GO WHERE YOU WANNA GO

With Washington State's Barry Anton soon to be assuming the Presidency of APA, our national Association should be very well served.  Barry has a long history of being a visionary advocate for addressing the pressing holistic needs of our nation's children and their families.  He truly appreciates the "bigger picture" and the critical importance of psychology being actively involved in shaping health policy.  Recently, Barry was instrumental in celebrating the 40^th anniversary of the APA Congressional Fellowship program at our Washington, DC convention.  As the first social science organization to participate in the AAAS Science and Technology Policy Fellowships Program, this is an extremely important program for all of psychology.  The very first fellow, Pamela Ebert Flattau, who frequently still wears her Walter Mondale button, is prominently involved in shaping national science policy as Director of a new start-up known as The PsySiP Project.  In 1994-1995, Libby Street (Central Washington University) served as a Fellow with U.S. Senator Edward Kennedy in his education office.  The following year, another Washington State former Fellow, Margie Heldring, was instrumental during her tenure with U.S. Senator Bill Bradley in having the federal government modify private health insurance benefits for the first time in our nation's history; effectively addressing "drive-through baby deliveries."  Her efforts were signed into Public Law by President Bill Clinton on September 26, 1996 [the Newborns and Mothers' Health Protection Act (P.L. 104-204)] in a Rose Garden ceremony which she got to attend.  Our President-elect has most recently focused upon the importance of psychology learning from international efforts to further integrated care models, pursuant to the proactive vision underlying President Obama's Patient Protection and Affordable Care Act (ACA).

            The Children's Defense Fund (CDF):  The CDF Overview of The State of America's Children 2014 reports that in 2012, for the first time the majority of children in the U.S. under the age of two were children of color, as were the majority of all children in 10 states.  By 2019, the majority of all children nationwide are expected to be children of color.  Child poverty has reached record levels; one in five children (16.1 million) was poor in 2012.  More than 7.1 million children (over 40% of poor children) live in extreme poverty at less than half the poverty level (for a family of four, $11,746 annually).  Children in single-parent families are nearly four times more likely to be poor than children in married-couple families.  Although almost 70% of all children live with two parents, more than half of Black children and nearly one in three Hispanic children live with only one parent, compared to one in five White children.  Nearly 1.2 million public school students are homeless, 73% more than before the recession.  More than one in nine children lack access to adequate food, a rate 23% higher than before the recession.  Guns kill or injure a child or teen every half hour; gun violence disproportionately affects children of color.  Child poverty costs the nation at least $500 billion annually in extra education, health, and criminal justice costs and in lost productivity.  Child abuse and neglect costs $80.3 billion each year in direct costs and lost productivity.

            The Institute of Medicine (IOM):  The IOM Board on Children, Youth, and Families, directed by psychologist Kimber Bogard, in conjunction with the IOM Board on Global Health, has recently launched its Forum on Investing in Young Children Globally.  This initiative seeks to create and sustain, over three years, an evidence-driven community of stakeholders across northern and southern countries who aim to explore existing, new, and innovative science and research from around the world and translate this evidence into sound and strategic investments in policies and practices that will make a difference in the lives of children and their caregivers.  Forum activities will highlight the science and economics of integrated investments in young children living in low resourced regions of the world across the areas of health, nutrition, education, and social protection.  The Forum will promote a holistic view of children and caregivers by integrating analyses and disciplines – e.g., from the microbiome to culture.  It will support an integrative vision linking human capital of individuals with the economic sustainability of nations.

            A concerted effort will be made to build bridges across sectors and partner with other organizations, including other science academies and coalitions working toward improving investments in young children globally.  Activities and products will be used to inform practices from local communities to government systems; policies at the country, state, and local levels; and research agendas.  Inter-generational approaches to investing in young children globally will be an important lens for developing future activities, with a particular emphasis on empowering women and girls.  Another lens to be used to view the science, implementation, and policies under consideration is the cultural contexts, including belief systems and visions of optimal child development from the familial and community perspective.

            Forum goals include identifying an integrated science on children's health, nutrition, education, and social protection and working with policymakers, practitioners, and researchers to raise awareness of integrated approaches to improve the lives of children and their caregivers.  Objectives include:  * To shape a global vision of healthy child development across cultures and contexts, extending from pre-conception through age eight, and across current "silo" areas of health, nutrition, education, and social protection.  * To identify opportunities for inter-sectorial coordination among researchers, policymakers, implementers/practitioners, and advocates to implement quality practices and bring these practices to scale, in the context of the economics of strategic, integrated investing in young children, spanning health, education, nutrition, and social protection.  * To inform ongoing conversations and activities of groups working on issues related to young children globally.  And, * To identify current models of program and policy financing across health, education, nutrition, and social protection, within the framework of reproductive, maternal, newborn and child health that aim to improve children's developmental potential.  This information could be used to illuminate opportunities for new financing structures and forms of investments that may be more effective in improving child outcomes and potentially drive economic development.  Aspirational goals to be sure, and exactly where APA's next President has been engaged for decades.  On a personal note, my fondest memory of WSPA was having the honor of presenting Colleen Hacker with an APA Presidential citation in 2000 for her years of dedication to our nation's female athletes, including those on the U.S. Women's Olympic teams -- my very last APA Presidential event.  Barry's soccer playing daughter attended that event.  These are indeed exciting times.  Do What You Want.  Aloha,

Pat DeLeon, former APA President – WSPA – November, 2014

 

I’M SITTING IN THE RAILWAY STATION

  The Institute of Medicine (IOM):  As one of the "learned professions," it is incumbent upon psychology and nursing to become aware of, and contribute meaningfully to, efforts by colleagues in other disciplines to address society's most pressing needs.  The Board on Children, Youth, and Families of the Institute of Medicine (IOM), directed by Kimber Bogard, released its most timely report Sports-Related Concussions in Youth: Improving the Science, Changing the Culture almost exactly one year ago.  This visionary effort has received considerable attention in the popular media and the White House.  With the intense focus currently on the health status of retired NFL players, and increasingly on those who played sports in college, the groundwork has perhaps been laid for fostering an important and scientifically-based national discussion – one for which psychological expertise should be highly relevant.  A major conclusion of the IOM report is that while some studies provide useful information, much remains unknown about the extent of concussions in youth; how to diagnose, manage, and prevent concussions; and the short- and long-term consequences of concussions, as well as repetitive head impacts that do not result in concussion symptoms.

            Interestingly, among male athletes at the high school and collegiate levels, football, ice hockey, lacrosse, wrestling, and soccer consistently are associated with the highest rates of concussions.  Among female athletes, soccer, lacrosse, basketball, and ice hockey are highest.  There has been little research on the frequency of concussions among those playing intramural and club sports and in those younger than high school age.  Accordingly, the IOM called upon the Centers for Disease Control and Prevention (CDC) to establish and oversee a national surveillance system to accurately determine the incidence of sports-related concussions among those aged 5 to 21.  Although some research indicates that a series of molecular and functional changes take place in the brain following injury, little research has been conducted specifically focusing upon changes in the brain or on the differences between females and males.  Diagnosis is currently based primarily on the symptoms reported by the individual rather than on objective diagnostic markers and there is little empirical evidence as to the optimal degree and duration of physical rest needed to promote recovery.

            The IOM specifically noted that today's culture of sports negatively influences athletes' self-reporting of concussion symptoms and their adherence to return-to-play guidance.  Athletes, their teammates, as well as coaches and parents may not fully appreciate the health threats posed by concussions.  Similarly for the nation's military population, recruits are immersed in a culture that includes devotion to duty and service before self; thus, the critical nature of concussions may often go unheeded.  It is postulated that if the youth sports community can adopt the belief that concussions are serious injuries and emphasize care for players with concussions until they are fully recovered, then the culture in which they compete will become much safer.

            AARP:  At the other end of the demographic continuum, around the same time, the AARP Public Policy Institute released its report exploring the probable availability (or lack thereof) of Family Caregivers in the foreseeable future.  As Lynn Feinberg discussed at our interdisciplinary USUHS health policy class, today the majority of long-term services and supports are provided by family members.  In 2010, the caregiver support ratio was more than 7 potential caregivers for every person in the high-risk years of 80-plus.  By 2030, this ratio is projected to decline significantly to 4 to 1; and is expected to fall further to less than 3 to 1 by 2050, when all "boomers" will be in the high-risk years of late life.

            Family caregivers – including family members, partners, or close friends – are a key factor in the ability to remain in one's home and in the community when disability strikes.  More than two-thirds (68%) of Americans believe that they will be able to rely on their families to meet their eventual long-term services and support needs when they require help.  However, if fewer family members are available to provide everyday assistance to frail older people, more individuals are likely to need institutional care – at significantly greater cost both to themselves and to society.  In recent years, the role of family caregivers has greatly expanded from coordinating and providing personal care and household chores to include medical and nursing tasks (such as wound care and administering injections).  These nursing tasks used to be provided in hospitals and nursing homes and by home care providers, but increasingly are now being provided by family members.  One of the major challenges facing the nation is addressing the sequela from possessing multiple chronic conditions (MCC).  Currently 26% of adults have MCC; 67% of Medicaid beneficiaries with disabilities have three or more conditions.  As conditions increase, so does the frequency of mortality, poor functional status, hospitalizations, readmissions, and adverse drug events.  Today 66% of health care costs are for individuals with MCC, a vulnerable population which we would suggest could benefit significantly from the ready availability of behavioral health expertise.

            AARP's report notes that research has demonstrated the critical importance of family support in maintaining independence and reducing nursing home use among older people with disabilities.  Between 1984 and 2004, institutional use declined by 37% among the older population, as the number of older people living in the community with two or more needs for assistance with activities of daily living (such as bathing, dressing, or using the toilet) rose by two-thirds.  Medicaid costs for institutional care would have been an estimated $24 billion higher in 2004 had utilization rates remained unchanged after 1984.  It is impossible to document the exact portion of these savings that is due to family caregiving; however, the high rates of family support among the growing number of older people with high levels of disabilities who live in the community strongly suggest that such support has been a critical factor in the dramatic decline of institutionalization and Medicaid use during the past couple of decades.

            Notwithstanding, AARP projects that the caregiver support ratio is expected to plummet as boomers transition from caregivers into old age with the decades of the 2010s and 2020s being a period of transition.  The population aged 45-64 is projected to increase by only 1% between 2010 and 2030; during the same period, the 80-plus population is projected to increase by 79%.  The impact of these demographic changes will undoubtedly be further complicated by recent data indicating that the declines in disability rates may have stalled (and perhaps even reversed) among the young old and pre-retirees, largely because of the increases in obesity (which clearly has relevance to behavioral health).  Accordingly, AARP has called for a national comprehensive person- and family-centered Long-Term Services and Supports policy that would better serve the needs of older persons with disabilities, support family and friends in their caregiving roles, and promote greater efficiencies in public spending.

            The Accountable Care Act (ACA):  On March 23, 2010, President Obama signed into public law the Patient Protection and Affordable Care Act (ACA) [P.L. 111-148].  The ACA represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation.   The Commonwealth Fund recently issued a report card on its status.  Four Defining Questions:  * Are the marketplaces fully functional?  Needs Improvement.  * Did people enroll in the law's new coverage options?  Good To Excellent.  * Are fewer people uninsured?  Good To Excellent.  * Is the quality of insurance improving?  Is underinsurance declining and are people satisfied with their plans?  Grade Pending.  For Extra Credit:  * Are people using their new insurance to get health care?  Grade Extra Credit:  * Is growth in health care costs moderating?  Grade Pending.  And finally, * Is the quality of care improving?  Grade Pending.  In summary: "It seems clear that where we have data, the ACA's implementation has been associated with significant progress.  Equally important, some of the potential problems it could have created such as much higher premiums in the individual market or a lack of insurer participation (which has actually increased for 2015) has not materialized.  If the question is: Is the health care system better off in September 2014 than it was in 2010, the answer would seem to be yes."  Impressively, the Commonwealth Fund found that the percentage of adults ages 19-64 who are uninsured has declined from 20% just prior to open enrollment to 15%, which means there are an estimated 9.5 million fewer uninsured adults.

            A critical component of the ACA's commitment to improving access to quality health care throughout the nation is a significant investment in the Federally Qualified Community Health Centers (FQHC) program.  Established during the Great Society Era of President Lyndon Johnson, when psychologist John Gardner was Secretary of the Department of Health, Education, and Welfare (HEW), these centers represent the true safety net for many Americans.  Accordingly, we were very pleased to learn that prescribing psychologist Earl Sutherland was recently appointed medical director for the Big Horn County FQHC where he is actively implementing their integrated care program – another key element of the ACA.  "Some people complain about getting older, but I prefer it to the alternative [Charles Brewer, APF benefactor extraordinaire]."  Homeward Bound.  Aloha,

Pat DeLeon, former APA President – Division 55 – October, 2014

 

OVER THE RAINBOW

    An Exciting Vision:  Upon occasion, I have been "accused" of being overly optimistic about the future of psychology, especially by senior colleagues who might be emotionally invested in the past.  Without question, the health care environment of the 21^st century is rapidly changing.  However, as long as the field continues to attract "the best and brightest," I am confident that psychology and our colleagues in nursing and pharmacy will do very well.  We must appreciate that the vision of our educational leadership is critical to the future.

I am currently serving on the nursing and psychology faculty of the Uniformed Services University of the Health Sciences (USUHS).  Since we are located near our nation's Capital, we are fortunate to be able to interact with psychology leaders from across the country, as well as senior APA staff.  Former APA Presidents Ron Fox and Don Bersoff have addressed our interdisciplinary health policy class, as well as several Directorate Executive Directors.  The students have been invited to a number of APA events, including the annual State Leadership conferences, the recent APA-ABA judicial conference, not to mention being included in ongoing convention activities.  A typical initial response to a very last minute expression of interest in the APA Education Leadership Conference:  "We would be happy to have some of your students participate.  At this point in time we have space limitations or I would try to make this work" (Catherine Grus, Education Directorate).  We fully expect that next time it will be possible.  Throughout these experiences the palpable enthusiasm of the next generation has been very evident, as has been their interest in shaping their own destiny.  USUHS recently announced that our current APA President Nadine Kaslow will be visiting with students and faculty.  APA's genuine responsiveness to the interests of our next generation is most impressive – Mahalo, Norman Anderson.

            Postdoctoral Opportunities:  One of the most exciting developments within the profession has been the establishment of psychology's postdoctoral training initiatives.  As we have evolved from being an exclusively mental health focused discipline into a bona fide health care profession, the breath of clinical opportunities for psychological expertise to improve the quality of patients' lives has been exponential.  During his APA Presidency, World War II Army veteran Jack Wiggins visited with VA Secretary Tony Principi, a Vietnam veteran, and as a result of that discussion, the Secretary called for the VA to begin a psychology postdoctoral training program.  Over the subsequent years, this initiative has steadily expanded, both in numbers and in its clinical focus.  Visionary VA senior psychologist Bob Zeiss:

            "Health professions education, across disciplines, is a core mission of the Department of Veterans Affairs (VA), with a general goal of providing high quality experiential learning opportunities to develop well educated and well trained health professionals for VA and for the nation.  VA's Office of Academic Affiliations (OAA) funds and oversees these training opportunities.  During my tenure at OAA (2005-2013) and continuing today (under the leadership of Kenneth Jones, Director of Associated Health Education), the number of funded postdoctoral training positions increased from 52 to 402.  Phase III of the five year Mental Health Expansion Initiative will increase those numbers even more for the 2015-2016 academic year.

            "Working closely with Mental Health Services and supporting VA's major initiatives to enhance both access to and quality of mental health care in VA, OAA committed to increase the number of trainees in all mental health disciplines.  Because of the strength of psychology staff across the nation, psychology as a discipline was particularly poised to develop new internship and postdoctoral programs and enhance existing ones.  In recent years, we have increased the focus on developing training opportunities in smaller and rural VA health care settings.  These programs provide the same kinds of opportunities as do larger, more traditional programs; they also are intended to generate a cadre of health care professionals eager to remain in and serve in those smaller and more rural settings.

            "The focus on postdoctoral training is based on the premise that VA training provides a particularly highly qualified set of candidates from which to recruit future VA staff.  Though graduating interns are generally experienced and skilled, the internship does not allow sufficient depth of training to become highly skilled in an emphasis or specialty area.  Adding a postdoctoral year to training provides precisely that opportunity.  Thus, not only does VA ensure that these new professionals have the skills relevant and necessary for quality care of Veterans, but we are also in a position to determine exactly which developing practitioners have the skills, attitudes, and dedication to VA care that we treasure in our employees."

            President Obama's Patient Protection and Affordable Care Act (ACA) envisions the health care environment of tomorrow as providing interdisciplinary data-based care, with a priority on wellness, prevention, and services which are high quality and cost-effective (i.e., the "Triple Aim" – simultaneously improving population health, improving the patient experience of care, and reducing per capita cost).  Combined with the Mental Health Parity legislation, the ACA represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation.  And, as Bob indicated, the Administration has demonstrated a concerted effort to engage all health care professions.  Mary Dougherty, Director of Nursing Education OAA, reports that the VA supports academic partnerships with Schools of Nursing via the VA Nursing Academic Partnership (VANAP) which funds both baccalaureate and graduate students.  The graduate programs are focused on Psychiatric Mental Health Nurse Practitioners (PMHNPs).  Both programs require a residency – a post baccalaureate nurse residency or a PMHNP residency.  The OAA provides funds for graduate and undergraduate faculty for both schools of nursing and VA, as well as stipends for graduate trainees, post baccalaureate nurse residents, and PMHNP residents.  The development of a standard PMHNP competency, curriculum, and accreditation standards are expected outcomes of this program.

            Population Focused Health Care:  I have recently been appointed to the national advisory committee on Interdisciplinary Community-Based Linkages of the Health Resources and Services Administration (HRSA).  The committee is charged with providing advice and recommendations on policy and program development to the Secretary of HHS concerning its various Title VII (Health Professions) training programs and is to submit an annual report to the Secretary and to Congress.  Included within its jurisdiction is the Psychology Graduate Education program, as well as the Area Health Education Center, Geriatric Education Center, Quentin N. Burdick Program for Rural Interdisciplinary Training, Allied Health, Mental and Behavioral Health Education and Training initiatives, Education and Training in Pain Care, and the Integration of Quality Improvement and Patient Safety Training into Clinical Education of Health Professionals programs.

            One of the challenges facing the nation is addressing the sequela from possessing multiple chronic conditions (MCC).  Currently 26% of adults have MCC; 67% of Medicaid beneficiaries with disabilities have three or more conditions.  Not surprisingly, as conditions increase, so does the frequency of mortality, poor functional status, hospitalizations, readmissions, and adverse drug events.  Sixty-six percent of US health care costs are for individuals with MCC and 93% of Medicare expenditures are for individuals with MCC.  For those inpatients 18-44 years of age with more than two chronic conditions, depression is the most prevalent.  The HHS Multiple Chronic Conditions Strategic Framework overarching goals include: * Fostering health care and public health system changes; * Maximizing the use of proven self-care management; * Providing better tools and information to workers who deliver care to those with MCC; and, * Facilitating research to fill knowledge gaps.  The poor health outcomes of individuals with serious mental illnesses and other behavioral health problems warrants special attention because of the co-occurrences of these conditions with other chronic conditions.  This is a priority patient population for which psychology's postdoctoral training would seem most appropriate; including those with specialized training in psychopharmacology.

            Ron Rozensky, who served as a former chair of the committee: "It was a great experience representing psychology and having the opportunity to work with the chairs and vice chairs of other advisory committees representing the full range of health care disciplines.  We collaborated on writing a letter to Congress during the drafting of the ACA underscoring the importance of the inclusion of interprofessional education, training, and service.  Our 10^th Report to Congresshighlighted the importance of health behavior as a key component of a truly integrated health care system – what a great honor to chair that report!"

Reflections:  I am intrigued by how our senior colleagues respond to retirement.  Margy Heldring, former APA Congressional Fellow:  "I am nearly full time with the group I founded, Grandmothers Against Gun Violence, after Sandy Hook.  It is amazing to build a new organization of 'Women of a Certain Age' and see everyone feel empowered and turn (return!) to activism.  What an experience!  Psychology seems farther and farther behind me, as I move out and back into policy and politics as a psychologist!"  Why, Oh, Why Can't I?  Aloha,

Pat DeLeon, former APA President – Division 55 – September, 2014

 

A VISION SOFTLY CREEPING

Congressional Engagement:  These are interesting times for our nation's non-physician health care providers, and particularly for those in the mental health/behavioral health field.  In deliberating on the Fiscal Year 2015 Appropriations bill for the Department of Defense (DoD), the U.S. Senate noted: "Mental Health Professionals. – The Committee recognizes that service members and their families face unique stresses beyond those of everyday life.  After over a decade of war, the need for mental health professionals in the Department is at an all-time high, and the Committee believes that every beneficiary of the Military Health System should have timely access to mental health services.  However, the Committee is concerned with the Department's inability to recruit and retain enough psychiatrists, psychologists, social workers, nurse practitioners, and registered nurses to provide adequate mental healthcare.  The Committee has asked the Government Accountability Office to review this issue including the Department's current inventory of mental health providers, current and future needs for providers, challenges the Department faces in recruitment and retention, actions taken to mitigate these challenges, and recommendations going forward to ensure an adequate inventory of mental health professionals within the Military Health System.  The Committee looks forward to receiving the results of this review and working with the Department to provide the tools necessary to implement any recommendations."  We would suggest that this is an excellent time for psychology to showcase its innovative treatment initiatives, communicate the ways in which the integration of behavioral and mental health services into primary care improves health outcomes, as well as its success in appropriately expanding its clinical scope of practice in obtaining prescriptive authority (RxP).

            The Patient Protection and Affordable Care Act (ACA):  President Obama's landmark Patient Protection and Affordable Care Act (P.L. 111-148) provides an exciting opportunity to make a real difference for those colleagues with vision and the willingness to demonstrate leadership.  Combined with the enacted Mental Health Parity legislation, this represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation.  Mental health and substance-use treatments are deemed "essential health benefits" under the ACA.  Priority will be given to prevention, wellness care, and services which are high quality and cost-effective, as our nation moves our health care system towards population health-based care, rather than stressing individual acute care episodes.  The ACA calls for the development of integrated, interdisciplinary systems of patient-centered care which will be transformational.  Chief among these is the integration of behavioral health and medical health care, where the public sector has consistently demonstrated proactive leadership.

The foundation is steadily being put in place for bringing the advances occurring within the communications and health information technology (HIT) fields into the health care environment.  As a nation, we are moving from reimbursement for specific clinical procedures towards encouraging value-based care – including the critical psychosocial-economic-cultural gradient of quality care.  This fundamental shift in emphasis is expected to result in the U.S. no longer being ranked by the Commonwealth Fund as last among developed nations on overall measures of health system quality, efficiency, access to care, equity, and healthy lives, as compared with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom.  This is in spite of the fact that we presently spend more on health care than anywhere in the world.

            The Need for Greater Public Awareness:  At the Uniformed Services University of the Health Sciences, we are fortunate to have a number of APA elected officials and senior staff address our interdisciplinary health policy seminar.  Rhea Farberman recently described APA's efforts to ensure that the value of psychological expertise is appreciated by health policy experts, other disciplines, and the public.  There is a surprisingly significant knowledge gap with only 4% of Americans being aware of the Mental Health Parity and Addiction Equity Act and what it means for their access to mental health and addictions care.  Consumers report that psychology can help people lead healthier lifestyles (51% somewhat agree and 42% strongly agree).  And, that health care can be improved through better understanding of human behavior (49% somewhat agree and 26% strongly agree).  Consumers believe that psychological research has a role to play in finding ways to address health issues such as obesity and smoking (49% somewhat significant and 23% very significant).  Yet, the public often doesn't pursue psychological services for themselves or loved ones when it could make all the difference in their treatment outcome.  This action gap could be the result of stigma; it could be due to access issues.  Regardless, it presents both an opportunity and responsibility for psychology.  As highly educated professionals, we may understand how psychology can contribute to improving the overall quality of health care in our nation if appropriately recognized.  However, we have a significant way to go before the rest of society does.  And, this is particularly true with our physician colleagues!  When physicians were asked:  Does psychological research have a role in finding ways to address health issues such as obesity and smoking – 45% responded somewhat significant and 40% very significant.  Even more telling: How helpful do you think a psychologist would be when it comes to assisting your patients in making lifestyle and behavior change?  Fifty-eight percent indicated somewhat helpful and 24% very helpful.

            Prescriptive Authority (RxP):  In her recent mailing to the membership, APA's Katherine Nordal praised the Illinois Psychological Association for their success in obtaining RxP.  "It's good news for our profession and very good news for the residents of Illinois….  Right now in our country, nearly 80% of psychotropic medications are being prescribed by primary care physicians who have very little training in mental health.  I'm sure you agree that mental health patients are well served by having qualified mental health professionals available to prescribe.  That's why the victory in Illinois is so important."  The World Health Organization (WHO) defines an adverse drug reaction as "harmful, unintended reactions to medicines that occur at doses normally used for treatment" and points out that these are among the leading causes of death in many countries.

Reflecting upon their success in Illinois, Beth Rom-Rymer reminds us that: "The Illinois Medical Society and the Illinois Psychiatric Society vigorously and vociferously lobbied against our RxP bill until they realized that we wouldn't stop fighting and until they had already spent $1 million to keep us out of the prescribing community!"  Persistence and community involvement are the key to long term change, which Beth and her colleagues vividly demonstrated.  Why is it that more colleagues within the VA have not sought prescriptive authority?  The experiences of their DoD colleagues clearly demonstrate that they can obtain these clinical skills and that the quality of care they would provide would be excellent.  The need is there.  There are a significant number of psychologists who are veterans and who belong to veterans' organizations -- the true beneficiaries.  Under President G.W. Bush, VA Secretary Tony Principi was quite open to initiating a pilot project, similar to the way that the DoD program initially began.  At that time psychology's leadership was not willing to demonstrate proactive leadership; notwithstanding that a number of individual VA psychologists had informed me that they were, in fact, prescribing.  Have we matured sufficiently as a bona fide healthcare profession to affirmatively accept this clinical responsibility?  The Sounds of Silence.  Aloha,

Pat DeLeon, former APA President – Division 18 – September, 2014

 

I’M SO PROUD TO KNOW

It was extraordinarily satisfying to learn from Beth Rom-Rymer that the Illinois Psychological Association (IPA) was successful in enacting your prescriptive authority (RxP) legislation this past June.  It has been a decade since Louisiana achieved their startling success, during which time leaders in the RxP movement have been steadily working to develop a "critical mass" of postdoctoral trained psychopharmacology clinicians.  Bob McGrath, Director of the Fairleigh Dickinson University Clinical Psychopharmacology training program, estimates that today there are 1750 graduates.  As vigorous as your opposition has been, it was impressive from a public policy perspective to see that, in the end, the Illinois Psychiatric Society and the Illinois Medical Society conceded that psychologists can prescribe.  Clearly this was a concession that only came after a hard-fought battle.  It was the perseverance and the determination of your IPA leaders, looking after the interests of the most vulnerable and at-risk residents in Illinois, that ultimately won the day.  And, as you now move quickly to implement your RxP legislation, with the drafting of the rules and regulations of the law and the signing up of various training facilities and universities and colleges throughout the state to train Illinois's prescribing psychologists, undoubtedly you will find that achieving the collaborative partnership of psychiatrists and medical directors has been greatly facilitated by your eleventh hour negotiated bill.  Congratulations!

            Our collective RxP discussions frequently refer to the successes of New Mexico (2002), Louisiana (2004), and colleagues in the Department of Defense (DoD) and U.S. Public Health Service (particularly, the Indian Health Service [IHS]).  Few seem to appreciate that the first state to pass RxP legislation was actually Indiana (1993, thanks to Mike Murphy), which was followed by Guam (1998, thanks to Mamie Balajadia).  Neither of these states has implemented their statutes to date; although progress has been reported in Guam.  Interestingly, Floyd Jennings was prescribing in the IHS back in 1988-1989 under the authority of the Santa Fe Indian Hospital bylaws.  Former APA President Ron Fox: "As of December 31, 2013 when I was chair of the APA Insurance Trust, I can attest to the fact that prescribing psychologists do NOT have to pay higher premiums for professional liability insurance as the Trust deemed an increase unnecessary; and, because the Trust policy provides insurance to cover expenses related to licensing board complaints I know that there have been NO complaints or actions taken by state licensing boards regarding prescribing abuses by appropriately trained psychologists."

Having been an informed observer throughout psychology's RxP quest, I was particularly pleased that your legislation recognizes, for the first time, the importance of encouraging pre-doctoral training.  This is an educational policy position that had been urged by practice visionary Gene Shapiro from the beginning and most recently by APA Past President Bob Resnick.  The initial requirement for postdoctoral training was a reasonable political compromise, addressing the sincere concerns of those who feared that our next generation of colleagues might never appreciate what psychological expertise could contribute to our patients' quality of life.  Their view was that otherwise "we would take the easy way out and become junior psychiatrists; substituting medication for therapy."  Over the years, the evidence has clearly not supported that contention.  In fact, our prescribing colleagues frequently report significantly modifying previously ordered medication protocols.  "The power to prescribe is the power to unprescribe," as New Mexico's Mario Marquez has stated on numerous occasions.

            The 1992 report submitted to the APA Council of Representatives by the ad hoc Task Force on Psychopharmacology, chaired by Mick Smyer, clearly appreciated the long term significance of "the importance of developing a subspecialty of psychology with comprehensive knowledge and experience in psychopharmacology.  Practitioners with combined training in psychopharmacology and psychosocial treatments can reasonably be viewed as a new form of health care professional, expected to bring to health care delivery the best of both psychological and pharmacological knowledge.  The contributions of this new form of psychopharmacological intervention have the potential to improve dramatically patient care and make important new advances in treatment."  And, as you have successfully demonstrated, the Task Force then focused on "the potential impact of the proposed training on two important concerns of consumers: (1) meeting unmet need for mental health services, and (2) effectively serving special populations."  Anita Brown was one of the APA staff liaisons to the Task Force.  She subsequently became one of the DoD prescribing psychologists.

            During his 2009 APA Presidency, James Bray hosted a Presidential Summit on the "Future of Psychology Practice."  One of the major themes presented was that "mental health care cannot be divorced from primary medical care, and that all attempts to do so are doomed to failure."  The enumerated Summit Principles were * Expand the focus of traditional psychological practice.  * From mental health to health care providers: Integrated health care.  * Integrating technology into practice.  * Meeting the needs of our diverse society.  And, * Apply basic and applied scientific evidence in our practice.  Shortly after the signing of your historic legislation James noted: "To stay as a viable profession psychology needs to take advantage of new opportunities in health care and business, otherwise we are likely to continue to financially decline.  Reimbursement rates for traditional mental health services have decreased in the past 10 years, while health care insurance premiums have seen double digit increases – Why is this?  Psychologists are being replaced by Masters level trained clinicians who will work for less and provide many of the same services.  We need to evolve into new positions of clinical leadership, consulting with business and gaining prescriptive authority where our services of doctoral trained psychologists will be rewarded.  If we don't step up now, other professions will and we will continue to see our incomes and opportunities drop."

            President Obama's landmark Patient Protection and Affordable Care Act (ACA) provides many opportunities for non-physicians with vision.  Combined with the recently enacted Mental Health Parity legislation this represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation.  It provides a priority for prevention, wellness care, and services which are high quality and cost-effective, and aims to move our health care system towards a population health-based system.  The ACA affirmatively calls for the development of integrated, interdisciplinary systems of patient-centered care which will be transformational.  Chief among them is the integration of behavioral health and medical health care systems.  Under the law mental health and substance use treatment are deemed "essential health benefits."  The foundation now exists for the steady integration of the advances occurring within the communications and health information (HIT) technology fields into the health care environment.  From this perspective alone, your success in obtaining the support of the American Nurses' Association-Illinois chapter and the Illinois Society for Advanced Practice Nursing for your RxP legislation is extraordinarily futuristic.

Substantive change always take time; often far longer than one expects.  Throughout today's discussions regarding the appropriateness and cost-effectiveness of integrating behavioral health/mental health within primary care settings, the high incidence of depression among patients is frequently noted.  The Agency for Health Care Policy and Research (AHCPR) was established by the Omnibus Budget Reconciliation Act of 1989 to enhance the quality, appropriateness, and effectiveness of health care services and access.  Among its responsibilities was facilitating the development and updating of clinical practice guidelines to assist practitioners in the prevention, diagnosis, treatment, and management of clinical conditions.  More than two decades ago (April 1993), AHCPR issued its guideline on Depression in Primary Care: Detection and Diagnosis – then-APA's Deputy Executive Director for Professional Practice, Russ Newman, was involved in ensuring that psychology's voice would be heard.

"Depression was selected as a topic for guideline development because: * Depressive disorders are commonly encountered in primary care, as well as in other treatment settings.  * Most depressed patients seek care from primary care practitioners.  * A range of effective treatments are available and commonly provided for these conditions.  * There is a large body of scientific evidence on which to base these guidelines.  * Practice surveys indicate that improvements are needed in primary care practitioners' ability to recognize and treat depressive disorders.  * Depressive disorders result in significant morbidity and mortality.  (And) * Depressive disorders have a high prevalence in the general population….  Despite the high prevalence of depressive symptoms and full major depressive episodes in patients of all ages, depression is underdiagnosed and undertreated by primary care and other nonpsychiatric practitioners, who are, paradoxically, the most likely to see these patients initially….  The social stigma surrounding depression is substantial and often prevents the optimal use of current knowledge and treatments.  The cost of the illness in pain, suffering, disability, and death is high….  Clinically significant depressive symptoms are detectable in approximately 12 to 36 percent of patients with another nonpsychiatric, general medical condition…. "  More than two decades ago….  GOOD DAY SUNSHINE.  Aloha,

Pat DeLeon, former APA President – Illinois Psychological Association – September, 2014

 

INTRIGUING REFLECTIONS

The 122^nd APA convention provided an excellent opportunity to reflect upon how far psychology has come in developing into a bona fide healthcare profession, advancing beyond viewing ourselves exclusively as metal health specialists.  It was wonderful to see Beth Rom-Rymer receive well deserved recognition for enacting prescriptive authority (RxP) legislation in Illinois, a decade after Louisiana's success.  For those who naively believe that her success in the backyard of the American Medical Association (AMA) was chance or a "lucky break," that is not at all true.  "The Illinois Medical Society and the Illinois Psychiatric Society vigorously and vociferously lobbied against our RxP bill until they realized that we wouldn't stop fighting and until they had already spent $1 million to keep us out of the prescribing community!"  The key to long term legislative success is community involvement.  Accordingly, we are very pleased that IPA and its state NAMI had each signed on as co-sponsors of their respective annual conferences in 2013 and are already making commitments to do the same for 2014/2015.   Perhaps our colleagues in Hawaii and Oregon, where earlier legislative efforts were vetoed, should reengage in this important legislative quest.

            This was also the 40^th anniversary of the APA Congressional Fellowship program which began with Pam Ebert and continues on today, joined by the APA Executive Branch program.  As Norman Anderson noted the program has supported 121 Fellows.  "As ambassadors for the field, APA Congressional Fellows consistently represent psychology in the best possible manner – to policymakers, their staff, and the scientists from other fields participating in the AAAS program."  This is another proactive initiative that State Associations could emulate at the local level, in conjunction with their academic colleagues.  We are confident that APA's Judith Glassgold, Micah Haskell-Hoehl, and Heather Kelly would be pleased to provide guidance for those interested.  It would be a worthwhile investment in the profession's future.

            Since my retirement from the ever-hectic U.S. Senate staff, I have become increasingly interested in how other colleagues have been adjusting to this new, essentially uncharted role.  Not surprisingly, I have found considerable interest across the country.  During the convention, Rod Baker, Ruth Paige, and Mike Sullivan discussed their personal journeys before an engaged audience reflecting all ages.  Rod has embarked upon a writing career; Ruth is learning not to accept every request for her time – thus spending more with those she really wants to, like family; and Mike continues his volunteer efforts from Peace Corps to Meals on Wheels.  "If you are not happy doing what you are doing, there is only one person you have to talk to!"  Informal discussions afterwards strongly suggest that physical concerns are becoming increasingly common; economic concerns much less so.  As a relatively young healthcare profession, we are increasingly maturing with a number of our individual colleagues actually aging.  We would suggest that this would be an excellent topic for our State Associations to address at annual conferences; especially when held in conjunction with other professions and/or interest groups such as NAMI.  Aging is an agenda which will ultimately impact every one of us.  Aloha,

Pat DeLeon, former APA President – Division 31 – September, 2014

 

COLLEGIAL EFFORTS REQUIRED FOR INCREASING ACCESS TO QUALITY CARE

Reflecting upon the extraordinarily successful APA-ABA 2014 National Conference on Violence, it intrigues me that I never hear about similar events in which State Psychological Associations collaborate with their counterparts representing other non-physician health care providers (or local Bar Association interest groups) in sponsoring joint conferences or annual meetings.  From a public policy frame of reference, there is considerable overlap of interests and clientele.  Throughout President Obama's Patient Protection and Accountable Care Act (ACA) there are a number of provisions encouraging the development of integrated systems of care, which are to be patient-centered and which will rely upon data-based clinical decision making (i.e., gold standard evidence-based protocols).  As the advances occurring within the communications and technology fields (e.g., telehealth, comparative effectiveness research, and various transformational initiatives sponsored by NIH) increasingly impact the health care environment, cross-provider and cross-population comparisons will become the norm.  There is no question that in this changing environment, psychologists will have to objectively demonstrate their "value-add," as APA Practice Directorate Executive Director Katherine Nordal keeps stressing at her annual State Leadership Conferences (SLCs).  Underlying these policy developments is the fundamental question of whether historical "scope-of-practice" limitations and geographical "licensure restrictions" really are in the best interest of patient care?  Unprecedented change is the future of practice.

            In 2010, the Institute of Medicine (IOM) released its report The Future of Nursing: Leading Change, Advancing Health.  Among its recommendations were: Nurses should practice to the full extent of their education and training; Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States; and, not surprisingly, Historical scope-of-practice barriers should be removed.  At the suggestion of the Chairperson, former HHS Secretary Donna Shalala, the Federal Trade Commission (FTC) was urged to: * Review existing and proposed state regulations concerning advanced practice registered nurses (APRNs) to identify those that have anticompetitive effects without contributing to the health and safety of the public.  States with unduly restrictive regulations should be urged to amend them to allow APRNs to provide care to patients in all circumstances in which they are qualified to do so.

            This Spring, the FTC held a public workshop to study activities and trends that may affect competition in the evolving health care industry.  Specifically, the intent was to explore current developments related to professional regulations; innovations in health care delivery; advancements in health care technology; measuring and assessing health care quality; and price transparency for health care services.  In the FTC's view: "Professional regulations may protect patient safety, improve quality of care, and provide useful information to consumers who are choosing among health care providers.  Greater competition may result when regulatory changes expand the number of health care providers or services available to consumers by increasing the use of advanced nurse practitioners, dental therapists, and other qualified non-physician or non-dental professionals.  Such increased competition may provide consumers with benefits such as lower prices and improved access to health care services.  Some regulations may, however, unnecessarily restrict the ability of non-physician health care professionals to practice to the full extent of their training, imposing costly limitations on professional services without well-founded consumer safety justifications or other consumer benefits to offset those costs.  Such overly restrictive professional regulations are likely to suppress beneficial competition by non-physician health care providers and may prevent institutional providers (such as hospitals) from developing innovative health care delivery models that rely more heavily on non-physician providers to provide efficient, safe care.  While all patients may be affected by reduced competition from non-physician health care professionals, the impact may be particularly severe for vulnerable and underserved patient populations."

            Some of the critical issues for which public comment was requested include: * To what extent do professional regulations vary by state?  Does state-by-state variation affect patient health, health care spending, or other important measures?  * How do current regulations concerning licensure and credentialing affect the ability of health care professionals to relocate or practice in more than one geographical area, particularly across state lines?  * Would greater state-to-state licensure portability improve competition?  What issues would increased licensure portability raise?  * To what extent is telemedicine being used today?  What new developments are occurring in telemedicine?  What role is telemedicine projected to play in the future?  * Are there regulatory or commercial barriers that may restrict the use of retail clinics, telemedicine, or other new models of health care delivery?  If so, are there any valid justifications to support such restrictions?  And, * What, if any, changes in government regulations would facilitate the emergence of new health care delivery models, enhance competition among health care providers, and encourage additional innovation?

            Earlier in the year, the FTC shared their views with the Massachusetts House of Representatives which was considering legislation (H. 2009) which would remove certain supervision requirements on the state's nurse practitioners (NPs) and nurse anesthetists (NAs).  "We recognize that patient health and safety concerns are of critical importance when states regulate the scope of practice of health care professionals, and FTC staff defer to Massachusetts on the ultimate health and safety standards that the Commonwealth may choose to establish.  We recommend, however, that the legislature seek to maintain only those NA and NP supervision requirements that advance patient protection….  H. 2009 would streamline APRN regulation and permit APRNs to more fully employ their education and experience in serving Massachusetts health care consumers, with regulatory oversight, but without certain formal physician supervision requirements now imposed under Massachusetts law.  Absent countervailing safety concerns regarding APRN practice, removing these supervision requirements has the potential to benefit consumers by improving access to care, containing costs, and expanding innovation in health care delivery."

            Psychology must appreciate that organized medicine's "public health hazard" concerns are not limited to any particular discipline.  In another New England state, a board-certified psychiatric pharmacy specialist "consults" for the University of Connecticut's Student Health Services.  His presence reflects the growing stress on college counseling centers nationally, with an overwhelming proportion of centers reporting seeing increases in the number of students with severe psychological problems.  Yet, the chair of the ApA's Committee on College Mental Health notes that while he understands the pressures on college counseling centers that might make this model seem attractive, it is not an approach he could embrace.  "I think that kind of care ought to be delivered by psychiatrists.  I think it's a very creative idea, in large part driven by cost savings to the university.  But it's not possible for me to be enthusiastic about it….  For me it's a quality of care issue for students at a university.  And the university is obliged to provide the best care possible."  Over time, advances in technology will make possible systematic cross-provider/cross-population comparisons, thereby providing objective data addressing the validity of organized medicine's alleged "patient safety" concerns.  Aloha,

Pat DeLeon, former APA President – Division 42 – August, 2014