THE ADVENT OF NATIONAL HEALTH INSURANCE (NHI)

In our judgment, the 2010 enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) reflects our nation's commitment to finally ensuring that all Americans will have timely access to "gold standard" health care when required. The underlying statute has been crafted to provide for incremental implementation with many of the major provisions taking effect by 2014 and still others by 2019-20. The individual states have been provided with considerable flexibility to shape broad federal mandates in a manner that best reflects local priorities and concerns. Complex and highly controversial, in upholding the constitutionality of the law the Chief Justice of the U.S. Supreme Court opined: "We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation's elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions." Justices Ginsburg and Sotomayor provided a different perspective: "The provision of health care is today a concern of national dimension, just as the provision of old-age and survivors' benefits was in the 1930's…. In enacting [ACA] Congress comprehensively reformed the national market for health-care products and services…. Unlike the market for almost any other product or service, the market for medical care is one in which all individuals inevitably participate…. Not all U.S. residents, however, have health insurance. In 2009, approximately 50 million people were uninsured, either by choice or, more likely, because they could not afford private insurance and did not qualify for government aid."
In developing ACA's underlying regulatory schema, Congress passed several bills, including the American Recovery and Reinvestment Act of 2009 (the Economic Stimulus legislation) which provided significant funding (estimated at $19+ billion) and comprehensive programmatic authority for aggressively moving our nation's health care system into the 21st century world of communications technology (i.e., virtual realities, electronic health records (EHRs), telehealth, and cross-patient and cross-diagnostic comparisons (competitive effectiveness research)). Partisan politics precluded the usual process of technical modifications and as a result, it is difficult to accurately predict ACA's specific impact upon the daily practices of our colleagues. Without question, however, the health care world of tomorrow will be fundamentally different than our practitioners and educators ever imagined. Health care will be patient-centered, integrated, and interdisciplinary in nature. Reimbursement priorities will shift from curative, procedure-driven acute illness care to holistic, wellness-oriented, primary and preventive care. Mental health services will be deemed "primary health care" services; no longer to be considered "specialty care" except under special conditions. As the Institute of Medicine (IOM) has repeatedly noted there is an "inextricable link between mental health and primary care…. Primary care providers address a broad range of health issues to which mental health concerns are integral. Mental, behavioral, and physical health are so closely entwined that they must be considered in conjunction with one another." From a policy frame of reference, the critical importance of the psychosocial-economic-cultural gradient of care will be increasingly recognized. In many ways psychology, nursing, and the behavioral sciences will have an unprecedented opportunity to shape the future of their professions and our nation. These will be exciting times, with unique opportunities and challenges.
I recently had the opportunity to visit the joint clinical-community doctoral psychology program at the University ofAlaska, including flying out to an Indian Health Service (Alaskan Native) clinic in ruralBethel. Students and faculty at the Anchorageand Fairbanks campuses interact seamlessly utilizing modern day video technology. Courses taught on either campus, including faculty and/or student meetings, are fully interactive. It was, for example, admittedly a bit startling to have participants introduce themselves along one side of the table, continue into the virtual space, and then cycle back to where I was sitting. Treatment staff at the Bethel clinic report being readily able to utilize in real-time the medication expertise of psychiatrists located in Washington State andMinnesota, who over time have become intimately familiar with their patients, again in a seamless fashion. From a policy frame of reference, distance learning, telehealth services, simulation labs, health information technology (HIT), and utilization of interactive electronic health records (EHRs) are inseparable – they represent the exciting infusion of communications technology into the health care environment. Interestingly, at the time ACA was enacted the Administration estimated that only 5% of physicians possessed fully functional electronic health records. Their goal was to bring this up to 90% by 2019.
Although electronic devices are pervasive throughout our culture, they are a relatively new phenomenon in the health care world. The Alliance for Health Reform notes that the Economic Stimulus legislation included a provision, the Health Information Technology for Economic and Clinical Health (HITECH) Act, which has already jump started the process, focusing upon "meaningful use." Health care transformation has begun, with HHS announcing that providers' adoption of HIT has doubled in two years. Nevertheless, special challenges exist for solo and small practices. Coordination of care, active patient involvement, and the development of a relevant workforce continue to be high priorities for the Administration. Under HITECH $677 million has already been allocated to support a nationwide system of Regional Exchange Centers to make sure that primary care providers receive the help they need. Change is definitely coming. The American Association of Colleges of Nursing 2012 Fall Semiannual meeting is entitled "Taking Advantage of Technology in Nursing Higher Education." What are we as psychologists doing to address the critical issue of licensure mobility? Why is a senior colleague who was licensed in Alaska, a former State Association President, not able to continue providing clinical services in ruralNew York during her retirement? The underlying policy rationale for licensure is patient protection. Are the residents of these two states so qualitatively different? Accordingly, I commend the National Register for its visionary efforts to effectively address this increasingly important issue as the advent of technology and NHI steadily overcomes traditional geographical barriers.
"Seems you are giving voice to the experiences of colleagues who are retiring from the field. I was in Denver a few weeks ago and attended a CE session on psychiatric disorders in the aging population. Among other things, I took note of the observation by the presenter that oftentimes depression occurs in successful CEO types who retire because no one listens to them anymore because they no longer have any authority. Hard to imagine this happening with the psychologists we know since I am sure most of them have lots of things they want to do when they retire. I sure did. Off to see daughter and husband inVermont with train rides down to NYC, NJ, and PA to see friends" [Jon Esty]. Aloha,

Pat DeLeon, former APA President – National Register – October, 2012

THE TRAIN KEEPS ON MOVING

The past has been good to psychology.  The number of successful practitioners, as well as our underlying clinical knowledge base, continues to expand nicely.  Colleagues such as Antonette Zeiss have been appointed to impressive leadership positions within such critical agencies as the Department of Veterans Affairs (VA) which has been instrumental in furthering psychology's post-doctoral presence.  Collectively, we have obtained formal recognition under a wide range of federal statutes; for example, the federal criminal code as expert witnesses; eligibility for serving as U.S. Public Health Surgeon General; pay bonuses for obtaining diplomat status; and most recently, the health professions Graduate Psychology Education (GPE) initiative as a result of the persistence and dedication of the APA Education Directorate.  As always, there remain numerous challenges ahead – Medicare's Graduate Medical Education (GME) and the Children's Hospital GME accounts to name but two.  With the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA) [P.L. 111-148] our profession is facing unprecedented challenges throughout the healthcare system, which is rapidly changing from its previous emphasis on reimbursing for specific clinical procedures targeted toward curative care, to a more comprehensive, patient-centered, holistic, data-driven health care system with a high priority on prevention, public health, interdisciplinary care, and effectively utilizing technology – especially, the extraordinary advances in communication sciences (i.e., Health Information Technology).

            Without question, there are several critical provisions within ACA where psychology currently is not recognized; i.e., the very important Accountable Care Organization (ACO) and Patient Centered Medical Home (PCMH) initiatives.  AsKatherine Nordal insightfully stresses at her annual State Leadership conferences, the key for psychology is enthusiastic engagement at the local level, in collaboration with similar-minded partners (such as Doctors of Nursing Practice (DNP) and Clinical Pharmacists (PharmD))  For it is at the state level where the real work of implementing health care reform will be taking place.  Conceptually we are in good shape.  Over the past decade, the Practice Directorate has built a robust State Leadership infrastructure.  APA's governance leadership appreciates the importance of embracing integrated care and expanded roles of practice (such as prescriptive authority (RxP)), as well as tele-psychology and the absolute necessity of licensure mobility.  As always, ultimately the key to recognition and support by our nation's elected officials is effectively addressing society's pressing needs.  Accordingly, we must pause and wonder: Why have we not been collectively interested in obtaining recognition under Medicaid?  And, Why do we not have an active presence within federally qualified community health centers?  For these are the true "safety net" envisioned by President Lyndon Johnson's Great Society?

            What must happen next from my public policy perspective is that our profession's training institutions must learn from their colleagues in medicine and nursing about the importance of possessing "homes of their own."  Within ACA there are impressive incentives recognizing the importance of encouraging the educational institutions of both of these professions to address society's pressing needs (i.e., by providing financial assistance).  For example, Nurse-Managed Health Clinics that will provide comprehensive primary health care and wellness services to vulnerable or underserved populations; a new Medicare Graduate Nurse Education Demonstration program for up to five eligible hospitals to receive support for clinical training costs attributed to providing advanced practice nurses with qualified training.  And, a Teaching Health Centers initiative to expand primary care residency programs.  The Senate Appropriations Committee has recommended that not less than $5 million be expended for the nurse-managed health clinic program, within the $231+ million allocated for nursing training.  The Children's Hospital GME initiative will receive $265+ million exclusively targeted for medical schools, notwithstanding the important psychosocial component of childhood and family care following accidents and for those children afflicted with potentially devastating diseases such as childhood cancer.  Historically, psychology's training programs have expressed little, if any, interest in expanding their legislative presence (other than most recently, under the newly authorized GPE program).

            As educated professionals, we should take serious notice of the unfortunate reality of the Institute of Medicine (IOM) finding that: "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."  This delay in the translation of evidence to practice is unacceptable and must be addressed.  We must come to appreciate that our training institutions are where the next generation of psychology's practitioners will learn their skills and practice patterns for decades to come.  They are also absolutely critical in bringing the most up-do-date clinical knowledge to the attention of today's practitioners.  With the expanding availability and exciting potential inherent in tele-psychology, virtual realities, and data-driven cross-patient comparisons, it must ultimately be our training institutions (and I expect it will be our professional schools) that must now demonstrate proactive leadership in making these connections – in bringing "town and gown" effectively together.

            For those colleagues who argue that we should not consider ourselves "health care providers"; that psychology should not seek to expand its scope of practice (i.e., pursue RxP); and that we need fewer students, rather than more, I can only say that "the train has already left the station."  Hopefully, our next generation of colleagues will appreciate what they might have individually contributed to our future, notwithstanding.  "I hear the train a comin'."  Aloha,

 

Pat DeLeon, former APA President – Division 42 Viewpoint – September, 2012

 

CRITICAL TIMES – AS ALWAYS, EXCITING OPPORTUNITIES

The annual APA Practice Directorate State Leadership conferences (SLC) provide an exciting opportunity for practitioners to personally experience how the public policy process will directly affect their future.  With the enactment of President Obama's landmarkPatient Protection and Affordable Care Act (ACA) [P.L. 111-148], our nation has finally joined the rest of the developed world in guaranteeing access to necessary health care for all of its citizens.  One of the most significant provisions of ACA is the establishment of health insurance exchanges which by 2014 will be available in every state.  These entities will ensure that all plans include the same package of essential health benefits, although they will vary by four different levels of "actuarial value," or percentage of costs that a plan pays on average.  In upholding its constitutionality, the U.S. Supreme Court estimated that by 2019, 24 million Americans will obtain their health insurance through one of the newly authorized exchanges.  Hawai'iwas the first state in the nation to declare its intent to establish a state-certified exchange and today is well underway in implementing its vision, having received a $61.8 million grant from the federal government this summer.

The Hawai'i Health Connector's executive director Coral Andrews (former Navy Nurse Corps): "The establishment of our health insurance exchange in Hawai'i is driving new business models between the private and public sector.  There is a high degree of collaboration with a focus on mutual success.  Our collective priority is to contribute positively to the health and well-being of the residents of Hawai'i.  With this recent supplemental grant award, it signals confidence in the work that we are doing and further supports the goal of developing a state certified health insurance exchange in Hawai'iby 2014."  Dean Mary Beth Kenkel, Florida Institute of Technology, and I long ago came to appreciate that enacted health policies represent the views and underlying value systems of engaged participants.  At this year's SLC, Katherine Nordal: "We are in for a change like probably none we have ever seen in terms of shaping what our practices are going to be like in the next decade or two.  We're facing unchartered territory with proposed new models of care delivery.  We know that the states are in the drivers' seat.  Most of what happens about health care reform is going to happen back home.  You've got to get involved in coalitions.  We're going to have to address health insurance exchanges."

Psychologists must come to appreciate that it is essential to be personally involved in the public policy/political process if we want to maintain our professional identity and independence.  The newly elected President of the American Medical Association (AMA), in response to questions regarding non-physician health care providers, has stated: "It's imperative that we collaborate.  The patients need that.  We think that care must be delivered in a physician-led team.  There are appropriate roles for other health-care providers, like nurse practitioners [NPs] and physician assistants [PAs].  They all have the ability to function to their highest level within a physician-lead team.  [Why 'physician-led team?']  The physician has the potential and capability to manage the unexpected, something that might not go as predicted.  And that's why you need a team.  The physician is the highest trained and the one who has to be in charge of the whole thing."

Perhaps not a surprising orientation.  However, last summer the Centers for Medicare and Medicaid Services (CMS) issued proposed conditions of participation for community mental health centers (CMHCs) which seem to take the AMA's view to another level.  "The comprehensive assessment would build from the initial evaluation and be completed by the physician-led interdisciplinary team in consultation with the patient's primary health care provider, if any….  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."  Interestingly, psychologists will be allowed to conduct psychiatric evaluations, if there is a "physician counter signature."  This summer the Department of Veterans Affairs (VA) requested: "A nationwide blanket tier exception for Psychiatrists… in order to provide a broader and more competitive salary range to potential recruits and provide greater retention to existing staff."  Hardly a vision of effectively utilizing the skills of non-physician providers by the current Administration.

President Obama recently issued an important Executive Order – Improving Access to Mental Health Services for Veterans, Service Members, and Military Families.  He called for the Departments of Veterans Affairs and Defense to jointly develop and implement a national suicide prevention campaign focused on connecting veterans and service members to mental health services.  An Interagency Task Force will be established to be co-chaired by the Secretaries of Defense, Veterans Affairs, and Health and Human Services, or their designees.  The critical question for psychology, as well as for other non-physician health care providers: What will our role be?  We would suggest that it would be extraordinarily naïve to assume that all those involved in establishing and implementing important national (and local) health care policies truly have "the best interest" of the client/patient in mind, rather than their own professional identity or "turf."  As our visionary leader Katherine Nordalproclaimed at this year's SLC: "We have to be ready to claim our place at the table.  We need to get involved at the ground level.  If we're not at the table, it's because we're on the menu."  For those senior colleagues who are wondering whether they should become more involved in the Nebraska Psychological Association's political efforts, these thoughtful words from former APA President Nick Cummings should be carefully considered:  "As one who forever keeps flunking retirement, I strongly recommend flunking…."  Get involved!  Aloha,

 

Pat DeLeon, former APA President – Nebraska Psychological Association – September, 2012

 

 

EMBRACING INTEGRATED HEALTH CARE

   Steady RxP Progress:  During ourOrlando convention, Illinois Psychological Association President-Elect Beth Rom-Rymer predicted an exciting future for those colleagues who embrace integrated care and who appreciate the importance of prescriptive authority (RxP) for the profession's future and quality of care that psychologists can provide within our nation's rapidly changing health care environment.  "There has been extensive movement in the RxP initiative since January 1, 2012.  The movement has been most productive in two states, Illinois and New Jersey, and the Canadian province of Ontario. Hawai'i is re-introducing RxP in 2013.  There has also been a recent announcement that theNew Zealand government has mandated that psychologists become trained to prescribe in that country in 2013, because of the critical shortage of psychiatrists and significant health risks to New Zealand citizens due to the lack of mental health prescribing providers.

            "The Illinois Psychological Association (IPA) is pursuing an aggressive campaign for RxP.  It all began on March 6, 2012, when the IPA RxP bill passed out of the Public Health Committee of our State Senate.  Its champion and sponsor was the President Pro-tem of the Senate, Don Harmon.  The Chair of the Public Health Committee, Senator William Delgado, was also key in this legislative success.  SinceMarch 6^th, IPA has created an extensive grassroots campaign, involving more than 200 psychologists, from around the state, who are meeting with their legislators and speaking to mental health associations, social service organizations, law enforcement associations, hospital groups, prison health care providers, among others.  The psychologists are emphasizing the robust training that prescribing psychologists receive; the critical shortage of mental health prescribing providers; the success of prescribing psychologists in the U.S. military, on Indian reservations, and in the states of New Mexico and Louisiana; and the need to prepare for the entry of hundreds of thousands of new patients into the mental health and primary health care system on January 1, 2014, when President Obama's Patient Protection and Affordable Care Act (ACA) [P.L. 111-148] takes hold in Illinois.  IPA's goal is passage of the RxP authority bill in the legislature in Spring, 2013.

            "The New Jersey Psychological Association (NJPA) and the New Jersey Academy of Medical Psychologists, under the leadership of Sean Evers, President-Elect of NJPA, is pursuing an aggressive campaign for RxP with its legislators.  They have support from Autism New Jersey, the National Association of County Veterans Service Officers, the VFW District 12, the National Association of County Veterans Service Officers, the VFW Post 6063, and the New Jersey Association of Veterans Service Officers, among others.  NJPA hopes for passage of their RxP bill in the General Assembly (the lower house of the state legislature) in the Fall of 2012.  They have received bi-partisan support from leadership in both houses of the legislature with the Senate Majority Leader signing on as a co-sponsor and positive interest from the administration.

            "The Ontario Psychological Association Committee for Prescription Privileges is chaired by Diana Velikonja and Jane Storrie, with Honorary Co-Chair, Marie Greenspan.  Their RxP Committee is working very hard to garner support for RxP.  Internally, the committee is seeking support from the Ontario Psychological Association's (OPA's) Board of Directors, the Canadian Psychological Association, and the College ofPsychologists in Ontario.  They are also seeking support from outside groups, including the Nurse Practitioners Association of Ontario, the Nurses Association of Ontario, the Collegeof Physicians of Ontario, the Pharmacy Association of Ontario, the Bureau of Indian Affairs, the Military, and the Ontario Medical Association.  There will be a motion to the OPA Board in September, 2012 for support of RxP and a submission to the Deb Mathews, Provincial Minister of Health, requesting expansion of practice for psychologists, in October 2012.

            "Darryl Salvador, President-Elect of the Hawai'i Psychological Association (HPA), is leading the continuing movement for RxP inHawaii.  In 2011, HPA added language to their existing RxP bill that would develop a 5-year, multi-phase pilot program that would limit prescriptive authority to psychologists practicing in the largest federally qualified community health center (FQCHC) in Hawai'i for the first two years and then expanding the training and subsequent practice to other FQCHCs in the following years.  HPA has enlisted the help of key Native Hawaiian community leaders and has secured the support of a psychiatrist to assist with supervising psychologists during the practicum phase of their RxP training.  There has been positive changes to the composition of the Hawaii Board of Psychology; a Master's of Science Program in Clinical Psychopharmacology in now housed within the University of Hawai'i at Hilo College of Pharmacy; and there are increased opportunities to work collaboratively with the new state government officials, including the Governor, the Lieutenant Governor, and the Director of the Department of Health.  HPA plans to introduce legislation during the 2013 legislative session.  Because of an election in 2012, the expectation is that there will be changes, favorable to RxP, in the House leadership and Committees."

            The Struggles Surrounding Professional Autonomy Continue:  The newly elected President of the American Medical Association (AMA) recently reaffirmed their support for President Obama's ACA, which is estimated to provide 32 million additional Americans with access to necessary primary health care.  In response to questions regarding non-physician health care providers, she stated: "It's imperative that we collaborate.  The patients need that.  We think that care must be delivered in a physician-led team.  There are appropriate roles for other health-care providers, like nurse practitioners [NPs] and physician assistants [PAs].  They all have the ability to function to their highest level within a physician-lead team.  [Why 'physician-led team?']  The physician has the potential and capability to manage the unexpected, something that might not go as predicted.  And that's why you need a team.  The physician is the highest trained and the one who has to be in charge of the whole thing.  I have worked with physician assistants and have a wonderful relationship.  I've worked with nurse practitioners and we work collaboratively.  But when there was an issue that needed something beyond the scope of the individual, I was the one managing that."

            This is at a time, as Morgan Sammonspoints out, combining NPs and PAs, the numbers of non-physician practitioners are on track to exceed that of primary care physicians in the near future.  There are approximately 250,000 NPs and PAs in the U.S., compared with 306,000 primary care allopathic physicians (medical and osteopathic).  This trend is consistent with projections made a decade ago.  It is also projected that a quarter million more nurses will be needed by 2025 to care for the growing and aging population, especially those with chronic care needs.  Forty-five percent of today's nurses say they plan to make a career change in the next one to three years.  Katherine Nordal's vision at the Spring State Leadership Conference that State Psychological Associations be actively engaged in health care reform deliberations at the local level, and in collaborations with our nursing colleagues, is absolutely critical.  Aloha,

Pat DeLeon, former APA President – HPA – September, 2012

 

THE CRITICAL IMPORTANCE OF INVOLVEMENT

    During this year's exciting State Leadership Conference, Katherine Nordal called upon the membership to become increasingly involved in shaping the future of our profession.  "We're facing unchartered territory with proposed new models of care.  Change is inevitable.  We have to be ready to claim our place at the table.  We need to be involved at the ground level when you get back home.  You've got to get involved in coalitions….  We're going to have to address health insurance exchanges.  These are exchanges that provide health plans for individuals and small businesses that will be set up at the state level."  Without question, President Obama's Patient Protection and Affordable Care Act [P.L. 111-148] is complex and will have an extraordinary impact upon psychology.  In 2014 health insurance exchanges will be available in every state with all plans including the same package of essential health benefits, although they will vary by four different levels of "actuarial value," or percentage of costs that a plan pays on average.  In upholding its constitutionality, the U.S. Supreme Court estimated that by 2019, 24 million Americans will obtain their health insurance through one of the newly authorized exchanges.

 

            The State of Hawai'i was the first in the nation to declare its intent to establish a state-certified exchange and is well underway in implementing its vision, having received $61.8 million from the federal government this summer.  The HHS grant will allow the state to meet several new milestones including multi-cultural community outreach, language access, customer relations management, and information technology training and operations.  Governor Neil Abercrombie: "The successful establishment of the Hawai'i Health Connector is part of our New Day Plan in transforming healthcare in Hawai'i."

 

            The Hawai'i Health Connector is an online health insurance exchange established by the state legislature as a non-profit organization in 2011.  Its aim is provide an online marketplace that is Hawai'i-for-Hawai'i, effectively taking into account the state's unique culture and Prepaid Health Care Act, an employer health mandate in effect since 1974.  The Connector has a 15 member board of directors.  For psychology or any other health profession not to be involved in these policy deliberations would be, to invoke Katherine's inspirational charge: "If we're not at the table, it's because we're on the menu…."  Energetic coalitions with like-minded colleagues, such as advanced practice nurses and clinical pharmacists, are absolutely critical to the future of our profession.  We are making significant progress embracing the 21^stcentury.  In Orlando, Illinois Psychological Association President-elect Beth Rom-Rymer noted that her colleague Michael Ranney reports that the Ohio Psychological Association bill, which will mandate up to 6 prescribing psychologists in the Ohio State Prison System, is expected to pass in the 2013 State Legislature.  Addressing society's pressing needs remains the key.  Aloha,

 

Pat DeLeon, former APA President – Division31 

September, 2012

 

AN EXCITING ORLANDO CONVENTION

   Psychopharmacology & Prescriptive Authority (RxP):  One of the most inspirational symposiums at this year's Orlando convention was that chaired by Kevin McGuinness of the U.S. Public Health Service Regular Corps who is a Prescribing Psychologist and President of Division 55, The American Society for the Advancement of Pharmacotherapy.  "We had a very well attended symposium entitled 'How to Become a Prescribing Psychologist.'  I had the honor of introducing the presentations by Bob McGrath (Fairleigh Dickinson University),Christina Vento (Southwest Institute for the Advancement of Psychotherapy/New Mexico State University, and Virginia Waters, an RxP graduate of the Fairleigh Dickinson program.  I outlined the APA's recommendations regarding postdoctoral education and training programs in psychopharmacology for prescriptive authority and described the requirements for licensure in New Mexico andLouisiana.  We included a discussion of grass roots advocacy, post-doctoral education, RxP licensure, social networking with psychologists, local political activism, affiliate health professions, and the integration of psychologists' roles in healthcare practice settings.  Regarding the integration of psychologist roles, we emphasized faithfulness/consistency to the primary role as 'clinical psychologist'; commitment to collaborative relationships with MDs, PCPs (primary care providers), and other psychologists; education of the public on the quality of comprehensive psychological service ('one-stop-shopping'), and the need for prescribing psychologists and other psychologists to find their niche in primary care, rural medicine, academia, public policy, and the APA governance.

            "Bob McGrath discussed the responsibility of clinical psychologists to understand clinical psychopharmacology in order to serve in consultative roles across the spectrum of health care settings.  He emphasized the role of post-doctoral training in clinical psychopharmacology to prepare such consultants and not only prescribers.  Bob asserted his belief that clinical psychologists with such training have saved many lives.  Virginia Waters discussed the value of her training at Bob's program for preparing her as a consultant in a state that has not yet granted prescriptive authority to psychologists.  She uses her training everyday in this capacity, especially when it comes to educating patients on the medications they are taking.  Christina Vento, on the other hand, utilizes her training as a licensed prescriber.  Both graduates functionally address polypharmacy by 'unprescribing' medications under appropriate circumstances and more fully utilizing psychotherapy as a primary therapeutic intervention.  Our tasty 'free lunch' for those attending was undoubtedly a successful drawing card."  As our nation's health care systems evolve towards integrated, patient-centered holistic care, it was very nice to see the next generation of psychology's practitioners appreciating the inherent challenges and opportunities for their professional future.

            Evolving Journeys:  Having retired from the U.S. Senate staff after 38+ years, I have become quite interested in how our colleagues are approaching this next phase (or journey) of their lives.  Ruth Paige and Steve Ragusea: "All our lives we've been busy achieving and meeting responsibilities and expectations to – do well in school, raise children, earn a living, be socially and culturally engaged – and then, we finally retire.  We haven't been trained for this.  And that makes it so urgent and scary for some….  But not others….  Some of us read the research on retirement long ago and began our preparations by slowing down and snorkeling.  It's not about stopping; it's about slowing down and taking more side roads along the highway of life."  Summing up what seems to be a consistent theme for those who are successful in adapting to their new life, a colleague who recently stepped down from a high level academic position: "Pretty good – miss the people but not some other aspects.  Am currently in North Carolina – was a bridesmaid in a wedding of friends fromHawaii – we were a mature wedding group – lots of fun.  How are you doing?"

            Academia:  "How to terminate tenured professors?  I am sure those of us who have reached or are reaching what has been the traditional age of retirement, age 65, contemplated retiring.  While those of us in defined pension plans may have the incentive of realizing that their pension may be very close to what they are earning, and thus they may be working for close to nothing, those of us in battered 401 plans see continued employment as trying to regain their losses over the past several years.  Moreover, the longer the latter group works the less money they will need because they will live fewer years in retirement; that is the real advantage to delaying retirement.

            "Being tenured does offer a great deal of job security if you are not in a medical center.  Terminating tenure for cause is a time consuming and drawn out procedure that administrators would prefer to avoid.  Voluntary retirement is the preferred strategy.  So how do you terminate a tenured professor?  One cause of voluntary termination is social pressure and local norms.  If the faculty member is in an environment that highly values research grants and publications then a professor who buys into those norms and is not performing might not feel good about continuing to work in such an environment.  I have seen several faculty retire under those conditions who are still effective teachers as evidenced by the willingness of the university to hire them back to teach courses at less than 10% of their previous salary.

            "An alternative to the above approach is to make the environment uncomfortable for the faculty member whose behavior is not governed by such norms.  I have seen this happen to faculty but it is a very difficult strategy.  Moving a faculty member's office to an unpleasant location may have worked in the past but with the Internet it doesn't matter where you work.  Assigning such a faculty member to lots of advisees or large classes is self-defeating for the university if the faculty member does a poor job.  Moreover, anything that increases the alienation of the faculty member will result in even poorer performance and weaken the ability to influence the faculty member through norms or peer pressure.

            "I have had a good life at VanderbiltUniversity.  I have been here 31 years (not an expectation my family or I had when we came) and actively participated in the governance of the College and University as associate dean for research, chair of the IRB, and chair of the most powerful committee on campus – traffic and parking.  I have also served two consecutive terms as chair of the faculty council.  On the other hand I have been housed outside the department most of my time, first at a policy research center and then in the administration building.  I have been director of a center since I came to Vanderbilt that has afforded me a great deal of autonomy.  I would characterize myself more a cosmopolitan rather than a parochial professor in the classic Jencks and Riesman's (1968) terms and thus local norms are less influential.  Although I only taught two classes a year, after 40 years of teaching I wanted to focus on other things in my life.

            "My wife partially retired several years ago but still serves as managing editor of a journal I edit.  We have three children and four grandchildren, who we would like to see more often but teaching classes requires, at a minimum, that you show up in class.  Some may see this as a minor inconvenience but with the traveling we wanted to do it is a significant barrier.  Second, in the last decade we have developed a web-based measurement and feedback system that the university is commercializing, from which I will receive some income if it is successful.  The system is based on several social psychological theories and has been shown to improve outcomes for youth receiving mental health services.  But becoming an entrepreneur/businessperson is a new challenge for me (and for the university since we are the first to do this inside the university structure) and takes a great deal of time and effort.  Given these interests, I was ready to tradeoff my teaching for other activities but the university had to make it attractive to give up my lifetime guarantee of employment.

            "At the end of June the university sent emails to all faculty members offering a new 'Retirement Assistance Program' for all tenured faculty in University Central that does not include the medical center.  I opted for the 'Transition Plan' the university has offered.  It was described as 'a one-time window of opportunity will be provided to full-time tenured faculty members who have at least 15 years of continuous full-time service to Vanderbilt University and will be at least 63 years of age as of July 1, 2012.'  In addition, the faculty member will receive one year of limited health care coverage for each five years of service.

            "I have been married 48 years and I always discuss decisions with my wife.  However, I saw my dean about 15 minutes after I received the email and I told her that I would probably take the offer.  She told me I was the second person to tell her that.  I considered it a no-brainer.  I was ready to give up my tenure, for a price, but not to retire.  The dean and I agreed that I could stay on as an untenured research professor as long as I could support my staff and myself.  With three or more years left on several grants, I thought this would work out just fine.  This year I teach my last graduate and undergraduate class.  The answer to the question posed in the title is simple – pay tenured professors to give up their tenure.  I don't know how the university came up with this plan but I would not be surprised if there were consulting companies that provided advice.  I am curious to see which other professors take the offer and if it works out best for the university and the professors [Len Bickman]."  Aloha,

Pat DeLeon, former APA President – Division 18 – September, 2012

 

UP IN THE MORNIN’, OUT ON THE JOB -- TIME KEEPS MOVING ON

   I recently had the opportunity of reviewing a most insightful book Retiring But Not Shy: Feminist Psychologists Create Their Post-Careers, edited by Ellen Cole and Mary Gergen.  This generation of colleagues has, over the years, significantly contributed to the impressive maturation of psychology as a discipline, and by their personal involvement within the APA governance helped shape the association into the public policy forum and political force that it has become.  They are now entering the twilight of their lives and are beginning to reflect upon what their careers have meant to them, their close friends, and their families.  Without question, their next journey can be a very interesting, productive, and creative time -- if they so desire.  As public service statesman -- and now author --Rod Baker has opined: "My definition of a 'good retirement'….  Doing what you want, as much as you want, and whenever you want.  And, if you are not doing that, you only have one person to talk to."  Personal vignettes:

During his 13 years with the Practice Directorate (1992-2005), Mike Sullivansignificantly shaped psychology's State Association presence.  "I've long been a big believer in the benefits of volunteering.  In my own life volunteering has opened many doors and led to new pathways in my career and my retirement.  Volunteering has also afforded me many opportunities to find satisfaction and fulfillment in giving back to others.  Three examples may help to convey these points.  * My experience as a Peace Corps volunteer right out of college expanded my horizons and gave me profound respect for bilingual and bicultural persons.  The challenge of communicating daily in a language as difficult at Korean dwarfed the supposed physical hardships of working in the underdeveloped Korean countryside of the 1960's.  * My experiences volunteering for the Coalition of Hospital and Institutional Psychologists and the New York State Psychological Association early in my psychology career were transformative.  I learned firsthand the importance of organizational leadership and the power of professional advocacy.  I saw how this can produce results in new laws benefitting psychology and the public.  My contributions of time were more than rewarded by becoming part of an inspiring network of like-minded colleagues across the country.  Ultimately this avocation became my vocation for half of my career, when I had the good fortune to work as Assistant Executive Director for State Advocacy in the APA Practice Directorate.  * My experience volunteering in the community during my 'retirement' has given me a wonderfully fulfilling life outside of psychology.  Here inColumbia, South Carolina, I deliver Meals on Wheels, exercise special need dogs at Howlmore Animal Sanctuary, and volunteer through my church at the Transitions Centerfor persons who are homeless.  Recently I was honored to be nominated for a national volunteer award given by the Meals on Wheels Association of America.  In reality, I believe the honor is in serving others.  Any day that I spend some time sharing my good fortune with others is a day that would leave me with no regrets if it turned out to be my last.  I endorse Marian Wright Edelman's belief that 'Service is the rent we pay for living.'  Volunteering is a wonderful vehicle for professional and community service.  And the opportunities abound!"  Not surprisingly, in recognition the Ohio Psychological Association in 2008 established the Division 31 (State, Provincial and Territorial Psychological Association Affairs) Michael Sullivan Diversity Scholarship Fund.  Highlighting the importance of involvement and activism: "Our parents at the Autism Center helped us again – their letters helped us to get a $120,000 state appropriation to develop an online parent training program which we intend to use with parents who cannot access our center-based services.  And their efforts with our annual fund raising event helped us raise $190,000 for the Center.  They know how to do it! [Mary Beth Kenkel]"

            Walter Penk, consultant in VA rehabilitation:  "One challenge I hope to hear more about is the Student Veteran.  VA psychologists have to do more for the Student Veteran.  I'm consulting with the Dean of Students at The University of Texas at Austin, developing support for combat veterans using the GI Bill returning to college.  The University already has about 1,000 veterans enrolled, including family members.  AustinCommunity College has many more, above 2,000.  Texas State University (where President Lyndon Baines Johnson went to college) in San Marcos, 30 miles south ofAustin, has 2,000+.  This is a quickly growing population for which we want to make sure that they have the support necessary to complete their educational objectives.  Some Student Veterans enter college and then drop out, discontinue, because they do not have as comprehensive an array of support that is needed, at the right time.  So we, as psychologists, have a major job ahead of us to ensure Student Veterans get many kinds of support when needed.  I'm pleased Secretary Shinseki has established the VITAL (Veterans Integration to Academic Leadership) program, led by Derek Blumke in the VA, assigning clinicians to work on campus.  We received one such position for the Austin Outpatient Clinic, hired a clinical psychologist, Jay Morrison, who had trained at the NationalPTSD Center in Boston, and, who is now seeing many veterans on campus at the university.  Student Veterans are such a rapidly growing population, marching now in the spirit of U.S. House of Representatives Edith Nourse Rogers – she who wrote the First GI Bill, signed by President Franklin Delano Roosevelt, on June 22, 1944.  Nathan Ainspan and I, along with Alexa Smith-Osborne, presented a CE workshop in Orlando.  The book Nate and I have written, When the Warrior Returns: Making the Transition at Home, will include these materials in more detail.  I hope to hear more about the Student Veterans Manual that Marsha Ellison of The Edith Nourse Rogers Memorial Veterans Hospital is developing and the services VA psychologists will be providing for these students as the VA increasingly collaborates with college campuses and the GI bill."

            Those who attended the inspirational Opening Ceremonies at our Orlandoconvention witnessed President Suzanne Bennett Johnson presenting Lifetime Achievement Awards to Kelly Brownell and Rena Wing for their decades of service to our nation and especially their groundbreaking research in effectively addressing obesity.  As our President noted, psychologists have developed treatment programs that work and although obesity is a major public health issue, as well as a high priority of the Obama Administration, psychologists are currently not being reimbursed for this clinical care under the provisions of the President's landmarkPatient Protection and Affordable Care Act (PPACA) [P.L. 111-148].  The statutory language and implementing regulations for the Accountable Care Organization (ACO) andPatient Centered Medical Home (PCMH) initiatives of the law also do not recognize psychology's expertise.  As a nation we currently spend more on health care than any other advanced country, spending 18% of our GDP vs. the next closest nations spending 12% or 13% of their GDP.  And yet, we do not have enviable comparative health outcomes.

The Patient Protection and Affordable Care Act is projected to increase the number of Americans eligible for primary care services by an additional 32 million.  This is at a time when, as Morgan Sammons points out, combining nurse practitioners (NPs) and physician assistants (PAs), the numbers of non-physician practitioners are on track to exceed that of primary care physicians in the not too distant future.  There are approximately 250,000 NPs and PAs in clinical practice in theUnited States, compared with approximately 306,000 primary care allopathic physicians (medical and osteopathic doctors).  This trend is highly consistent with projections made a decade ago.  Interestingly, in March 1994 during the Clinton Administration health care reform deliberations, the APA Monitorpublished an article entitled: "Nurses are a model in health reform" quoting then Practice Directorate Executive Director Russ Newman.  "Because nurses and psychologists share many of the same issues in regard to practice, the two professions can work together.  At the center of both the nurses' issue and our [own]… is the question of collaborative treatment.  How do non-physician providers and physicians collaborate to provide necessary treatment that is cost-effective, non-duplicative and uses appropriate resources?"  As the current Executive Director for the Practice DirectorateKatherine Nordal strongly urged during this year's State Leadership conference which focused upon primary care, it is imperative that psychologists get personally involved at the local and state level in the ongoing health policy deliberations surrounding the implementation of PPACA.  "We know that we can't do it alone.  Our advocacy depends on effective collaborations and effective partnerships, and those are the relationships that we have to develop back home if we're going to get the job done."  It is at the state and local level that the specifics of health care reform are being determined today.

            Timely Changes Are Coming:  During his Fiscal Year 2013 testimony before the Senate Appropriations Committee the Surgeon General of the U.S. Navy provided a thoughtful glimpse into the future.  "I can report to you Navy Medicine remains strong, capable and mission-ready to deliver world class care, anytime, anywhere.  We are operating forward and globally engaged, no matter what the environment and regardless of the challenge….  It is a challenge, but one that we are privileged to undertake."  We see tremendous progress in joint medical operations with the Army and Air Force.  Health is not simply the absence of infirmity or disease -- it is the complete state of physical, mental, spiritual and social well being.  As our wounded warriors return from combat and begin the healing process, they deserve a seamless and comprehensive approach to their recovery.  Our focus is integrative, complementary and multidisciplinary, bringing together clinical specialists, behavioral health providers, case managers, and chaplains.

We continue a robust translation research program in wound healing and wound care, moving technologies developed at the bench to deployment in the clinic to enhance the care of the wounded warfighter.  We are focused on improving the capability and capacity to provide comprehensive and interdisciplinary pain management from the operational setting to the medical treatment facility to home.  This priority includes pain management education and training to providers, patients, and families to prevent over-prescribing, misuse of medications, and promoting alternative therapies.  Preserving the psychological health of service members and their families is one of the greatest challenges we face today.  We continue to foster a culture of support for psychological health as an essential component to total force fitness and readiness.  We address stigma by encouraging prevention, early intervention, and help-seeking behaviors.  Navy Medicine has continued to adapt psychological health support across traditional and non-traditional health care systems.  Access to psychological health services have increased in venues designed to reduce the effects associated with mental health stigma.  We are focused on suicide prevention.  We are integrating behavioral health providers in our Medical Home Port (MHP) program to help address the needs of our patients in the primary care setting.  Post-Traumatic Stress Disorder (PTSD) is one of many psychological health conditions that adversely impacts operational readiness and quality of life.  We have an umbrella of psychological health programs that target multiple, often co-occurring, mental health conditions.  These support prevention, diagnosis, mitigation, treatment, and rehabilitation of PTSD.  For our Marine Corps and Navy reserve populations, we have developed the Reserve Psychological Health Outreach Program (PHOP) 24/7 for unit leaders, reservists, and their families.  Navy Medicine continues to leverage its unique relationships with the Army, Air Force, the VA, as well as other federal and civilian partners.  This helps create system-wide synergies and fosters best practices in care, education and training, research, and technology.  We share and collaborate with the VA throughout our enterprise.  "The lucky old sun.  He's got nothing to do.  But roll around heaven all day."  Aloha,

Pat DeLeon, former APA President – Division 42 – September, 2012