AN IMPRESSIVE EVOLUTION

  On March 6, 2002, Governor Johnson signed New Mexico's HB.170 into public law, authorizing appropriately trained psychologists to prescribe.  On January 7, 2005, Mario Marquez applied for his "conditional certification."  In May 2004, Louisianafollowed suit and medical psychologist John Bolter wrote his first script on January 20, 2005.  Both the New Mexico and Louisiana State Psychological Associations had been working on their ultimately successful legislation for over five years.  When did psychology's prescriptive authority quest actually begin?  In 1984, U.S. Senator Daniel K. Inouye urged the Hawaii Psychological Association to seek this authority.  In 1972, visionary APA President, Nick Cummingsraised this possibility with his Board of Directors.  In August, 1995, the APA Council of Representatives formally endorsed prescriptive authority as APA.  By the end of 2008, Glenn Ally estimated that 200,000 psychotropic medication orders had been written by his Louisiana colleagues.  Today, now CSPP Dean Morgan Sammons postulates that between 800-1,000 colleagues have completed their formal psychopharmacological training.  The numbers are indeed impressive.

            With the passage of President Obama's landmark Patient Protection and Affordable Care Act (P.L.111-148), 32+ million Americans will soon have access to high quality, patient-centered primary care for the first time in their lives.  The President's vision calls for the utilization of the most up-to-date advances in communications and computer technology, an emphasis upon prevention and wellness care, and the steady development of comprehensive systems of care (Accountable Care Organizations (ACOs)) throughout the land.  Under previous Administrations, these would probably have been considered Health Maintenance Organizations (HMOs – President Nixon) and/or Managed Care (President Clinton).  Interdisciplinary care, comparison across diagnoses and patient populations, and reliance upon objective gold standards will increasingly become the norm.  The Administration is providing the States with sufficient flexibility to craft the health care environment which best fits their unique situations.  Within this broader policy frame of reference, I would suggest that psychology's prescriptive authority quest fundamentally represents an important evolution of the field into primary care health psychology.  And, I would also suggest that over the next decade there will be an increasing number of psychologists providing integrated care as employees in organized systems such as federally qualified community health centers (FQCHCs) and ACOs, rather than working in a traditional independent small practice or community mental health center.  Times are changing.

            As I reflect upon the professional literature over the past 25years, there have been consistent and increasing calls for the integration of mental health (now frequently called "behavioral health") services within primary care.  Whether one considers Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention(1979) or the Institute of Medicine reportHealth and Behavior: Frontiers of Research in the Biobehavioral Sciences (1982), the underlying message is very clear.  Primary care providers, with considerably less mental health training than psychologists, have been providing care for 60-80% of those with discernible mental health disorders.  Most practicing psychologists have been trained in a traditional mental health setting, pursuant to the community mental health center movement of President Kennedy' era, the psychological services organization of the VA, and/or university-based mental health clinics.  Collectively we have not been aware of the far reaching community health center initiatives of President Johnson's Great Society era, which represent the federal safety net for millions of Americans.

Those federal (and increasingly civilian) psychologists who do possess prescriptive authority have emphasized that their clinical skills are in definite demand and that their integrated skills have allowed them to clinically modify prescribed regimens of psychotropic medications more appropriately for their patients' benefit.  Within the Indian Health Service, pioneers such as Floyd Jennings prescribed with standing orders at the Santa Fe Indian hospital, New Mexico, during the mid-1980s, where quality assurance reviews of cases were quite positive.  In June 1994, APA President Bob Resnick attended the graduation ceremony for the first two Department of Defense psychopharmacology training graduates, John Sexton and Morgan Sammons. When one studies the literature for various subpopulations, such as the elderly, children, ethnic minorities, etc., the picture is again quite clear: psychologists with prescriptive authority provide the highest quality of care.

Although I have been involved in this movement over the years, it is impossible to predict with any sense of certainty which will be the next state to enact prescriptive authority legislation.  Will, for example, Hawaii andOregon be successful in overcoming their vetoed bills?  The numbers of psychologists completing their advanced training continues to grow.  As of the Fall of 2010, 276 graduates had been admitted to take the APA PEP (Psychopharmacology Examination for Psychologists) developed by the APAPO Practice Organization's College ofProfessional Psychology.  With the advances occurring in educational technology, I would expect that those on their clinical internships will soon have ready access to medication decision protocols.  Over the years, slightly more than one third of our State Associations have established task forces to coordinate prescriptive authority activities, with nearly a quarter having introduced relevant legislation.  Fundamental change always takes time; oftentimes, longer than one might initially expect.  Today, several of the States pursuing prescriptive authority, such as Arizona and New Jersey were initially considered to be among those that their leaders felt would be the "last in the nation" to undertake such action.

            Leadership changes, as does the nation's health care environment.  Looking over the Congressional landscape, it is evident that we will continue to see an increasing number of non-physician primary care providers adopting the doctoral level of training as their standard and expanding their scopes of practice to fully utilize their clinical expertise.  The right to prescribe medications by nurse practitioners and doctors of nursing practice, as well as by clinical pharmacists, for example, continues to mature exponentially across the nation and to be appropriate for their training.  They are calling for patients to have the freedom to choose the practitioner of their choice.  Sound familiar?

I am confident that psychology's leadership will appreciate the growing importance of proactive vision and action.  As the President of the Institute of Medicine has stated: "Dealing equally with health care for mental, substance-use, and general health conditions requires a fundamental change in how we as a society and health care systems think about and respond to these problems and illnesses.  Mental and substance-use problems and illnesses should not be viewed as separate from, and unrelated to, overall health and general health care (2006)."  Aloha,

 Pat DeLeon, former APA President

The National Psychologist – February, 2012

THE ADMINISTRATION’S VISION

     Earlier this year HHS Secretary Kathleen Sebelius highlighted the ability of President Obama's Patient Protection and Affordable Care Act (ACA) to significantly curtail the ever escalating costs of health care.  "The rising cost of health insurance coverage has imposed a heavy burden on our nation….  If health-care costs continue to rise unchecked, they will threaten America's ability to compete and will become unaffordable for most families.  One of the major reasons we passed [ACA] was to bring down costs… tackling the underlying cost of medical care….  [ACA] gives us tools to reduce costs by promoting better health and providing better care, especially in Medicare and Medicaid, which can be tremendous forces for positive change across the entire health-care system.  The law emphasizes prevention because we know it is far less expensive to prevent disease than to treat it….    The health-care law gives us dozens of tools to improve chronic-disease management, coordinate care among multiple providers and foster innovation.  Experts who have studied the law, from the Medicare trustees to the independent Congressional Budget Office, agree that it will put the brakes on skyrocketing Medicare costs.  And last January, 272 of America's top economists wrote to the House Budget Committee that the ACA 'contains essentially every cost-containment provision policy analysts have considered effective in reducing the rate of medical spending.'  It won't be easy and it won't happen overnight.  But at a time when some claim that our only options are to allow health-care costs to continue to skyrocket or to make some of the most dramatic cuts to our health-care programs ever proposed, the Affordable Care Act provides a better way forward."

            It is important for all of the health care professions to appreciate the magnitude of change that our nation's health care environment will soon be experiencing.  Watching the President's State of the Union Address every practitioner should understand that unprecedented change is coming.  "I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny you coverage, or charge women differently from men.  And I will not go back to the days when Wall Street was allowed to play by its own set of rules…."  From our perspective, significant policy decisions will evolve at both the local and national level.  Are we sufficiently engaged?

ACA is fundamentally patient-centered, heralding a major commitment, over time, to data-based decision making.  "What objectively works and under what conditions?" might be seen as its underlying orientation.  And yet, given the intensity of efforts being made by various health interest groups (including professional associations), one must expect that active engagement in the public policy/political process will become a major element of decision making.  Will, for example, the conceptualized "medical home" require physician direction under an historical "captain of the ship" philosophy or will it embrace true interdisciplinary care, facilitating each discipline practicing to the fullest extent of its training?  One factor will undoubtedly be the extent to which the various non-physician professions are successful in modifying federal statutes (e.g., Medicare and Medicaid) to ensure that their training institutions and practitioners have ready access to the same resources that medicine has historically possessed (e.g., financial support for implementing electronic medical record systems and telehealth/telepsychology reimbursement).  In the abstract, moving from historically isolated silos of practice and training to interdisciplinary care makes sense, especially under ACA.  How to accomplish this monumental change in orientation will be the evolving question.

            A Renewed Focus:  I recently accepted the exciting opportunity to join the faculty of the Uniform Services University of the Health Sciences (USUHS) of the Department of Defense.  I will be located within the School ofNursing and the Department of Psychology, the latter having been on the forefront of the Health Psychology movement thanks to the vision of former APA President Joe Matarazzo, as a member of the Board of Regents.  The chair of the Department is David Krantz, another of the original visionaries.  I will have the opportunity to become increasingly familiar with the culture and literature of our health profession colleagues.  For example, how do they (and perhaps psychology) address the needs of the growing number of individuals with chronic diseases?  The Centers for Disease Control and Prevention (CDC) estimates that 7 of 10 deaths among Americans each year are from chronic diseases with obesity becoming a major public health concern (almost 1 in every 3 adults being obese; as is almost 1 in every 5 youth, between the ages of 6 and 19).  Seventy-six percent of Medicare spending is currently on patients with 5 or more chronic diseases.  By 2020, our nation is projected to spend $685 billion a year in direct medical costs for individuals with chronic diseases.

            David and I visited the USUHS Centerfor Deployment Psychology (CDP) which was established 5 years ago, after considerable involvement by the APA Education Directorate (Cynthia Belar and Nina Levitt).  Since 2007, the Center has trained more than 20,000 mental health providers working throughout the deployment cycle.  The Deputy Director, Bill Brim, is a health psychologist with over a decade of service within the USAF.  Former APA Congressional Fellow Paula Domenici is the Director of Training Programs, overseeing several initiatives educating mental health providers about the unique needs of service members, veterans, and their families; and the best strategies to assist them.  Since many veterans seek help from community-based clinicians, both immediately and years after their deployment, CDP trains military and non-military providers who care for the warriors and their loved ones.  One of CDP's hallmark offerings isAddressing the Psychological Health of Warriors and Their Families, a 1-week course that has been presented in 27 cities, includingHonolulu, San Diego, Albuquerque,Minneapolis, Austin, Nashville, andPittsburgh, to reach civilian audiences across the country.  Through this program, over 2,300 psychologists, social workers and other professionals have learned about military culture, the deployment experience, and evidence-based psychotherapies to treat PTSD.  Congressman Tim Murphy, a clinical psychologist, emphasized the value of CDP's mission after completing this course: "Although PTSD is treatable, we simply do not have enough trained military and civilian clinicians to meet the needs….  These (CDP) courses provide solid foundations in that critically important training."  [www.DeploymentPsych.org].

            Clinical Pharmacy:  The USPHS Report to the Surgeon General from the Office of the Chief Pharmacist is entitled: ImprovingPatient and Health System Outcomes through Advanced Pharmacy Practice.  "The 2011 Report provides rationale and compelling discussion to support health reform through pharmacists delivering expanded patient care services.  In collaboration with other providers, this is an existing, accepted, and additional model of improved health care delivery that meets growing health care demands in theUnited States.  Health care delivery (including preventive or supportive care) in the United States is challenged by demands of access, safety, quality, and cost.  These challenges are amplified by provider workforce shortages and dramatic increases in primary and chronic care visits.  Projections suggest worsening of this situation.  New or additional paradigms of care must be implemented to reduce these burdens.  Current health care demands provide an opportunity for health leadership to recognize and adopt additional and significant health care delivery models….

            "The federal sector has already implemented and embraced such a health care delivery model through physician-pharmacist collaboration.  This collaboration, through extensive performance data, has demonstrated that patient care services delivered by pharmacists can improve patient outcomes, promote patient involvement, increase cost-efficiency, and reduce demands affecting the health care system.  For over forty years, federal pharmacists have collaboratively managed disease through medication use, and other cognitive and clinical pharmacy services.  Although these models are accepted in the non-federal sector, utilization is often impeded due to policy, legislation, and compensation barriers…."

            Once a diagnosis is made by the primary care provider, pharmacists do manage disease and provide primary care.  Pharmacists -- Perform patient assessment (subjective and objective data including physical assessment).  Have prescriptive authority (initiate, adjust, or discontinue treatment) to manage disease through medication use and deliver collaborative drug therapy or medication management.  Order, interpret and monitor laboratory tests.  Formulate clinical assessments and develop therapeutic plans.  Provide care coordination and other health services for wellness and prevention of disease.  And, Develop partnerships with patients for ongoing (follow-up) care.  Under ACA, HHS has considerable flexibility in defining "preventive services" and "essential health benefits" as broadly as desired.  Those following psychology's prescriptive authority (RxP) quest will not be surprised to learn that in 1996, the then Director of the Indian Health Service (IHS) issued a Special General Memorandum (SGM 96-2) recognizing Clinical Pharmacy Specialists (CPSs) as primary care providers with prescribing authority.  The Dean of one of the nation's leading schools of pharmacy emphasized that clinical pharmacists must complete a four-year postgraduate program focusing on managing complex medications and are extraordinarily cost-effective.  At Kaiser PermanenteColorado, pharmacists worked with physician-approved protocols targeting patients with coronary artery disease and hit their blood pressure and cholesterol targets.  They achieved an 89% reduction in their patients' overall mortality and nearly $22,000 annual savings in health care costs per patient.  Similarly, targeting city employees with diabetes, pharmacists were successful in reducing the annual direct medical costs per worker, on average, by $1,200 to $1,872 – an estimated savings of $4 for every $1 invested.  Not surprisingly, the city has since expanded this program to cover other chronic diseases, including hypertension and asthma.

            Looking Forward:  Having retired from the U.S. Senate staff after 38+ years, I have become quite interested in the experiences of senior colleagues.  Reflections from Ed Sheridan, a pioneer in Health Psychology and now Professor/Senior Vice President & Provost Emeritus, University ofHouston:  "You certainly are correct that most of us do not think much about retirement until we decide to do it.  One reason seems to be that we are among the first generations to be free to work or retire while previous generations had mandatory retirement at age 65 (if you lived that long!).  I have only a few suggestions to offer that may be important.  If there is a prominent mistake couples seem to make, it is they do not spend enough time in discussing what each person wants from retirement before deciding to retire.  Since couples likely will spend much more time together, especially if they retire at the same time, it is essential they share what they desire and what each hopes the partner will want to do.  These discussions need to include each partner's strongest wishes for a quality life, whether each finds the other's desires compatible, what to do with potential challenges (e.g., caring for a very ill parent), and what household duties each will agree to accept.  Additionally, couples especially need to discuss what they want as a life style in the next few years.  There are lots of choices.  One consideration is to downsize one's home and use that money for other initiatives (e.g., seeing more of the grandkids, traveling, developing new interests or improving on former ones -- bridge, tennis, dancing, etc. --  teaching part time, consulting).  In my case, I find teaching undergraduates (something I did very little of in my first 35 postdoctoral years) is real fun.  It is like having an unlimited number of eager grandchildren.  Even with such discussions, couples need to realize that retirement requires that each person be willing to be very flexible since no one anticipates all the challenges that eventually will come with this new lifestyle.

            "Speaking of homes, I find many couples decide to own two homes, one in a warm environment for the winter and one near the grandchildren.  Most eventually realize this was a mistake.  As the grandchildren get older, they only desire a limited amount of time with the grandparents and the grandparents find they are spending a lot of money on the upkeep of two homes and this limits travel and other opportunities for stimulation.  Most people wonder what they will do with 'all their free time.'  Actually, I find there still is not enough time to accomplish what I wish to do.  I suspect our colleagues will find the same.  The one big change is that you have more control over your time but it still is not enough.

            "Having read some literature on financing retirement from organizations like AARP, I did not find their predictions were helpful to us.  One common proposal was a couple needs about 80% of their preretirement income.  In our case, we spend as much in retirement as we previously spent.  One reason may be that as a Dean and Provost, I had almost every lunch and most dinners paid for.  I also had a free car.  In addition, we received free tickets to most sports events, plays, musicals, etc. and now we pay for these items.  One item that does cost less is clothing.  In terms of finances, I do think it is important to talk with a financial planner who has no stake in how you invest and get good direction on how you can achieve your income goals.  We were fortunate in that we anticipated the Bush fiasco and we were not hurt.  However, we have numerous friends who lost 20%-35% of their retirement income by not anticipating the downturn.  It also is hard to anticipate what your needs will be if you live 30 or more additional years.

            "Healthcare opportunities also is an important topic for consideration.  Kathy and I always intended to retire to Kauai (we already had land there to build a home).  Then, having spent decades working closely with the leadership of the various health professions, we realized that we would not want to rely on obtaining care at Wilcox Hospital with its considerable rural challenges, while the closest medical center was on Oahu.  We understand that subsequently the leadership of MauiMemorial Medical Center has been seeking to fulfill this historical neighbor island gap.  Nevertheless, making the decision to be near good health care has paid important dividends for us and we are very appreciative that we recognized this need.  Aloha."

PatDeLeon – Division 29 – February, 2012

 

PUFF, THE MAGIC DRAGON

"Lived by the Sea…."  At the end of the fiscal year, I retired from the U.S. Senate staff after 38+ years, having served from the first day of the infamous Watergate hearings.  Already the types of information readily available to me have shifted, not to mention the "demands of the moment."  I have finally had time to have a leisurely lunch with several of my favorite professional colleagues.  They say, "Puff frolicked in the Autumn mist in a land called Honah Lee."  Looking perhaps now from afar, it remains increasingly clear that the health care environment of the next decade will be dramatically impacted by the advances occurring within the communications and technology fields, and further that psychology must strive for licensure mobility and a meaningful presence within integrated health care (i.e., obtaining prescriptive authority (RxP)).

            This Fall the State of Hawaii received significant funding from the Department of Health and Human Services (HHS) to help establish and implement the Hawaii Health Connector, an on-line health insurance exchange designed to help Hawaii's consumers find affordable health care plans.  This is viewed as a critical step towards ensuring that all residents of Hawaii will ultimately have access to high quality, affordable health care, pursuant to President Obama's Patient Protection and Affordable Health Care (PPACA) legislation.

            "Globalization – It's relevance toHawaii's Health Care Delivery System Vision.  When we were offered the opportunity to share our thoughts with the readership, we contemplated our approach.  Our curiosities led to broader questions:  How do the efforts to transform Hawaii's health care delivery system affect social change?  Does our vision of health care transformation have the opportunity to have a broader impact on social systems and our state's economic foundation?  How can key initiatives contained within the Affordable Care Act (ACA), currently being implemented in Hawaii, accomplish parallel outcomes to globalization ideologies?  What can the transformation yield so that it ties to the broader vision for the State of Hawaii… to be the conduit between U.S. and Asian markets?

            "Let's start with globalization:  Globalization, as defined by the Rockefeller Foundation, is the technological, social, and economic process by which people around the world have grown inextricably interdependent.  In 1998 the University of Hawaii's School ofSocial Sciences presented a seminar on Globalization in which Fred Riggs presented dimensions of globalization that included economics, political science, sociology, psychology, anthropology, communications, and geography.  Concepts of globalization can be similarly applied to a state level as the focus is on benefits being shared widely such that economic and social challenges can be overcome.  Collaboration among individual communities and across the state can lead to positive outcomes across boundaries, whether socioeconomic, political, etc.  A shared goal of globalization is to promote the well-being of humanity.  In order to achieve this, systems are integrated.  Information is transported more readily which also contributes to health promotion, social advancement, and improved economic viability.

            "The Patient Protection and Affordable Care Act (ACA), a transformational initiative in health care, was passed in March 2010.  Its goals are to increase access to care, to expand health care coverage, and to increase the focus on prevention.  Like globalization, it is intending to promote well-being.  The health of communities is directly linked to individuals' abilities to contribute positively to the economic viability of their communities as well.

            "Hawaii is demonstrating progress in implementing federal health reform through several initiatives underway statewide.  They include: the Hawaii Island Beacon Community, the Hawaii Health Information Exchange/Regional Extension Center, and the Hawaii Health Connector (insurance exchange).  Each is described below.  Hawaii Island Beacon Community:  Established in May 2010, this federally funded collaborative project ($16.1 million grant) is administered through the College of Pharmacy at theUniversity of Hawaii, Hilo.  Its goals include: improving access to health care, chronic disease prevention, focused reductions in health disparities of Native Hawaiians and other at-risk populations, and increased use of electronic health records to support information sharing between primary care providers.  Hawaii Health Information Exchange (HHIE) and Regional ExtensionCenter (REC):  Established in 2009, the HHIE is focused on the implementation of a statewide health information exchange that will ultimately feed into the national health information network.  Its goals are to transform the current state of health care into one that coordinates care, reduces costs (for patients and providers), addresses the needs of the aging population, and provides incentives to engage patients in a proactive approach to their health care.  The REC, also established in 2009, provides technical support to health care providers who are striving to meet the meaningful use requirements (electronic health records use) as described in the ACA.  HawaiiHealth Insurance Exchange:  Act 205, signed into law in 2011, established the Hawaii Health Connector (the state's health insurance exchange).  HHS has awarded the State a total of $15.4 million to plan for and establish the exchange.  States are operating under a very short timeline to implement their exchanges (by January 2014).  Its goal is to create a marketplace for individuals and small businesses to purchase health care insurance.

            "Each of these initiatives has a role in transforming Hawaii's healthcare delivery system but will only affect social change in the broader framework of health and healthcare transformation.  Hawaii's Governor Neil Abercrombie also wants to transform the healthcare delivery system.  His vision includes creating a patient-centered system that relies on comprehensive primary care, empowering a team of care-givers that expertly deliver medical, behavioral health, pharmaceutical, nutritional, and care coordination.  The Governor's vision also includes developing and deploying a robust system of timely feedback and information to improve provider performance and transparency in reporting to guide consumer choices.

            "These changes in healthcare will be reflected in Hawaii's economy as the cost for public and private insurance is stabilized but it also represents new career opportunities for our residents who might never aspire to be clinicians but can contribute meaningfully as care coordinators.  This model of healthcare also offers hope for sustainability for rural and isolated communities that can't attract a physician or specialist in this era of shortages.

            "Our ultimate vision for health is one where no group suffers disparities and the effects of poverty, lack of education, and other social determinates are erased.  Improving the economy, creating new jobs that value community and cultural competence, and prioritizing patient experience and engagement all contribute to that vision.  Healthcare transformation must be an on-going community-wide effort and we believe Hawaiiis ready for the challenge" [Coral Andrews, Hawaii Health Connector; Beth Giesting, Hawaii Healthcare Transformation.]

            The Past Is Prologue For The Future:  The future for our nation's health care delivery systems will embrace integrated, interdisciplinary, and patient-centered cross-disciplinary care.  No longer will the individual professions be encouraged to practice in isolated, silo-oriented environments.  Bringing science directly to the clinician will become an increasing policy priority.  At the final Senate Labor-HHS-Education appropriations subcommittee hearing which I attended, the Director of the National Institutes of Health (NIH) and several of his colleagues testified on the NIH's Investments in Innovation strategy: accelerating discovery through technology; applying science to prevention; enhancing theU.S. economy and global competitiveness; and, advancing translational science.  When asked what the single most important clinical intervention was, in their professional judgment, each of the NIH directors quickly spoke to the value of regular exercise.  Finally, the psychosocial-cultural-economic gradient of quality care is being formally recognized at the highest policy levels.  No one discipline can possibly know (or reasonably consider itself to be) the totality of health care – collaboration is absolutely critical.

            In the early stages of psychology's prescriptive authority quest, visionary Linda Campbell worked closely with her Georgiapharmacy colleagues to develop a psychology-friendly training program.  Recently, theCollege of Pharmacy at the University ofHawaii, Hilo (UHH) has been similarly engaged in collaborating with psychology.  "On August 25, 2011, I attended the Board of Regents meeting to answer any questions posed by Board members concerning the MS in Clinical Psychopharmacology program we were developing.  This program had already progressed through the entire University ofHawaii at Hilo review process.  This last step would officially allow the UHH College ofPharmacy to offer the program.  After a brief introduction, and overview of the program presented by the Vice Chancellor for Academic Affairs, UHH, the floor was opened for questions.  The question and answer session lasted approximately 30 minutes.  Some areas of concern voiced were: the sustainability of the program, the Continuing Education process of program graduates, and the current situation regarding the graduate's ability to prescribe.  I believe that I was able to adequately answer all of their questions.  The University President showed her support of the program by interjecting her opinion on administrative maters raised by the Board.  She stated that this is provisional approval, and that all provisional programs must come back to the Board again, before they officially becomeUniversity of Hawaii programs.  The vote was overwhelmingly in favor of the program with one negative vote [Ed Fisher, Associate Dean for Academic Affairs, UHH].

            As we indicated earlier, Licensure Mobility is a critical issue for all clinicians.  Reciprocity of pharmacy licensure is currently possible across all the States, Puerto Rico, and the District of Columbia and is facilitated by a national licensure transfer process and a national jurisprudence exam.  There is no multi-state compact, however, as in nursing.  The National Association of Boards of Pharmacy (NABP) provides these national mobility resources as a service to member state boards of pharmacy and to licensees.  NABP also provides the Model Pharmacy Practice Act and updates it regularly.  The Model Act addresses key issues, including the regulatory framework for collaborative drug therapy management (CDTM), agreements between pharmacists and physicians, nurse practitioners, and other prescribers.  It facilitates pharmacists' patient management activities which include the initiation, modification, and cessation of medications.  Psychology could learn much from pharmacy's experiences.

            Over the years, I have been particularly impressed by the heroic efforts of Bill Howelland Vicki Vandaveer in struggling with the underlying applicability of licensure (and APA accreditation) for our Industrial-Organizational (IO) colleagues.  There are clearly several areas in which the legitimate interests of health care providers and non-health care providers essentially clash.  For example, Must all doctoral programs be APA accredited?  Are pre- and post-supervision requirements relevant?  The considerable mobility needs of national/international IO psychologists may be more pressing that those presently experienced by most clinicians.  And, Do not most state licensure exams focus more on clinically-oriented content than IO colleagues would find relevant to their work?  How do other professions address similar concerns?  Collectively, we must elevate our consideration of addressing the underlying issues of competence, timeliness, and consumer protection.  "Puff, the magic dragon lived by the sea.  And frolicked in the Autumn mist in a land called Honah Lee."  Aloha,

 

Pat DeLeon, former APA President -- Division 55 -- January, 2012

IF YOU MISS THE TRAIN I’M ON….

Women's Preventive Health Care:  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 5 to 10 years, it is important for psychology to appreciate the significance of Katherine Nordal's State Leadership charge to "get personally involved."  The underlying legislation is broadly written, endorsing important long-range objectives, while providing the States and the Administration with considerable flexibility to craft the implementing details.  This Summer, the Institute of Medicine (IOM) released its recommendations to the Department of Health and Human Services (HHS) Clinical Preventive Services for Women: Closing the Gaps.  The Committee chairperson and former Director of the National Institute for Occupational Safety and Health:  "The Patient Protection and Affordable Care Act of 2010 has afforded us an historic occasion.  For the first time, prevention plays a central role within the scope of new health insurance plans in theUnited States.  Also, an ongoing focus on women's preventive services is expected to be included in these efforts.  Given the history of inadequate attention to women's health research and preventive services noted by many, (including previous IOM committees), I am truly optimistic that gains in women's health and well-being will ensue.  With the multiple roles that women play in society, to invest in the health and well-being of women is to invest in progress for all."  Exciting opportunities….

The preventive services and screenings specified in PPACA, and ultimately expanded by HHS, will be fully covered without patient copayment.  The three sets of guidelines currently being utilized to define "preventive services" include recommendations made by the U.S. Preventive Services Task Force, the Bright Futures for Adolescents of the American Academy of Pediatrics, and the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.  The charge to the IOM: "Convene an expert committee to review what preventive services are necessary for women's health and well-being and should be considered in the development of comprehensive guidelines for preventive services for women.  The committee will also provide guidance on a process for regularly updating the preventive screenings and services to be considered."  Issues to be explored included: What is the scope of preventive services not included?  What additional screening and preventive services have been shown to be effective for women?  What services and screenings are needed to fill gaps in recommended preventive services for women?  And, What models could HHS and its agencies use to coordinate regular updates of the comprehensive guidelines for preventive services and screenings for women and adolescent girls?

In fulfilling its mission, the IOM sought to identify preventive measures that were aimed at filling the gaps that it had identified.  In most cases these measures had already been proposed in the guidelines of other professional organizations.  Those preventive measures that were clearly not developed, tested, or known well enough to have a measurable impact were eliminated from consideration.  Fundamentally, the IOM asked: Are high-quality systematic evidence reviews available which indicate that the service is effective in women?  Are quality peer-reviewed studies available demonstrating effectiveness of the service in women?  Has the measure been identified as a federal priority to address in women's preventive services?  And, Are there existing federal, state, or international practices, professional guidelines, or federal reimbursement policies that support the use of the measure available?

The IOM noted that prevention is a well-recognized, effective tool in improving health and well-being and has been shown to be cost-effective in addressing many conditions early.  Prevention goes well beyond the use of disease prevention measures.  Historically, the many disparate components of our health care system have relied more on responding to acute problems and the urgent needs of patients than on prevention.  The provision of preventive health care services is inherently different from the treatment of acute problems, but our nation's health care system has fallen short in the provision of such services.  Compared with a system that prevents avoidable conditions early, a system that responds to the acute health care needs of patients can be inefficient and costly, and a focus on response instead of prevention is a major barrier to the enactment of optimal health and well-being by Americans.  Our nation's current orientation is in spite of the fact that for nearly two decades we have collectively known that nearly half of all deaths in the U.S. are caused by modifiable health behaviors.  And, research indicates that an increase in the use of clinical preventive services in the U.S. could result in the saving of more than 2 million life-years annually.  On average, women tend to use more preventive care than men, owing to reproductive and gender-specific conditions, causing significant out-of-pocket expenditures.  This creates a particular challenge to women, who typically earn less than men and who disproportionately have low incomes.  Before PPACA, there was little standardization of the preventive services offered by both private and public payers.  Medicaid, for which the benefits are essentially crafted at the State level, offers coverage for many preventive services for its approximately 66 million beneficiaries, including 30 million children.  In our judgment, it is unfortunate that psychology did not have the foresight to seek express recognition under the federal Medicaid statute prior to the enactment of PPACA.

Although none of the IOM committee members were psychologists, one of the important "Identified Gaps" addressed by the IOM was mental health care.  Depression is a widespread mental disorder that affects approximately 121 million people worldwide and has been identified to be 1 of the top 10 leading causes of disease burden.  Depression may lead to suicidal ideation and actions.  Postpartum depression is a condition specific to new mothers.  Depression can occur throughout the life cycle, from childhood to late in life.  Suicide rates in women are highest within the age range of 45 to 54 years.  Across the life course, women may develop depression more often or more prominently around the time of certain reproductive events, such as menstruation, pregnancy, loss of a baby, birth of a baby, infertility, and menopause.  Women are consistently rated as a high-risk group for depression as depression is significantly more prevalent in women than in men at almost twice the rate.  Between 10% and 20% of mothers experience postpartum depression within the first year after giving birth, which has significant consequences for both the child's development and the mother's well-being.  Depression is a condition commonly encountered in primary care because those with major depression utilize health care at higher rates and mental health issues are increasingly becoming a part of primary care, in part because of increased physician education.  The primary gap in prevention services recognized by the IOM is that the current recommendation for depression screening and follow-up does not address suicide and postpartum depression as related conditions to be evaluated.  We would postulate that if psychology had been more actively engaged in this important IOM study a significantly broader recommendation would have evolved.  As Katherine Nordalemphatically stressed, our nation's health care system is undergoing unprecedented change and would significantly benefit from psychology's concerted presence.

            MACPAC:  One of the most satisfying aspects of serving in the public policy arena is the opportunity of working closely with our nation's next generation of public servants.  Coming from varying backgrounds, these leaders of tomorrow are extraordinary bright, enthusiastic, and dedicated.  Hopefully, as they mature into seasoned professionals, they will retain these defining traits.  "Only a year out of my undergraduate studies and interning inWashington, DC for the first time, I have found myself diving head first into a veritable sea of complex issues I had never had to look more closely at than the articles in my local newspaper.  I have been fortunate enough to have the opportunity to work closely on many different health related issues during my short tenure here and am struck by the inseparable bond existing between the health issues I study and the debt talks going on all around me.  As the struggle to reform healthcare and balance the Federal budget continues, the U.S. is increasingly looking at patient-centered and team-based approaches as a more effective way to not only treat patients, but also to manage their long-term care.  With so much change being implemented on the system as a whole, the role of the psychologist within the new healthcare system is also evolving.  On the one hand, recent studies show the tremendous psychological effect of expanded Medicaid or access to medical insurance.  Evidence from the first year of the Oregon Health Insurance Experiment indicates that 'when poor people are given medical insurance, they not only find regular doctors and see doctors more often but they also feel better, are less depressed and are better able to maintain financial stability.'  On the other hand is the problem of finding adequate funding to support these initiatives.

            "Persons requiring mental health services, while representing a comparatively small portion of the Medicaid recipient population, also incur a disproportionately high level of associated cost.  The APA reports that most Medicaid beneficiaries are not entitled to psychological services.  With the exception of children under the age of 21, who are covered by Medicaid as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefits for psychological services, access for low-income families and disabled persons varies from state to state.  Because it is considered an 'optional benefit,' only 50% of the states offer psychological services through independent practices while the other half may cover services in certain situations only, such as through a hospital, according to the APA.  However, in those circumstances, psychologists are not able to bill Medicaid directly.  States' policies on psychological treatment as an 'optional benefit' vary considerably and are at risk for cuts as states facing budget shortfalls must make tough choices.

            "In an effort to confront the national goal of cutting spending while improving the care management necessary for this population's complex needs, states have been increasingly trending away from fee-for-service and towards managed care in Medicaid, a movement that is likely to continue, according to the Medicaid and CHIP Payment and Access Commission's (MACPAC's) recent Report to Congress: The Evolution of Managed Care in Medicaid.  Managed care can be used to define many different arrangements for delivering and financing health care services, though the main three arrangements are comprehensive risk-based plans, primary care case management programs, and limited benefit plans.  While each state takes a slightly different approach, 48 states and the District of Columbia now use some combination of managed care, incorporating 71% of all Medicaid enrollees.

            "This being said, another paradox exists regarding Medicaid and behavioral health patients.  Medicaid enrollees generally tend to have a higher prevalence of behavioral health issues than the greater population; and further, mental health conditions can exacerbate other existing medical conditions.  Conversely, behavioral health services are often the most 'carved out' services in Medicaid programs, causing enrollees to have to struggle with a complex system and coordinating services.  These problems are further compounded when, in some states, the behavioral health services are 'carved out' of the plan benefit package but the pharmaceutical costs associated with them are included.  Other states have taken a more limited-benefit approach to their plans and have contracts to manage the subset of benefits and services required for particular subpopulations, such as individuals in need of inpatient mental health services.

            "The particular and increasing relevance of managed care in Medicaid comes not from its apparent discrepancies or from the challenges it has had in securing provider participation, but rather from PPACA, which is expected to be fully implemented by 2014.  Notably, this Act will require the states to establish coverage for nonelderly parents, childless adults, and adults with disabilities with incomes up to 138% of poverty.  It also calls for the creation of Accountable Care Organizations (ACOs), which are networks of hospitals, doctors, and other health professionals that agree to share responsibility for the care received by patients.  Falling under the broader category of 'other professionals,' psychologists and other behavioral health specialists will undoubtedly play an integral role as part of these health teams.  Perhaps as we look to the future of healthcare reform in this country, the need for psychologists to be more than just 'other professionals' legislatively will become more apparent and both the government and the psychological community will be called upon to provide both the funding and the necessary professionals to meet the needs of the American people" (Anna Borris, Intern for U.S. Senator Daniel K. Inouye).

            Conditions of Participation for Community Mental Health Centers:  This Summer HHS proposed regulations for community mental health centers which would require comprehensive patient assessments by a "physician-led interdisciplinary team in consultation with the client's primary health care provider, if any.  The interdisciplinary team would be composed of a doctor of medicine, osteopathy or psychiatry, a psychiatric registered nurse, clinical psychologist, a clinical social worker, an occupational therapist, and other licensed mental health counselors, as necessary."  The required psychiatric evaluation must be "completed by a psychiatrist or psychologist with physician counter signature, that includes the medical history and severity of symptoms."  "The CMHC must designate a physician-led interdisciplinary treatment team that is responsible, with the client, for directing, coordinating, and managing the care and services furnished for each client.  The interdisciplinary treatment team is composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and therapeutic needs of CMHC clients."  We would suggest that Katherine's message is extraordinary important if psychology is to remain an independent health care profession under PPACA.  I will soon be retiring from the U.S. Senate staff after 38+ years of a fascinating journey.  "If you miss the train I'm on, you will know that I am gone.  You can hear the whistle blow a hundred miles."  Aloha,

Pat DeLeon, former APA President – Division 29 – August, 2011

 

LICENSURE MOBILITY

            Over the years, psychology's elected leadership has increasingly called for focused attention upon the importance of facilitating licensure mobility.  Stan Moldawsky obtained the endorsement of the APA Council of Representatives slightly over a decade ago and mobility was a significant topic at James Bray's 2009 Presidential Summit on the Future of Psychology.  James notes: "Australia implemented national licensure in 2010 – it was a challenge to get it started, but initial reports indicate that it has helped psychologists practice across the vast country and better serve the broadly dispersed population from the cities to the outback.  The Australia Psychological Society was the key mover of this legislative change."  This Spring, HRSA submitted its report to Congress on licensure portability, assessing the level of cooperation among the various licensing boards and evolving models.  "Licensure portability is seen as one element in the panoply of strategies needed to improve access to quality health care services through the deployment of telehealth and other electronic practice services (e-care or e-health services) in this country….  Overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals in order to address workforce needs and improve access…."

            Steve DeMers, Association of State and Provincial Psychology Boards (ASPPB): "In addition to our Credentials Bank, Disciplinary Data System and Certificate of Professional Qualification programs that promote mobility, we are also pilot testing in two jurisdictions a Uniform Application for Psychology Licensure system.  In these two jurisdictions, applicants for licensure will actually apply through ASPPB and we will both primary source verify and store the applicant's licensure related information before transmitting it to the jurisdiction for a licensure decision.  We are largely following the Federation of State Medical Boards (FSMB) model of expedited licensure rather than the Nursing Compact approach.  ASPPB is planning on seeking a federal (HRSA) grant to support model programs to expedite licensure as a means of promoting telepractice."

Examples of the magnitude of change just over the horizon: HHS has proposed regulations to assist rural patients, under which practitioners credentialed at one hospital would be allowed to utilize telemedicine – interacting with a patient over interactive video devices – even if they are not credentialed at the hospital where the patient is receiving care.  The House of Representatives Department of Defense (DoD) authorization act includes a provision expanding the state licensure exception to include qualified and credentialed contractor and civilian health care professionals, in order to allow the National Guard, reserves, veterans, and retirees quicker and more efficient access to care.  "This amendment will allow for new technologies in telephone and Internet communications to expand into the [DoD], which will greatly expand access, especially in rural America.  It will also allow more specialists to be involved in providing care….  (Quoting the Vice Chief of Staff of the Army): 'The Army, like the larger American society, is suffering from a shortage of behavioral health specialists, and that is, in fact, a national crisis.  Efforts in tele-behavioral health – allowing specialists to meet with patients through teleconferencing technology, for instance – could increase the effectiveness and reach of a limited number of providers….  There are challenges regarding the credentialing and licensing of specialists to work across State lines.'"

We would rhetorically ask: Have our State Association members engaged in discussions with their own licensure board in order to ensure that licensure mobility becomes a significant priority?  Currently, 24 States have adopted the Nursing Compact approach; 37 States are in some phase of implementation of the FSMB Uniform Licensure Application approach.  Where are your State Association and Licensing Board in this important discussion?  Aloha,

 

Pat DeLeon, former APA President – Division31 – June, 2011

 

 

AN EXCITING VISION FOR THE FUTURE

The Department of Veterans Affairs:  I recently had the opportunity to attend the 14^th annual VA Psychology Leadership Conference, "Innovation through Leadership, Research, Service, and Advocacy."  This was the largest gathering in their history with over 200 excited colleagues attending, many for the first time.  Maui'sKathy McNamara and Kathleen Piercerepresented Hawaii.  APA President Melba Vasquez gave a truly inspiration report on the Association's efforts on behalf of our nation's veterans, as well as her Presidential initiatives; for example, carefully addressing the needs of our increasing immigrant population. Katherine Nordal and Randy Phelps from the Practice Directorate highlighted the importance of psychology seeing itself as a bona fide health care profession and working hard to ensure that our nation's health policy experts (including those in the White House) appreciate all that we can bring to their vision.  VA Central Office was well represented.  I was very pleased with the extent to which Bob Zeiss has been systematically expanding our post-doctoral presence; this year funding 267 positions at 58 sites in 31 states and the District of Columbiaand Puerto Rico.

Over half of our profession's clinicians have had some VA training experience.  Many of us grew up in families in which loved ones served in the military.  VA is working hard to transform itself into a veteran-centric, highly responsive integrated health care system utilizing the most up-to-date technology to provide state-of-the-art care.  Historically practitioner-comfortable "silos" must give way to interdisciplinary, coordinated care.  VA will attract retiring DoD colleagues with their unique veteran's perspective.  And, with the military already authorizing prescriptive authority, VA will eventually follow suit.  The federal sector has a unique opportunity, with its considerable resources and national presence, to bring the rest of the health care world into the 21^st century capitalizing upon the unprecedented developments occurring within the health information technology (HIT) environment.  Is there, for example, any meaningful difference between on-site supervision and that conducted via telehealth?  At the highest level, VA and DoD are committed to integrating their electronic health records.  This will allow seamless care from active duty to retirement, and across-patient and family comparisons of effectiveness and need.  VA visionaries Toni Zeiss and Lisa Kearney truly did an outstanding job.

            "Telepsychology is knocking:  The key to responsible use in our clinical work is the training of psychologists regarding the existing legal, ethical, and clinical issues involved with not only e-mail but video-chat such as Skype, Facebook, text messaging, iPhone apps, as well as a number of other technologies.  Handling the barrage of new electronic services promising to make practice 'easier' is fraught with nuances that are difficult for the average clinician to detect.  Privacy and confidentiality; licensure and other regulatory issues; patient and practitioner authentication; HIPPA requirements; appropriate online professionalism, including boundaries in social media sites; treatment ramifications of searching for patient information online; reputation management and reacting to negative reviews in online rating websites; mandated reporting of abuse or suicide and homicide intent; what to include in the informed consent discussion and document; what to include in the patient record; how online technology is likely to evolve, including the electronic health records and what they mean for psychologists – all these issues are at our doorstep.  When the patient floats from one to another technology and asks that the psychologist accommodate him or her, what is the responsible psychologist to do?" (Marlene Maheu, a visionary leader in telehealth).

            An Interdisciplinary Perspective:  Sandy Harding, MSW, with the AmericanAcademy of Physician Assistants: "The physician assistant (PA) profession was created over 40 years ago in response to a shortage of primary care physicians.  In 1970, there were approximately 250 PAs.  Today, over 75,000 PAs provide high quality, cost effective care in virtually all health care settings and in every medical and surgical specialty.  PAs are one of three health care professionals providing primary medical care in the U.S.  By design, PAs always practice in teams with physicians, extending the reach of medicine and the promise of health care to the most remote and in need-communities.  PAs often provide autonomous medical care, have their own patient panels, and are granted prescribing authority in all 50 states.  In 2009, nearly 300 million patient visits were made to PAs.  By all accounts, the primary health care workforce must grow in order to provide care to the individuals and families who will receive access to covered medical care as a result of the implementations of President Obama's Patient Protection and Affordable Care Act.  PAs are a key part of the solution to today's and tomorrow's health care workforce shortage.  However, to fully utilize PAs in the nation's primary care workforce, Congress must: * Eliminate unnecessary federal barriers to the quality medical care provided by PAs; and, * Integrate PAs into all federal programs designed to promote growth in the primary care workforce.  Currently, for example, Medicare imposes a barrier to hospice care and the Federal Employees' Compensation Act will not honor a clinic-based claim where the PA is the only health care worker on site, but will provide for reimbursement in a hospital emergency room."

            A Historical Perspective:  Jerry Michael, former Dean of the University of Hawaii School of Public Health and Assistant Surgeon General of the U.S. Public Health Service, prophetically observed in 1968: "For broad planning purposes, we can project long-range trends in health manpower supply and demand.  In contrast to our scientific and economic successes and people's expectations based upon them, we see gross inadequacies in trained manpower.  I cannot emphasize too strongly that the value of any auxiliary health worker is directly proportional to the quality of his training and the quality of his supervision.  Quality training and quality supervision are essential.  It is also essential to determine just what jobs the workers are to do – and where – and to train them for the specific jobs.  These precepts are so elementary that it is almost redundant to state them, yet we see all too many instances in which these obvious first steps have been forgotten or overlooked.  The keystone in better utilization of health care facilities is improved planning, training, and education.  Thus it would follow that these elements are equally crucial in the utilization of health personnel.  In addition, planning aimed at the most effective use of health manpower must also be responsive to changing knowledge and social changes and to the increasing expectations of health service consumers.  The scarcity of health manpower must be viewed as both a national and a local problem, and the approach to its solution must be systematic, based on sound knowledge of the makeup of the health system and with the needs of the patient identified and kept paramount."  VA, DoD, and increasinglyHawaii's political leadership appreciate this vision.  Above all else, our system must be patient-centered and no longer concerned with being highly provider comfortable.  Aloha,

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

 

THE ADVENT OF TECHNOLOGY

Technology's Contribution To Health Care Reform:  As President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act (PPACA) [P.L. 111-148], is being steadily implemented, the concerns raised from a number of vantage points can be seen as a testament to his vision, as well as to the magnitude of change involved.  Change is always unsettling, especially for those comfortable with the status quo.  One of the underlying objectives of PPACA is to focus the unprecedented advances occurring within the communications and technology fields directly upon the health care environment, as they are already impacting every other segment of our economy.  This can be seen with the significant resources provided for Comparative Clinical Effectiveness Research (i.e., determining objectively what services work, for what symptoms, and under what conditions); ensuring that all providers have ready access to electronic health records, thus providing the capacity to compare outcomes across patients and diagnoses (Health Information Technology (HIT)); and increasing the applicability of telehealth care, so that one's geographical location will no longer be a barrier to receiving quality care.  There can be no question that central to effectively utilizing this technology are critical and complex licensure issues.  Perhaps the underlying question is: Whether our nation looks at providing necessary health care as representing a societal responsibility or an individual patient/provider decision?

            Organized psychology appreciates the importance of being proactive.  In February, the APA Council of Representatives approved the creation of a Telepsychology Task Force, co-chaired by Linda Campbell and Fred Millan, that will be comprised of four APA representatives, four ASPPB representatives, and two APAIT representatives.  One of the issues that the task force will face is inter-jurisdictional practice/licensure mobility.  Their first meeting is scheduled for mid-July. Judy Hall, National Register Executive Officer: "The National Register of Health Service Providers in Psychology (NR) is uniquely positioned to serve as the primary licensure mobility credential for psychologists in the United States, Canada, and beyond.  We are by far the largest credentialing organization for psychologists, with 11,000 members; have standards and credentialing procedures that are well established and are widely approved by licensing boards to expedite licensure mobility.  To date, we have verified credentials to licensure boards for more than 1,300 Registrants.  The NR is ranked by both early career and more senior psychologists as one of the most valuable benefits, both for the here-and-now value and as an insurance policy for those who may apply for additional licenses later in their careers.  For a list of jurisdictions approving the National Register, seewww.nationalregister.org."

            Health Resources and Services Administration (HRSA):  APA's Debra Baker shared with us the report released this Spring by HRSA: "Health Licensing Board Report To Congress."  Requested by the FY'2010 Senate Appropriations bill, the report updated efforts being made on licensure portability and the level of cooperation between health licensing boards, the best models for such cooperation, and the barriers to cross-state licensing arrangements.  HRSA focused on physicians and nurses since in its view these are: "the two professional groups for which there is the most information on alternative approaches to overcoming licensing barriers to cross-state practice."  Utilizing funding from FY' 2006, HRSA created its licensure portability grant program which has subsequently funded projects submitted by the Federation of State Medical Boards (FSMB) and the National Council of State Boards of Nursing (NCSBN), as well as the State of Wisconsin Department of Regulation and Licensing.

            "Licensure portability is seen as one element in the panoply of strategies needed to improve access to quality health care services through the deployment of telehealth and other electronic practice services (e-care or e-health services) in this country.  But licensure portability goes beyond improving the efficiency and effectiveness of electronic practice services.  Overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals in order to address workforce needs and improve access to health care services, particularly in light of increasing shortages of healthcare professionals.  It is also seen as a way of improving the efficiency of the licensing system in this country so that scarce resources can be better used in the disciplinary and enforcement activities of state boards, rather than in duplicative licensing processes."

            Those involved in the licensing process of both medicine and nursing are seeking ways to simplify the licensing process for those members of their professions who are interested in obtaining licenses in more than one state, although they have taken different strategic approaches to date.  Nursing has developed a far reaching mutual recognition model under which practice across state lines would be allowed, whether physical or electronic, unless the individual practitioner is under discipline or a monitoring agreement that restricts practice across state lines.  This approach requires each state to enter into an interstate compact, called the Nurse Licensure Compact.  This was first implemented on January 1, 2000 by Maryland, Texas, Utah, and Wisconsin.  Currently 24 states participate.

            Medicine has been encouraging states to adopt the model of expedited endorsement.  This is a method of setting criteria to approve the valid license of another state.  The process accepts a license issued in one state that was verified and sets requirements for endorsing a license granted in another state.  Idaho, Iowa,Michigan, Nevada, New Mexico, North Carolina, Oregon, and Rhode Island currently have adopted the expedited endorsement process.

Some state authorities are clearly uncomfortable with accepting the licensing process of another state.  Concerns expressed include: not every state board requires criminal background checks and state boards are ultimately responsible for maintaining public protection within the state.  Control/lack of authority; lack of uniform standards; cost/loss of revenue; fear among unions and state professional associations that this could facilitate strike breaking; a general misunderstanding about the process among practitioners; and the lack of independent evaluations have all been noted as potential barriers.  A number of these concerns can be satisfactorily addressed, especially as the broader provider community becomes more clinically comfortable with the use of advanced technology (HIT) in their daily practices.  To place this evolution in perspective, at the time the Obama Administration began its successful quest for health care reform, their goal was to bring physician HIT utilization up from five percent to 90 percent by 2019 and hospital utilization to 70 percent during the same time frame, with their estimate being that only 1.5 percent of hospitals had a comprehensive electronic system available in all units.

For over a century, health care in theUnited States has primarily been regulated by the states.  Such regulation includes the establishment of licensure requirements and enforcement of standards of practice for health providers.  The licensure authority is administered with the goal of ensuring that health care professionals are academically qualified, competent, and mentally and physically fit to provide the activities covered by the license.  "As the U.S. health system evolves to meet the changing needs of consumers, traditional methods of healthcare delivery are being transformed.  No longer do the patient and the provider need to be in the same location to receive quality health services.  Telehealth (telecommunications and information) technologies are being used to provide healthcare services in a more efficient and effective manner to address the shortages and maldistribution of healthcare professionals that result in lack of access to quality healthcare services, whether due to geographic, economic, or other social factors.  Telehealth services are increasingly becoming part of the mainstream of healthcare.  For these reasons, the number of physicians and the number of other health providers practicing across state boundaries have increased in recent years.  This trend is expected to continue in the foreseeable future."

The purpose of licensing health care professionals is to protect the public from incompetent or impaired practitioners.  A licensure system must be able to administer and enforce its standards.  The basic standards for medical and nursing licensure have become largely uniform across all states.  Physicians and nurses must graduate from nationally approved educational programs and pass national licensure examination.  However, there are significant differences in administrative and filing requirements among the states.

The American Bar Association Health Law Section in its 2008 report proposed a model for allowing the cross-state licensure of physicians, which was approved by the ABA House of Delegates.  The Federal Communications Commission (FCC) released its National Broadband Plan in 2010 urging states to revise licensure requirements to enable "e-care."  Noting that current licensure requirements limited practitioners' ability to treat patients across state lines, which hindered access to care, the FCC urged increased collaboration.  And, if the states failed to develop reasonable licensing policies to facilitate electronic practice over the next 18 months, it recommended that Congress ensure that Medicare and Medicaid beneficiaries are not denied the benefits of "e-care."  Some have already called for the federal government to enact national licensure.  In our view, the states still have time to demonstrate vision.  "You know I feel all right."  Aloha,

Pat DeLeon, former APA President – Division 18 column – June, 2011