor and delivery; new born nursery and same day surgery units; working as a board certified women's health nurse practitioner, as well as managing various clinical arenas.  Until recently, I commanded 190 personnel in an outpatient facility with over 280 employees providing 65,000 outpatient visits and 9,600 referrals annually at Minot AFB, North Dakota.  I also served as the Chief Nurse Executive and oversaw all nursing care provided by 135 professional and para-professional nursing staff.  Most recently I was selected for the prestigious Congressional Military Nursing Fellowship.

            "It has been six amazing weeks since I began a year long military nurse fellowship in Senator Inouye's office and what an experience it has been!  It started out with a bang as the first Session of the 112^th Congress began two days after my arrival.  In the six short weeks of my experience here in the Senate, there have been so many things that stand out that it is difficult to pick out the true highlights.

            "One of the most memorable experiences occurred on opening day of the new Congress as I sat in the Senate gallery watching the events of the day unfold.  I was awestruck as I watched the distinguished men and women of the Senate take the oath of office administered by the Vice President of the United States, Mr. Joe Biden, as their families watched from above the Senate floor.  Upon her swearing in, Senator Barbara Mikulski became the longest serving female Senator in the history of the nation.  After the event I had the pleasure of meeting Senator Inouye in person.  As we chatted for a few moments I was struck by how humble and sincere the Senator is.  It was truly an honor being in his presence!

            "The next few weeks were filled with a flurry of activity as we worked feverously to make sure all the health related bills the Senator introduced in the 111^th Congress were update and ready for reintroduction in the 112^th Congress.  During this time I learned that any bill introduced in the previous Congress that did not become law, needed to be reintroduced again in the hopes that this time around the bill would become law.  Another highlight was helping prepare a speech for the Senator to give at a rural health conference.  The day was spent learning how to research information for the speech.  The amazing part was seeing how the Senator's vision for the contents of the speech was molded into a wonderful fifteen minute speech.

            "The majority of the days are often filled with constituent, lobbyist and organization meetings.  During these meetings various issues and concerns are raised.  The common premise of these visits revolves around funding and legislation concerns in addition to ensuring their voices are heard.  It is interesting to see the delivery of the groups that come through the office doors.  One of the meetings actually resulted in the development of a brand new bill that the Senator introduced.  It was interesting to learn how to write a bill and how to write a floor statement to accompany the bill's introduction, as well as learning how to drum up support for the bill so that it will gain momentum and ultimately result in the bill being passed into law.  The most memorable meetings to date have been and continue to be those that I sit on with individuals meeting with Senator Inouye!

            "Another interesting part of my time here has been learning about the budget process.  More specifically, the impact of not passing the FY' 2011 budget or the Omnibus Appropriations bill during the "Lame Duck" session of Congress as Senator Inouye recommended and how this has affected the country as a whole.  A key piece of my experience has been soaking in the wisdom of those around me including learning how the "ear-mark" process worked and seeing truly how many organizations and communities across the country will be adversely affected by the moratorium on this activity"  [The views expressed are personal and do not necessarily reflect those of the USAF.]

            Promises Kept -- Exciting Opportunities:  Candidate Barack Obama: "I… believe that every American has the right to affordable health care."  Earlier this yearTom Driskill, former CEO of the Hawaii Health Systems Corporation and currently with the Honolulu VA, reported that the VA had created a new Office of Tribal Government Relations to ensure that the more than 200,000 Veterans who are American Indians, Alaska Natives, Hawaiian Natives, or are part of the Alaska Native Corporations will receive the VA benefits they have earned.  "There is a long, distinguished tradition of military service among tribal peoples," said Secretary Eric K. Shinseki.  "VA is committed to providing these Veterans with the full range of VA programs, as befits their service to our nation."  The office has a charter that officially extends to Veterans who are American Indians, Alaska Natives, Native Hawaiians, and Alaska Native Corporations.  Interesting times.  Aloha,

 

Pat DeLeon, former APA President – HPA – March, 2011

 

 

SO PLEASE DON’T EVER CHANGE

         The Institute of Medicine:  Last year the Institute of Medicine (IOM) issued its report Informing the Future: Critical Issues in Health.  Released prior to the final enactment of President Obama's landmark health care reform legislation, the Patient Protection and Affordable Care Act [PPACA], the IOM foresaw the changes coming.  "Increasing effectiveness and efficiency of the health care system.  By all accounts, the nation's current health care system is flawed, marked by rising costs, lack of evidence about the effectiveness of even the most widespread medical procedures, and a growing number of people who are uninsured.  Among suggested changes, HHS should work with Congress to establish a capability for assessing the comparative value – including clinical and cost effectiveness – of medical interventions and procedures, preventive and treatment technologies, and methods of organizing and delivering care.  This effort will require expanded information sharing, both within the department as well as with external organizations, in order to better evaluate and inform the health care system."

The IOM called for the federal government to: * Define a 21^st century vision for how to provide the greatest value in protecting and improving health in today's climate of varied, complex, and sometimes changing health needs.  * Strengthen the health care workforce.  Serious shortages exist across the health care spectrum of professionals with the right backgrounds, training, and skills.  There is an aging workforce, new health challenges requiring new skills, an imbalance between primary care providers and specialists, and an underrepresentation of minority groups.  And, * Assessing what works in health care.  Many studies have documented spending on ineffective care and significant variations in how multiple health care providers treat the same condition.  At the same time, health plans face the need to constantly learn how their beneficiaries might benefit from – or be harmed by – newly available health services.  Rigorous standards for creating clinical practice guidelines which could help clinicians and patients make informed decisions about appropriate health care for specific clinical conditions should be developed and promoted.  Evidence-based health care is critical as we enter the 21^st century.  And yet, it is unquestionably an evolving and highly complex process.

            APA – Getting Ahead of the Curve:  During the past year, President Carol Goodheart's APA Presidential Task Force on Advancing Practice, on which Hawaii's Darryl Salvador and long time colleague Jeff Zimmerman serve, addressed their basic mission of identifying educational and other resources needed by practicing psychologists and prioritizing and advancing the development and dissemination of such resources.  The ultimate objective is to create an outcomes framework and a clinical resources framework in order to integrate practice and science in useful ways that support practitioner efforts to develop quality services.  "In this era of ever increasing demands for accountability, the best way for psychologists to demonstrate the effectiveness of services is to measure outcomes."

            Jeff's report: "So, you're sitting in your office and have a question about practice (clinical issues, practice management, insurance, etc.) or you are involved in research and want to float some ideas, or you are searching for information about outcome measures.  What do you do?  Well typically we use one of the common search engines, pose a question and get millions of hits to sort through.  While search engines can offer a great diversity of hits, we are often unsure how to better pinpoint what we need and we can be unsure of the quality of information obtained.  Similarly, on the many list serves we may be on, we have to sort through countless e-mails or digests to find pertinent information.  Now members of APA have another choice – PsycLINK.

            "If you go to my.apa.org and click under Tools, you will be taken to APA's new wiki platform PsycLINK.  There you will find the beginnings of a new initiative started by the APA Task Force appointed by Carol and chaired by Karen Zager.  Thanks to the work of the task force, which included APA members and Practice Directorate Executive Director Katherine Nordal and her staff Lynn Bufka and Joan Freund, PsycLINK is a platform that is continuing to develop and is a community built by psychologists for psychologists.  As it grows, the breadth and depth of information will grow as well.  Searches will be more comprehensive and to the point, as many results of the public search engines will be screened out.  Additionally, the diversity of input from colleagues in different Divisions and professional roles can be more easily realized, when compared to a more singular listserv hosted by one professional subgroup.

            "PsychLINK is not e-mail intensive in the slightest.  You can set it to send you one e-mail a day of all the titles of the postings, or you can check it when you care to.  To post comments or start new posts you have to register – again, a very simple process.  So, check it out.  Ask a question, post something you think may be of use, or comment on a posting to lend a hand to a colleague.  This isour virtual community.  Let's help it grow."

            A Highly Complex Process:  Another IOM report focused upon Policy Issues in the Development of Personalized Medicine in Oncology and noted that personalized cancer medicine is defined as medical care based on the particular biological characteristics of the disease process in individual patients.  In oncology, personalized medicine has the potential to be especially influential in patient treatment because of the complexity and heterogeneity of each form of cancer.  However, the current classifications of cancer are not as useful as they need to be for making treatment decisions.  Treatment needs to evolve toward a focus on targeted treatments based on individual characterizations of the disease.  Although this underlying concept has great promise, a number of policy issues must be clarified and resolved before personalized medicine can reach its full potential.  These include technological, regulatory, and reimbursement hurdles.  Addressing the reimbursement possibilities, the report noted that while some Medicare coverage decisions are made at the national (CMS) level, approximately 85 to 90 percent of coverage decisions are actually made by local contractors.  That is, local contractors can increase national coverage and reimburse additional procedures and tests, if deemed to be "reasonable and necessary" in order to improve clinically meaningful health outcomes.  Evidence is assessed using standard principles of evidence-based medicine.

            Women Veterans:  With the significant number of active duty personal, veterans, and called up national guard troops in Hawaii, another IOM report should be of particular interest.  That document recommended that DoD and VA quantify the number and distribution of mental health professionals needed to provide treatment to the full population of returning service members, veterans, and their families who might suffer from mental health disorders such as PTSD, major depression, and substance abuse, so that they can readjust to life outside of theater.  The committee also recommended that DoD and VA continue to implement programs for the recruitment and retention of mental health professionals, particularly to serve those in hard-to-reach areas.  Women now constitute 14% of deployed forces in the U.S. military, and although technically they are barred from serving in combat, a growing and unprecedented number of female soldiers are deployed to combat areas where their lives are at risk.  All service members are exposed to high levels of workplace stress; however, women in the military were found to face some unique stressors, such as sexual harassment and trauma exposure that may affect their mental health and emotional well-being.  Female veterans report a higher burden of medical illnesses, worse quality-of-life outcomes, and earlier psychologic morbidity than do men who are exposed to the same levels of trauma.  Both the military and family life requires commitment and loyalty, and servicewomen who have families may experience intense conflict between the demands of their military roles and their family roles.  Deployment involves being separated from children and families for months at a time and leaving children behind with spouses or alternative caregivers.  Single mothers confront special challenges.  Interestingly, deployment appears to affect the marital stability of male and female soldiers differently.  It has been found that deployment led to a large, statistically significant increase in divorce rates in women in the military, but not men.  Psychologists Margarita Alegria, John Corrigan, and Janice Krupnick served on this IOM committee.  I KIND OF LIKE YOU JUST THE WAY YOU ARE (Beatles, 1963).  Yet, fundamental change is definitely coming.  Aloha,

 

Pat DeLeon, former APA President – Hawaii Psychological Association – December, 2010

 

A REFRESHING LONG-TERM VISION FOR THE NATION

Over the next five to ten years, our nation will experience the steady implementation of President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act [PPACA].  It is important to appreciate that the underlying vision behind this wide ranging initiative is the nurturing of a patient-centered (and not provider-centric) comprehensive delivery system in which timely access to high quality Primary Care is the highest priority.  The Act represents the broadest changes to the health care system since the enactment of Medicare and Medicaid in 1965 under President Lyndon Johnson's Great Society.  Over time, various technical modifications will undoubtedly be made.  With the States being given considerable latitude to experiment with local options, we should experience a revitalization of their historical role as "laboratories of social change."  And, notwithstanding many highly emotional campaign promises, we are confident that there is very little likelihood that the President's fundamental vision will be significantly modified during the next decade.  Health Promotion, Disease Prevention, and encouraging Healthy Lifestyles will finally become a priority.  Interdisciplinary care and multidisciplinary training initiatives are the future.  Historically isolated professional silos of treatment and training will simply be unacceptable.  The behavioral sciences couldflourish.

The federal government will increasingly invest in Health Information Technology (HIT) and data-driven Comparative Competitive Research (CER) in order to ensure that the care provided will, in fact, be appropriate and based upon the most up-to-date scientific knowledge.  An additional 32 million previously uninsured Americans will have access to necessary health insurance, while the Congressional Budget Office (CBO) estimates that the bill will reduce the deficit by $143 billion over the first decade of enactment and effectively bend the ever-escalating cost curve.  No longer will the Institute of Medicine (IOM) report: "The lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of about 15 to 20 years.  Even then, adherence of clinical practice to the evidence is highly uneven."  Licensure mobility will become the norm.  The public sector with its budgetary resources, and especially the Department of Defense (DoD) and the Veterans Administration (VA), will undoubtedly take the lead in demonstrating the effectiveness of "seamless care" and the unprecedented opportunities for developing individualized gold standard protocols utilizing the unprecedented advances occurring within the communications and technology fields.  Virtual realities, 24/7world-wide expert consultations, and home-based care will become what the public (and their elected officials) expect.  Over the years we have learned that change is always unsettling, especially for those whose future suddenly seems unpredictable and perhaps out of their control.  And yet, unprecedented change is undoubtedly upon us.

This Fall the IOM, in conjunction with the Robert Wood Johnson Foundation, released a truly visionary report: The Future of Nursing: Leading Change, Advancing Health.  Nursing is the largest sector of the health professions, with more than 3 million registered nurses in the United States.  Acknowledging that the American health care system is undergoing fundamental transformation and chaired by former HHS Secretary Donna Shalala, the IOM committee proclaimed: "Nurses should practice to the full extent of their education and training.  To ensure that all Americans have access to needed health care services and that nurses' unique contributions to the health care team are maximized, federal and state actions are required to update and standardize scope-of-practice regulations to take advantage of the full capacity and education of APRNs [Advanced Practice Registered Nurses].  State and insurance companies must follow through with specific regulatory, policy, and financial changes that give patients the freedom to chose from a range of providers, including APRNs, to best meet their health needs.  Removing regulatory, policy, and financial barriers to promote patient choice and patient-centered care should be foundational in the building of a reformed health care system."

The committee urged: "Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.  Major changes in the U.S. health care system and practice environment will require equally profound changes in the education of nurses both before and after they receive their licenses.  An improved education system is necessary to ensure that the current and future generations of nurses can deliver safe, quality, patient-centered care across all settings, especially in such areas as primary care and community and public health….  Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States."  For many health care providers the vision of the President and the IOM calls for a fundamental re-conceptualization of the role of nursing, as well as that of a wide range of non-physician providers.  In particular, practitioners must come to appreciate that it is the patient who ultimately will assume primary responsibility for his or her own health care, as the all important psychosocial-economic-cultural gradient of care becomes appropriately recognized and reimbursed.

The clinical skill set of professional nursing covers a broad continuum from health promotion, to disease prevention, to coordination of care, to cure – where possible – and to palliative care when cure is not possible.  Many members of the nursing profession admittedly require more education and preparation to adopt new roles in response to rapidly changing health care settings and the evolving health care system.  Today's restrictions on their scope of practice, policy- and reimbursement-related limitations, and professional tensions have undermined the nursing profession's ability to provide and improve both general and advanced care.  Developing a health care system that delivers the right care – quality care that is patient centered, accessible, evidence based, and sustainable – at the right time will require transforming the work environment, scope of practice, education, and numbers of America's nurses.  If today's generation of psychologists reflects upon the efforts of their senior colleagues who worked hard to obtain the statutory right to "diagnose and treat," obtain direct reimbursement from public and private insurance companies (i.e., enact freedom-of-choice legislation), seek hospital privileges, and most recently obtain prescriptive (RxP) authority, the necessary foundation for their success in challenging the medically-oriented status quo was obtaining and demonstrating to the public (and to their elected officials) that they possessed the quality education necessary to competently fulfill these sought after clinical responsibilities.  And, we must not forget that they almost always experienced the vocal opposition of organized medicine, proffering that non-physicians would harm patients (i.e., were "public health hazards") if we were allowed to treat our patients without direct physician supervision and control.

The IOM committee was truly interdisciplinary in composition, including a former Administrator of HCFA (now CMS).  It appreciated that: "Strong leadership is critical if the vision of a transformed health care system is to be realized.  To play an active role in achieving this vision, the nursing profession must produce leaders throughout the system, from the bedside to the boardroom.  These leaders must act as full partners with physicians and other health professionals, and must be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions.  Being a full partner transcends all levels of the nursing profession and requires leadership skills and competencies that must be applied within the profession and in collaboration with other health professionals….  To be effective in reconceptualized roles, nurses must see policy as something they can shape rather than something that happens to them.  Nurses should have a voice in health policy decision making and be engaged in implementation efforts related to health care reform.  Nurses also should serve actively on advisory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care."  Those colleagues fortunate to have attended the APA Practice Directorate State Leadership conferences will recall that these are the same powerful messages that Katherine Nordalinspirationally delivered to her audiences.

Over the years we have learned that substantive change always takes time.  In June 2005 Senator Dodd, one of the major architects of PPACA, re-introduced the Information Technology for Health Care Quality Act which is a major component of the President's initiative.  "By encouraging health care providers to invest in information technology (IT), this legislation has the potential to bring skyrocketing health care costs under control and improve the overall quality of care in our nation….  (E)xpanding the use of IT in health care is the best tool we have to control costs.  Studies have shown that as much as one-third of health care spending is for redundant or inappropriate care….  Most experts in the field of patient safety and health care quality, including the IOM, agree that improving IT is one of the crucial steps towards safer and better health care….  (T)his legislation would provide for the development of a standard set of health care quality measures."

Calling for an increased investment in obtaining reliable data on which to transform our nation's workforce and practitioners' scopes of clinical practice, the IOM made a series of far-reaching policy recommendations including: * Expanding the Medicare program to include coverage of APRNs just as physicians are currently covered; * Authorizing APRNs to perform admission assessments, as well as certification of patients for home health care services and for admission to hospice and skilled nursing facilities under Medicare; * Requiring third-party payers that participate in fee-for-service arrangements to provide direct reimbursement to APRNs; * Amend or clarify the requirements for hospital participation in Medicare to ensure that APRNs are eligible for clinical privileges, admitting privileges, and membership on medical staff; and, Requiring the Federal Trade Commission to review existing and proposed state regulations concerning APRNs to identify those that have anticompetitive effects without contributing to the health and safety of the public.  State Boards of Nursing, accrediting bodies, government, and health care organizations were urged to support nurses' completion of a transition-to-practice nurse residency.  Schools of nursing should double the number of nurses with a doctorate degree by 2020.  And, nurses should be systematically encouraged to engage in lifelong learning by making the necessary resources available to facilitate interprofessional continuing competency (i.e., CE) programs.

"The [IOM] committee recognizes that improved primary care is not a panacea and that acute care services will always be needed.  However, the committee sees primary care in community settings as an opportunity to improve health by reaching people where they live, work, and play.  Nurses serving in primary care roles could expand access to care, educate people about health risks, promote healthy lifestyles and behaviors to prevent disease, manage chronic diseases, and coordinate care….  Recognizing the importance of primary care… the committee viewed the potential contributions of these nurses to meeting the great need for primary care services if they could practice uniformly to the full extent of their education and training."  Education has always been the key to our nation's future.  As we enter the 21^stcentury, times are definitely changing.  Those colleagues who possess degrees in both nursing and psychology – one of whom is APA President Carol Goodheart – must be particularly proud.  They instinctively invested in their future long before many of us began to understand the intimate connection between the mind, body, and psychosocial-economic-cultural gradient of health care.  Aloha,

Pat DeLeon, former APA President – Division 42 – December, 2010

 

THE IMPORTANCE OF VISIONARY LEADERS

International:  Last year the Institute of Medicine (IOM) released its report The U.S. Commitment to Global Health.  AGlobal health is the goal of improving health for all nations by promoting wellness and eliminating avoidable disease, disability, and death.  It can be attained by combining population-based health promotion and disease prevention measures with individual-level clinical care.  This ambitious endeavor calls for an understanding of health determinants, practices, and solutions, as well as basic and applied research on risk factors, disease, and disability....  The U.S. government, along with U.S.-based foundations, nongovernmental organizations, universities, and commercial entities, can take immediate concrete action to accelerate progress on the urgent task of improving health globally by working with partners around the world to scale up existing interventions, generate and share knowledge, build human and institutional capacity, increase and fulfill financial commitments, and establish respectful partnerships.  U.S. leadership in global health reflects many motives: the national interest of protecting U.S. residents from threats to their health; the humanitarian obligation to enable healthy individuals, families, and communities everywhere to live more productive and fulfilling lives; and the broader mission of U.S. foreign policy to reduce poverty, build stronger economics, promote peace, increase national security, and strengthen the image of the United States in the world.@  As has often been said: AWhen you=re up to your neck in alligators, it=s hard to focus on draining the swamp.@  However, as we evolve into the 21^st century and President Obama=s vision for implementing his landmark Patient Protection and Affordable Care Act (PPACA) takes hold, psychology (and the other health professions) must accept their societal responsibility for providing visionary leadership in addressing our nation=s and world=s most pressing needs.  This is especially true for our professional schools.  The alternative is to become obsolete, if not irrelevant.  Protecting the status quo is not a viable option.

The IOM emphasized that health is inextricably connected to the broader goals of hastening development and reducing poverty.  Significant progress has been made in the last 50 years with life expectancy increasing more than in the preceding 5,000 years.  The creation, dissemination, and adoption of knowledge has been one of the main drivers of these health gains, delivering marked improvements in low- and middle-income countries that have invested in sustainable and equitable systems to deliver proven, cost-effective interventions.  Our nation has an unprecedented opportunity to improve global health.  The promise of potential solutions has captured the interest of a new generation of philanthropists, students, scientists, healthcare professionals, private sector leaders, and citizens B all eager to make a difference in this interconnected world.

The IOM identified five areas for action: * Scale up existing interventions to achieve significant health gains; * Generate and share knowledge to address health problems endemic to the global poor; * Invest in people, institutions, and capacity building with global partners; * Increase U.S. financial commitments to global health; and, * Set the example of engaging in respectful partnerships.  The global health community has reached a critical juncture.  The knowledge, innovative technologies, and proven tools to help millions of people in need are within reach.  Yet even with demonstrated success in tackling certain health issues, a wide gap remains between what can be done with existing knowledge, and what is actually being done.  Existing interventions are not widely used even though many are inexpensive and easy to administer.  As the advocates for PPACA constantly pointed out, even within our own modern day health care delivery system, the lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of about 15 to 20 years.  The timeless health problems associated with poverty are now coupled with new challenges.  Infectious diseases are emerging at the historically unprecedented rate of one per year.  With airlines carrying more than 2 billion passengers annually, and systems of trade more interconnected than in any time in human history, the opportunities for the rapid international spread of infectious agents and their vectors have vastly increased.  The rising tide of chronic diseases and injuries in low- and middle-income countries, where 80 percent of the world=s deaths from chronic, non-infectious diseases now occur, cannot be ignored.

One of the greatest contributions we can offer to the global campaign to improve health is to share America=s traditional strength B the creation of knowledge B for the benefit of the global poor.  Not surprisingly, Americans traditionally focus upon conditions that affect people within our own borders and as a result, we often ignore or significantly neglect diseases or conditions that are overwhelmingly or exclusively incident in low- and middle-income countries.  For example, globally more than 2 billion people are at risk of malaria each year.  Despite dramatic reductions in malaria incidence and mortality in many parts of the world, approximately 500 million people still contract the disease, resulting in 1 million deaths annually.  The IOM expressly noted that global health would greatly benefit from developing and disseminating a variety of novel behavioral and biomedical prevention strategies to combat infectious diseases.  Focusing upon two disease entities for which the behavioral sciences clearly have particular expertise: Obesity is escalating worldwide at an alarming pace, along with rates of type 2 diabetes, hypertension, and lipid abnormalities associated with obesity.  More than 1 billion adults are overweight; 300 million are clinically obese.  Mental disorders affect millions worldwide; about 14 percent of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders and psychosis.

Margy Heldring=s vision of establishing a senior-scientist/practitioner U.S. Public Health Service Corps is most timely.  As she points out, many of our colleagues are entering the twilight years of their careers.  They want to make a difference and are not yet ready to fully retire.  How can their considerable expertise be effectively utilized?  The vision expressed by President Lyndon Johnson at the University of Michigan comes to mind: AThe challenge of the next half century is whether we have the wisdom to use that wealth to enrich and elevate our national life, and to advance the quality of our American civilization....  This is the place where the Peace Corps was started....  Will you join in the battle to build the Great Society, to prove that our material progress is only the foundation on which we will build a richer life of mind and spirit?  There are those timid souls who say this battle cannot be won; that we are condemned to a soulless wealth.  I do not agree.  We have the power to shape the civilization that we want....  Those who came to this land sought to build more than just a new country.  They sought a new world.@  The following year Medicare became the law of the land.

Unlike the United States, in low- and middle-income countries, universities, science academics, and the research community are often absent from public policy engagement.  Our government, which is the largest funder of many international organizations and a significant donor of bilateral aid, carries considerable influence in shaping the global health environment and thus possesses the opportunity to be a good steward for health at both the national and global levels.  AHealth is a highly valued, visible, and concrete investment that has the power to both save lives and enhance the image of the United States in the eyes of the world....  Working with partners around the world and building on previous commitments, the United Stateshas the responsibility and chance to save and improve the lives of millions; this is an opportunity that the [IOM] committee hopes the United States will seize.@

Integrated/Co-located Care:  Retired Rear Admiral Chris Bruzek-Kohler recently shared her vision for the health care environment of the 21^st century.  AOne place to look to as an encouraging story of health care delivery transformation and a way forward for civilian mental health professionals is the Navy.  Navy Medicine has successfully implemented two programs providing mental health care in non-traditional settings: on the battlefield with Marines and in primary care practice.  A primary component of the Navy=s promotion of a >Culture of Fitness= is mental health.  Recognizing their responsibility to effectively prevent, identify, and treat all psychological health conditions and the ill effects of war, Navy Medicine mental health stationed with the Marines developed Operational Stress Control and Readiness (OSCAR) Teams, which embed psychologists, psychiatrists, psychiatric nurse practitioners and psychiatric technicians as organic assets in operational units.  The goal of the OSCAR teams is to be as far forward and to spend as much time as possible with the Marines to build the trust, cohesion, and understanding necessary to break the stigma of mental health care with military patients.

AThe concept of OSCAR is to demystify the whole process of psychiatric treatment.  The Marines often call the mental health provider >the wizard.=  The origins of this term were not only because the mental health provider could >make people disappear,= i.e., suddenly remove them from their units without warning, but it also provoked the image of the mysterious Wizard of Oz pulling the smoke levers behind the mirror.  This is not the case with OSCAR.  The mental health provider interacts with the Marines in the normal routine of the day.  In this way the mental health provider becomes a real person that the Marines can trust and get to know.  Being a full member of the Marine Corps unit, the Marines are more likely to ask questions about minor issues without the stigma of being seen as patients and before the>minor= issue becomes something major.  The OSCAR provider is also highly effective when they are a trusted advisor to mid-level leaders who can gain perspective from the provider, thereby helping them to become better leaders.  There is a heightened sense of trust and awareness on both sides and a profound improvement in communication among the warfighters, their leaders, and medical.

AThe power of having providers embedded is unmistakable.  Retired Navy Medical Corps Officer, Captain William P. Nash: >OSCAR builds a bridge across the cultural gap between the warfighter and the mental health professional the only way a bridge can be built B by drawing the mental health professional as fully as possible into the culture and life of the military unit to be supported.=  OSCAR=s success is evident in the enthusiasm surrounding the program in the Marine Corps and the desire of military commanders outside of the regimental level to expand it to air wings, logistics groups, and reserve forces for the benefit of their service members.

ANavy Medicine is also utilizing mental health professionals in innovative ways on the home front.  To improve quality and access to care, Navy Medicine has created integrated Medical Home Teams within its Internal Medicine and Primary Care clinics to provide personalized, coordinated, and proactive care to patients.  The Medical Home initiative is unique because it is an integrated care model where primary care services and behavioral health assets are together in the same clinic space.  The embedded behavioral health consultant provides health assessment and intervention expertise to primary care managers and their patients.  Clinical Psychologists are ideally suited for the Navy=s Medical Home Team model.

AA report from a 2007 DoD Task Force on Mental Health suggested that the integration of mental health providers within the Medical Home would improve access and decrease stigma by maximizing the number of interventions that can be conducted in a primary care setting.  Research supports the Task Force=s assertion and provides evidence of significant improvement in clinical outcomes and reduced psychological stress among service members served by behavioral health providers in primary care settings.  The Medical Home Model with integrated behavioral health specialists was first implemented at National Naval Medical Center (NNMC) in Bethesda, Maryland in2008, followed by Naval Medical Center inSan Diego and Naval Hospital Pensacola.  Building on early successes, the Navy will roll out the Medical Home Model at all remaining treatment sites this summer.@ 

Innovative Practices:  One of the more visionary provisions contained in the President=s Health Care Reform legislation (PPACA) authorized demonstration programs to train or employ alternative dental health providers in order to increase access to dental health care services in rural and other underserved communities.  This Fall the W. K. Kellogg Foundation released its report on the Alaska Dental Therapists program, which was strongly opposed by organized dentistry essentially proffering that these providers would be Apublic health hazards,@affirmatively harming their patients if allowed to practice.  The Kellogg Foundation found that: Adental therapists practicing in Alaskaprovide safe, competent and appropriate dental care.  The two-year, intensive evaluation is the first independent evaluation of its scale to assess care provided by dental therapists practicing in the United States.  It confirms for us what numerous prior studies of dental therapists practicing in other countries have already shown: that dental therapists provide safe care for underserved populations.@

Dental therapists have been providing preventive and basic dental care to children and families in remote Alaska Native villages since 2006.  Although new to the U.S., dental therapy has been well-established for decades in more than 50 countries, including those with advanced dental care systems similar to ours.  The evaluation assessed the work of dental therapists in five communities, as well as the experience of hundreds of patients.  They were directly observed performing sealant placement, composite and amalgam preparations, stainless steel crown placement, and oral health instruction.  The evaluation relied on examination standards used for assessing clinical competency for board certification of U.S. dental school graduates.  Alaskan dental therapists are technically competent to perform the procedures within their scope of work and do so safely and appropriately.  After graduating and completing a 400-hour externship under the direct supervision of a dentist, dental therapists are certified to provide a limited scope of dental services under the general supervision of a dentist.  They successfully treat cavities and help to relieve pain for people who often had to wait months or travel hours to seek treatment; patient satisfaction with their care is very high; and, they are will-accepted in tribal villages.  The report further noted that severe shortages of dentists disproportionately affect low-income communities and communities of color; that lack of affordable dental care is putting sorely needed dental services out of reach for nearly 50 million Americans, particularly those in rural and underserved areas.  Hawaii=s federally qualified community health centers have been particularly supportive of this (r)evolution as access to dental care and/or behavioral health care has continued to be their top priorities over the past decade.  The dental therapists are well respected in their communities.  Because many dental therapists return to practice in their home communities, they typically have the cultural skills and language fluency needed to educate and motivate people towards behavioral change.  As role models they serve as important oral health advocates.  ASimply training more dentists will not solve this problem.  TheAlaska model is a community-driven solution that can work in communities across the country.@  Aloha,

 

Pat DeLeon, former APA President BDivision 29 B November, 2010

PPACA -- THE IMPLEMENTATION STAGE

As our nation experiences the steady implementation of President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act (PPACA), over the next five to ten years, it is important to appreciate that the bill was crafted primarily with consumers (i.e., patients) in mind and not clinicians.  Perhaps as legislative modifications are made, based upon practical experiences, we will eventually see the enactment of the Single Payer System which the liberals so vocally championed.  There are a multitude of questions to be answered.  For example, how will the provision which requires health insurance plans to utilize at least 80% to 85% of the premium dollars collected to pay medical bills or otherwise improve their customers' health, ultimately be interpreted?  Will this allow insurance companies to pay clinicians for upgrading their office computers or attending continuing education (CE) courses?  The nonpartisan Congressional Budget Office (CBO) estimates that PPACA will reduce the federal deficit by $143 billion over the first ten years of enactment, ensure that 94% of Americans have health insurance, and effectively bend the ever-escalating cost curve.  Does this suggest that with 76% of Medicare spending currently being for patients with five or more chronic diseases, that we will see a special, national focus upon this growing population?  It is simply too early to predict with any sense of certainty.  Change is always unsettling and takes time, especially when important.

It is useful to view the enactment of PPACA within its historical context.  On May 22, 1964 President Lyndon Johnson laid out his vision for a Great Society at a Universityof Michigan commencement, which at that time was the most attended non-football event in campus history.  "I have come today from the turmoil of your Capitol to the tranquility of your campus to speak about the future of your country.  The purpose of protecting the life of our Nation and preserving the liberty of our citizens is to pursue the happiness of our people.  Our success in that pursuit is the test of our success as a Nation.  For a century we labored to settle and to subdue a continent.  For half a century we called upon unbounded invention and untiring industry to create an order of plenty for all of our people.  The challenge of the next half century is whether we have the wisdom to use that wealth to enrich and elevate our national life, and to advance the quality of our American civilization.…  Will you join in the battle to build the Great Society, to prove that our material progress is only the foundation on which we build a richer life of mind and spirit?  There are those timid souls who say this battle cannot be won; that we are condemned to a soulless wealth.  I do not agree.  We have the power to shape the civilization that we want.  But we need your will, your labor, your hearts, if we are to build that kind of society.  Those who came to this land sought to build more than just a new country.  They sought a new world."  On July 30, 1965 the President signed P.L. 89-97, the Social Security Amendments of 1965, and thus made Medicare [and Medicaid] the law of the land.

During his address before his first Joint Session of Congress, President Obama held out a similar vision and challenge.  "We will rebuild, we will recover, and the United States of America will emerge stronger than ever….  The costs of health care eats up more and more of our savings each year, yet we keep delaying reform….  Now is the time to jumpstart job creation, re-start lending, and invest in areas like energy, health care, and education that will grow our economy, even as we make hard choices to bring our deficits down.…  (T)his is America.  We don't do what's easy.  We do what is necessary to move this country forward….  (W)e can no longer afford to put health care reform on hold….  I suffer no illusions that this will be an easy process.  It will be hard.  But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of health care has weighed down our economy and the conscience of our Nation long enough.  So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year."  Compelling visions provide the context within which day-by-day experiences shape specific implementation strategies.

Six months after enactment of PPACA, the Chairmen of the two Senate Committees which were most involved in crafting the legislation stated:  Finance -- "Americans have reason to celebrate.  The new law put Americaon the road to a more sustainable consumer-friendly health care system.  The new law putAmerica on the road to a healthcare system in which all Americans have access to quality, affordable health insurance.  And the new law put America on the road to a health care system in which patients and their doctors – not insurance companies – control patient care.  These transformative changes will not happen overnight….  Today, with this 6-month mark, we pass a key milestone on our road to providing quality, affordable health care to all Americans.  This milestone is justone of many along the road.  But this milestone is one that signals an end to the insurance companies' worst abuses."

Health, Education, Labor, and Pensions (HELP) -- "On September 23, the law's six-month anniversary, six major reforms kicked in.  Now the law: * Bans insurance companies from dropping patients' coverage….  * Bans denial of coverage for children with pre-existing conditions….  * Cracks down on benefit payment limits.  Insurance companies are prohibited from imposing lifetime dollar limits on essential benefits….  * Provides for appeal of insurance company decisions….  * Guarantees free preventive care….  * Extends coverage for young adults.  Young adults are now allowed to stay on the parents' plan until 26….  [And, mental health parity is finally the law of the land.]  As many predicted, the law is increasingly popular as Americans get better acquainted with its broad range of benefits and consumer protections….  Mark my words: Americans will not allow their hard-earned benefits and protections to be taken away.  We will stay the course, defending the strong reforms in this new law and creating a reformed insurance and health care system that works not just for the healthy and the wealthy but for all Americans."  President Obama's vision will ultimately curtail the ever-escalating costs of health care; enhance the availability of high quality Primary Care; make Wellness and Preventive Care a national priority, as well as eliminating racial and geographical Health Disparities; and empower Educated Consumers to take responsibility fortheir health care, utilizing the most up-to-date advances in the communications and technology fields (i.e., Health Information Technology, Telehealth, and the utilization of data-based Gold Standards of care).  The next decade will be very "interesting," for consumers and practitioners alike – truly uncharted waters.

The health care environment of the 21^st century in which psychology will practice will be increasingly interdisciplinary in nature.  California nurse-psychologist Ann Carson, reflecting upon the Nurse Managed Health Clinic provision in PPACA: "This is an amazing document and gives me hope for the future of nursing and health care.  In many ways, a return to the earlier practice of nursing within the public health realm would be a huge step forward.  I was taught prevention (primary prevention) in my nursing program in the late 1960s.  The rest of the health care world, especially medicine, seems a bit delayed in recognizing the value."

In December, 2009 President Obama issued a Memorandum for the Secretary of Health and Human Services, calling for a Medicare demonstration to test Medical Homes in federally qualified health centers.  "My Administration is committed to building a high-quality, efficient health care system and improving access to health care for all Americans.  Health centers are a vital part of the health care delivery system.  For more than 40 years, health centers have served populations with limited access to health care, treating all patients regardless of ability to pay….  There are over 1,100 health centers across the country, delivering care at over 7,500 sites.  These centers served more than 17 million patients in 2008 and are estimated to serve more than 20 million in 2010….  Health centers use interdisciplinary teams to treat the 'whole patient' and focus on chronic disease management to reduce the use of costlier providers of care, such as emergency rooms and hospitals.  Federally qualified health centers provide an excellent environment to demonstrate the further improvements to health care that may be offered by the medical homes approach.  In general, this approach emphasizes the patient's relationship with a primary care provider who coordinates the patient's care and serves as the patient's principal point of contact for care….  (They) also emphasize activities related to quality improvement… and coordination….  Therefore, I direct you to implement a Medicare Federally Qualified Health Center Advanced Primary Care Practice demonstration."

We fully expect that those colleagues who possess psychopharmacological skills will be at a distinct advantage in the ever-evolving healthcare system.  Accordingly, we were pleased to learn from Steve Tulkin that this September, the Postdoctoral Master of Science Program in Clinical Psychopharmacology at the California School of Professional Psychology at Alliant International Universitybegan its fourth National Cohort with close to 60 students.  Students attend classes live over the Internet, and can ask questions and participate in class discussions utilizing this technology.  Psychologists in 23 states (fromHawaii to New York) are participating in the class, and one psychologist is participating live from South Africa.  He spoke briefly during the first meeting of the class to thank his U.S. colleagues, and express his hope thatSouth Africa will enact prescriptive authority legislation in the next couple of years.  Aloha,

Pat DeLeon, former APA President – National Register – October, 2010