INTEGRATED CARE -- MICHAEL, ROW YOUR BOAT ASHORE

            From a national public policy perspective, it is becoming increasingly evident that our nation is steadily evolving towards embracing an integrated, primary care-oriented health care delivery system.  The enactment of President Obama's landmarkPatient Protection and Affordable Care Act [PPACA] is unquestionably the most dramatic indication.  This law provides the various States and the Administration with considerable flexibility to reach national objectives, as it is systematically implemented over the next five to ten years.  The legislation is fundamentally patient-centered and not provider-centric.  Psychology must appreciate that the clinical services our practitioners provide are, in today's political and policy world, deemed to be health care services.  Accordingly, how the nation addresses the complexities of that environment will have a direct and profound impact upon the profession's future (i.e., practice, education, and research).  Substantive change evolves over time and is almost always based upon foundations established by visionaries from the past.  We would urge that psychology pay careful attention to the views expressed by those Institute of Medicine (IOM) participants who have, and frequently still are serving as health policy appointees within the Bush and Obama Administrations.  Their focused attention upon curtailing the ever-escalating cost of health care and bringing data-based, scientific knowledge to the daily delivery of care is unprecedented.  The advances occurring within computer sciences and related communications fields make their vision achievable.

            Movement Towards Integrated Care:  Five years ago the State ofMassachusetts joined Hawaii in enacting legislation which took a significant step towards guaranteeing that all of its citizens would have access to necessary health care.  Recently, due primarily to ever-escalating costs, it is considering replacing its fee-for-service system with an increasingly capitated approach that is very similar to President Obama's Accountable Care Organization (ACO) initiative (which many have suggested is founded upon President Nixon's HMO vision).  The underlying concept is to provide pre-set payments to organized teams of health care providers which would be responsible for all of the care required by a group of patients, with the possibility of bonuses for keeping people healthy.  Currently 98% of Mass.residents are insured with the Senate President acknowledging: "We did access first.  Now we have to figure out how we afford that."  The Governor's proposal builds upon a consensus among leaders from the state's insurance and hospital industries, medical society, and legislature who served on a special state commission.  Fee-for-service "is a primary contributor to escalating costs and pervasive problems of uneven quality" the commission unanimously concluded.

            The Healthcare Imperative: Lowering Costs and Improving Outcomes:  The IOM has proposed lowering the nation's health care expenditures by 10% in 10 years, while improving patient health and the quality of care provided.  The Congressional Budget Office (CBO) estimates that federal spending on health care will double in the next decade, consuming 27% of the budget by 2020.  The overarching IOM vision is to have 90% of clinical decisions being supported by accurate, timely, and up-to-date clinical information by 2020.  To accomplish this, it will be necessary to develop a learning health system that is designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider and to drive the process of discovery to become a natural outgrowth of patient care, while ensuring innovation, quality, safety, and value in health care.  Evidence development must not be merely an occasional byproduct of health care, but instead evidence capture and analysis, as well as its application, must be systematically structured as an integral and natural component of the care process.

            An IOM workshop identified six domains of excess costs in health care: unnecessary services (volume), services delivered inefficiently, prices that are too high, excessive administrative costs, missed prevention opportunities, and fraud.  The participants concluded that each is an important contributor to excessive health care costs and the amount of excessive costs incurred from each is tremendous.  Excess costs stemming from waste and inefficiency in the nation's health care system was estimated by IOM to total between $750 billion and $785 billion in 2009.

Health care cost increases continue to outpace the price and spending growth rates for the rest of the economy by a considerable margin.  At $2.5 trillion and 17% of the GDP in 2009, health spending in our nation commanded twice the per capita expenditures of the average for other developed countries.  "Moreover, there are compelling signals that much of health spending does little to improve health, and, in certain circumstances, may be associated with poorer health outcomes."  Interestingly, the Peter G. Peterson Foundation which supported this workshop is primarily dedicated to the mission of increasing public awareness of the nature and urgency of key economic challenges threatening the nation's fiscal future, and accelerating action by identifying sensible, sustainable solutions.  It has committed significant resources and attention to the area of health care costs and solutions given health care's direct impact upon the economy.

            Without significant action, by 2050 Medicare and Medicaid expenditures will account for nearly a quarter of the entire U.S.economy.  In 2008, Medicaid spending accounted for approximately 21% of total state spending and represented the single largest component of state spending.  Similarly, in the private sector health care costs have contributed to slowing the growth in wages and jobs.  "While the United States has the highest per capita spending on health care of any industrialized nation – 50 percent greater than the second highest and twice as high as the average for Europe, it continually lags behind other nations on many healthcare outcomes, including life expectancy and infant mortality."

            A number of common themes surfaced.  The Cost and Outcome Challenges. * Health Cost Excesses with Personal, Institutional, and National Consequences.  * Health Outcomes Far Short of Expectations.  Racial disparities in access lead to poorer outcomes, lost productivity, and lower quality of life.  * Fragmented Decision Points, Inconsistent Principles, Political Distortions. The Drivers of the Shortfalls.  * Scientific Uncertainty.  The gap between practice needs and available guidance is growing.  * Perverse Economic and Practice Incentives. * System Fragmentation. * Opacity as to Cost, Quality, and Outcomes. * Changes in the Population's Health Status.  Since 48% of Medicare beneficiaries have at least three chronic conditions and 21% have five or more conditions, it has been estimated that approximately 60 million Americans have multiple morbidities, a number that is expected to increase to 81 million by 2020.  * Lack ofPatient Engagement in Decisions.  Almost 40% of Americans possess only "basic" or "below-basic" health literacy skills.  Thus, their ability to make informed decisions becomes increasingly difficult as the volume and complexity of data available to them increases.  * Under-Investment in Population Health.  Only about 6% of national health expenditures are spent on public and population health.  Levers to Address the Drivers.  * Streamlined and Harmonized Health Insurance Regulation.  * Administrative Simplification and Consistency.  * Payment Redesign to Focus Incentives on Results and Value.  There is a need to better target resources on those patients at highest risk of poor outcomes.  * Quality and Consistency in Treatment, with a Focus on the Medically Complex.  There are already more than 3,000 guidelines from more than 280 organizations registered with the National Guideline Clearinghouse, thus consistency in guideline recommendations is a concern.  * Evidence That Is Timely, Independent, and Understandable.  * Transparency Requirements as to Cost, Quality, and Outcomes.  * Clinical Records That Are Reliable, Sharable, and Secure.  * Data That Are Protected But Accessible for Continuous Learning.  * Culture and Activities Framed by Patient Perspective.  With 25% of Medicare expenditures attributed to unwanted variation in preference-sensitive care, it was noted by many of the participants that much of health care delivery has been shaped over the past generation with the primary convenience and interests of the clinician, not the patient, in mind.  * Medical Liability Reform.  And, * Prevention at the Personal and Population Levels.

As one should expect, there was considerable discussion surrounding the potential benefits of Comparative Effectiveness Research and Health Information Technology (i.e., electronic records and telehealth services).  One of the participants asserted that: "(E)nhancing the effectiveness and efficiency of the U.S.healthcare system was dependent upon maximizing the contributions of healthcare professionals who are not physicians.  She identified a number of current barriers which limit appropriate use of such providers, including federal and state laws and regulations; opposition from healthcare systems, professional medical groups, and managed care organizations; reimbursement and other payment policies; and exclusion from demonstrations proposed as part of health reform."

Psychology's Visionaries – Interdisciplinary Care:  "I have had the privilege of serving on the Board of Advisors of the Duke University School of Nursing for the last four years at the request of the Dean who is the current President of the Association for the Advancement of Nursing.  While I have always been a strong advocate of collaborative care, this experience is an education for me in the roles that nurses play in our emerging healthcare systems.  I have learned about the roles nurses play in Global Health, such as the Duke nurses who develop and staff clinics in rural Tanzania with others leading distance education programs in the British West Indies.  I have learned about the new professional degree for nurses, the Doctor of Nursing Practice (DNP).  At Duke, DNPs are being prepared to innovate and provide leadership in clinical service delivery, and to translate evidence into practice at the point of care.  I have learned about the innovative on-line educational programs now available to nurses.  I was able to attend a course for Nurse Informatacists on the Second Life platform.  I have learned about the science of nursing, and the role Ph.D. faculty play in advancing healthcare science and education.  Some nurses ARE psychologists, having earned their Ph.D. in psychology after attending nursing school; for example our immediate APA Past-President Carol Goodheart.  Carol truly appreciates the emerging data on the social determinants of health as well as the importance of the primary healthcare providers in our country: family (as defined by the patient) caregivers, for acute and chronic conditions, which was one of her impressive Presidential initiatives.  I have learned about how effective nursing organizations and their leadership are in their advocacy efforts, supporting their discipline and focused on better patient care.  There is a profound research-practice gap in all disciplines.  Researchers must come to understand the values and beliefs of particular clinicians in order to achieve wide dissemination.  Psychology has much to learn from our sister discipline of nursing, whether through interdisciplinary courses or collaborative research or advocacy" [Susan McDaniel, University of Rochester Medical Center].

Ensuring Culturally Sensitive Care:  "I Ola Lahui Rural Hawai'i Behavioral Health Program opened its doors in August of 2007 with the specific intention of developing an APA accredited internship program to helpHawai'i 'grow its own.'  With only four APA accredited internships in the state, many of the best and brightest have been forced to leaveHawai'i during their crucial training years.  On November 9^th, 2010 the I Ola Lahui Internship Program was approved as an APA accredited program beginning in December, 2009.  Since 2007, we have trained 10 psychologists with eight of them living and working in medically underserved areas.  We currently have five more in training.

"Native Hawaiians continue to have major health and socioeconomic concerns that are disproportionately greater than other ethnic groups in Hawai'i.  Native Hawaiians have the highest rate of untreated medical and psychological concerns, and those who do seek services rely primarily on state and federally sponsored programs for their health care.  Greater medical and psychological concerns coupled with disparities in income and education and the cultural distress experienced by Native Hawaiians have created an unprecedented demand for health and mental health services.  Further exacerbating the dire need for mental health treatment in underserved areas is the reluctance of patients to seek treatment due to the stigma of mental health problems.  Increased access to quality health care for Native Hawaiians and other medically underserved populations in Hawai'iis desperately needed to combat these health disparities.

"The idea of creating I Ola Lahui arose from the growing behavioral and mental health care needs of the medically underserved and people who reside in the rural communities of Hawai'i.  As with many medically underserved and rural communities across the U.S., those in Hawai'i face challenges in receiving quality medical and psychological services.  Often people do not access care, are offered limited care, or are referred to specialty health care services in urban areas miles away or even on another island in our state.  I Ola Lahui provides a sustainable source of behavioral health care that is tailored to the unique needs of this group.

"I Ola Lahui expresses our intent to improve the health and well being of our people.  It means, 'So that the people will live and thrive.'  The I Ola Lahui mission is to provide culturally-minded, evidence-based behavioral health care that is responsive to the needs of medically underserved and predominately Native Hawaiian rural communities.  In recognition of Hawai'i's urgent need for more quality mental health care, I Ola Lahui is committed not only to providing services, but also to investigating the effectiveness of the services we provide and to training future providers with the hope of increasing the number of doctoral level behavioral health providers and services available in the medically underserved and rural areas of Hawai'i.

"I Ola Lahui is designed to serve Native Hawaiians and other medically underserved groups through specialized training exclusively in Hawai'i's Native Hawaiian Health Care System (NHHCS) clinics, Federally Qualified Community Health Centers (FQCHCs), and related programs.  Although we, as an organization, aspire to have a significant impact upon the health and well being of all Native Hawaiians and other medically underserved groups living in rural areas, our mission is simple and based soundly in a real desire to improve the lives of the people in our islands.  We are honored that this year we had 70 applicants for the two internship slots we can offer" [Robin Miyamoto, former HPA President].  "Chills the body but not the soul, hallelujah…. Michael row the boat ashore, hallelujah."  Aloha,

Pat DeLeon, former APA President 

LEAVING ON A JET PLANE

            Over the next five to ten years, President Obama's landmark Health Care Reform legislation (the Patient Protection and Affordable Care Act [PPACA]) will be systematically implemented.  Psychology should appreciate that the law is fundamentally patient-oriented and not provider-centric.  The States and Administration have considerable flexibility to address overarching national objectives.  Increasing access to quality primary health care and making scientifically-based clinical decisions are central to its vision.  The 21^stcentury will be an era of educated consumers, interdisciplinary and integrated health service delivery systems, and an unprecedented utilization of communications technology (e.g., telehealth and electronic health records).

            Telehealth – Service Delivery Of The Future:  The HHS Budget notes that the Office of Telehealth is an integral component of its Improve Rural Healthcare Initiative, with the goal of expanding the use of telecommunications technologies to increase access to, and the quality of, healthcare provided to rural populations.  A major goal is to strengthen partnerships among rural health care providers, recruit and retain rural health care professionals, and modernize the health care infrastructure in rural (and urban) areas.  These technologies are not viewed as products or ends in themselves, but as the means to provide services at a distance and to overcome geographic, economic, and other social barriers to obtaining health care.  A related objective is to increase the number of states adopting a common licensure application and participating in mutual recognition of each other's licenses.  Evaluation activities will focus upon telehealth's economic impact, particularly on the implications for coverage by government and third party payers which are critical for its viability.

The APA Council of Representatives recently established a ten person Task Force on the Development of Telepsychology Guidelines, co-chaired by Linda Campbelland Fred Millan (ASPPB), in conjunction with the APA Insurance Trust.  The goal is to provide direction to psychologists as they navigate the numerous ethical, regulatory, legal, and practice issues in their increasing utilization of this exciting technology for the delivery of psychological care.  Nevada is the home of the U.S. Senate Majority Leader.  His colleague, Senator Sheldon Whitehouse has introduced legislation (S. 539), the Behavioral Health Information Technology Act, which would extend eligibility for psychologists and other behavioral health care providers to obtain federal assistance in moving into the rapidly evolving technological era.  APA'sMarilyn Richmond would appreciate your active support of this legislation.  "I'm leaving on a jet plane.  I don't know when I'll be back again.  Oh babe, I hate to go."  Aloha,

 

Pat DeLeon, former APA President – Nevada Psychological Association – April, 2011

STEADILY FORWARD IN UNCHARTED WATERS

            Over the next five to ten years psychology will experience the steady implementation of President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act [PPACA].  The President's vision is fundamentally patient-centered, rather than provider-centric, and provides the Department of Health and Human Services (HHS) and the States with considerable flexibility to meet overarching national goals.  From a public policy frame of reference, we will see the revitalization of the states as "living laboratories" of social reform.  It is estimated that at least 32+ million currently uninsured Americans will obtain primary care coverage by 2014, although some experts predict a significantly higher number of nearly 50 million.  With an aging provider workforce and concerted efforts in the newly elected House of Representatives to repeal ObamaCare at all costs, Who will be available to provide these necessary services? And, What role will psychology ultimately play?

            Accountable Care Organizations: What Are They?  The Accountable Care Organizations (ACOs) concept is among the most visible health care payment and delivery system models provided for in the now one-year old health reform law [P.L. 111-148].  ACOs have the dual purpose of realigning the provider payment system and retooling performance measurement approaches to ensure accountability; thereby, shifting health care practice from a volume and intensity-based system to one that supports coordinated, high quality, and cost-effective care.  Specifically, this section of the federal statute focuses upon promoting accountability for Medicare beneficiaries through voluntary participation in the Medicare Shared Savings Program (which will be created before January 1, 2012), via ACOs.  The law defines ACOs as provider-led organizations, which may include hospitals, that share with payers accountability for care quality and cost containment and address the continuum of care and specialty needs for a patient population (of at least 5,000).  Accountability is fostered primarily through cost and quality transparency and economic rewards shared by providers and payers when costs are reduced.  The initiative will be implemented in January, 2012 and the Centers for Medicare and Medicaid Services (CMS) regulations are scheduled to come out in the near future.  Providers, executives, and even health insurance companies are scrambling to design and establish ACOs, but structural details are still forthcoming.

            ACOs have been characterized as "the elusive unicorn – everyone seems to know what it looks like, but nobody's actually seen one."  Ultimately, the shape of ACOs will likely depend on a variety of factors including proposed CMS regulations and the related financing environment, relevant statutory definitions; and, in some cases, state practice acts.  High stakeholder demands for flexibility and regulation nimbleness – until we learn what works – indicate that the debate around which entities will qualify will likely be ongoing.  Leading experts do agree that four general models capture the essential elements of potential ACOs: an integrated delivery system, multi-specialty group practice, physician-hospital organization, and independent practice association.  Historically, whenever any complex legislation, such as PPACA, has been enacted, over the next couple of years the committees with jurisdiction will recommend bipartisan "technical fixes" in order to smooth the implementation process, based upon practical experiences.  Unfortunately, in the current Congressional climate such necessary legislative oversight seems unlikely.

            Exciting Opportunities For Psychology:  As the exact nature of ACOs is still evolving, it is important for organized psychology to affirmatively enter into the policy debate, at both the local and federal level, especially in determining the fate of non-physician providers and non-physician led practices.  Will the ACOs be broadly defined and horizontally-organized including behavioral health providers as equal partners (or leaders)?  Or, Will they take on a physician-dominated hierarchical structure?  As the four models above indicate, ACOs are not necessarily physician focused.  They address all facets of a patient's condition and foster shared accountability for overall quality and costs encompassing a larger range of providers.

            With respect to the quality and integration side of the equation, the opportunities for psychology are clear.  First, the role of the behavioral health provider will only become more essential.  Mental health and substance-use problems are the leading cause of combined disability and death of women and second highest in men in theUnited States.  Currently, only 7% of health care expenditures go to mental health treatment.  This, despite the fact that over 70% of people dually eligible for Medicare and Medicaid have mental illness.  Further, we know that 67% of adults and more than 92% of people with serious mental illness do not receive effective mental health and substance-use treatment.  This is due to multiple variables that affect success and acceptability of care, but these statistics highlight the type of patient who will be served in ACOs.  As with health homes (or "medical homes"), the ACO concept emphasizes prevention, early identification and intervention, chronic disease management, person-centered approaches, and implies adoption of evidence-based practice.  There are now several compelling examples of high value integrated care interventions targeting mental health and substance-use in elderly adults that include psychological interventions/supervision.  Two examples of cost-effective models with good outcomes include the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) and the Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) programs.

            Second, quality care depends upon access to the well-implemented, cost-effective best practices.  Psychologists can fill a knowledge and skill void here, in a number of ways.  They include: a.) recruiting, training, and retraining a competent behavioral health workforce; b.) developing and studying effective implementation and service delivery models including: c.) screening and assessment technology: instrument selection and construction, administration and interpretation, training, supervision, and research; d.) bridging science and service and facilitating the dynamic, iterative learning process resulting from their interplay; e.) client- and family-centered shared decision making: intervention design, training and supervision, and basic and applied research; f.) competency in developmental psychology across the lifespan; specifically in older adults and adults with psychiatric disabilities: training and supervision, development of selection tools and interventions, and conducting and translating research; g.) developing decisional algorithms for referral to specialty services; and, h.) implementing outcome-driven, culturally-informed, evidence-based intervention strategies.  In addition, high quality, multidisciplinary care and cross-training is rife with interest for psychologists in both practice and research fronts.  Some examples include: standardized screening, outcome measures, data collection, analysis and interpretation in the context of multiple literatures, training of staff on behavioral health evidence-based practices and process, patient engagement, and, of course, conducting research and translating findings into practice top the list of examples.  Finally, coordinating communication and treatment planning across a multidisciplinary team requires appreciation for the overlapping and unique knowledge bases and skill sets of each participating discipline and managing group dynamics in the context of delivering quality-based care.  Regardless of the fate (or face) of ACOs, it is clear that psychologists can and must play a critical role in their development and successful implementation.  ACOs are being developed within the policy context of reports by the Institute of Medicine (IOM) that excessive costs stemming from waste and inefficiency within the nation's health care system currently total between $750-$785 billion annually.

            Visionary Leadership:  Susan McDaniel of the University of Rochester Medical Center has long been in the forefront of psychology's evolution into integrated care.  "I have had the privilege of serving on the Board of Advisors of the Duke University School of Nursing for the last four years at the request of the Dean who is the current President of the Association for the Advancement of Nursing.  While I have always been a strong advocate of collaborative care, this experience is an education for me in the roles that nurses play in our emerging healthcare systems.  I have learned about the roles nurses play in Global Health, such as the Duke nurses who develop and staff clinics in rural Tanzania with others leading distance education programs in the British West Indies.  I have learned about the new professional degree for nurses, the Doctor of Nursing Practice (DNP).  At Duke, DNPs are being prepared to innovate and provide leadership in clinical service delivery, and to translate evidence into practice at the point of care.  I have learned about the innovative on-line educational programs now available to nurses.  I was able to attend a course for Nurse Informatacists on the Second Life platform.  I have learned about the science of nursing, and the role Ph.D. faculty play in advancing healthcare science and education.  Some nurses ARE psychologists, having earned their Ph.D. in psychology after attending nursing school (for example, our immediate APA Past-President Carol Goodheart).  I have learned about how effective nursing organizations and their leadership are in their advocacy efforts, supporting their discipline and focused on better patient care.  Psychology has much to learn from our sister discipline of nursing, whether through interdisciplinary courses or collaborative research or advocacy."  Aloha,

Sandra Wilkniss, APA/AAAS Congressional Fellow & Pat DeLeon, former APA President.  National Register – March, 2011

 

AN EXCITING OPPORTUNITY

            As President Obama's landmarkPatient Protection and Affordable Care Act [PPACA] [P.L. 111-148] is systematically implemented over the next 5-10 years, it is important that our State Associations appreciate that the law is fundamentally patient-centered, and not provider-centric, andfurther that the States have considerable flexibility to develop local approaches which address broad, often non-specific, national objectives.  Psychology is one of the nation's health care professions and as such, must increase its efforts to work collaboratively with other disciplines, engage patients in taking responsibility for their own health care, and begin utilizing the unprecedented advances occurring within the communications and technology fields (i.e., telehealth and virtual realities) to ensure data-based, high quality care.  Geographical boundaries (for example, in rural America) no longer are acceptable excuses for denying care.  State Associations must work with their legislatures and licensing boards to achieve licensure portability.

            The Robert Wood Johnson Foundation (RWJF) recently announced a new grant program Public Health Law Research: Making the Case for Laws That Improve Health.  RWJF seeks to build the evidence for, and strengthen the use of, regulatory, legal, and policy solutions to improve public health and help individuals lead healthier lives.  It is equally interested in identifying and ameliorating laws and legal practices that unintentionally harm health.  Critical questions: How does law influence health and health behavior?  Which laws have the greatest impact?  Can current laws be made more effective through better enforcement, or do they require amendment?  Preference will be given to applicants that are public entities or nonprofit tax-exempt (501(c)(3)) organizations.  Short-term study grants up to 18 months ($150,000 each); complex and comprehensive study grants up to 30 months ($450,000 each).  A total of $2.85 million will be available for this round of grants.

            The Call for Proposals focuses upon three topics: 1.) Effects of laws and legal practices on population health outcomes.  2.) Using innovative regulatory tools to promote health.  And, 3.) Effects of law, regulation, and policy on the performance of public health systems and the delivery of public health services.  Examples include: studies that will investigate the design and implementation of a new legal intervention or assess effects of an existing law or enforcement strategy on physical or mental health; exploring the impact of the criminal justice system on the health of communities; studies of the unintended effects of law on the incidence or prevention of chronic diseases; and, studies of the organization, financing, and delivery of public health services, including public mental and behavioral health services, and the effects of those services on public health.  One selection criterion is effective collaboration between public health, legal researchers, and practitioners.  We would suggest that this RWJF initiative provides an exciting opportunity for state psychological, nursing, and bar associations to collaboratively address some of society's most pressing needs.  Law and business remain the most common professional backgrounds of elected officials.  Early career exposure goes a long way towards encouraging professional respect for other disciplines.  This Spring, Hawaii Psychological Association was successful in having their prescriptive authority (RxP) legislation pass the State Senate on an 18-3-4vote.  With mutual respect comes legislative success.  Aloha,

 

Pat DeLeon, former APA President – Division 31 – March, 2011

 

THE STEADY EVOLUTION OF THE PRESIDENT’S VISION

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

ALOHA – MAKING A REAL DIFFERENCE

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

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

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

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

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

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

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

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

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

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

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

 

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

 

 

SO PLEASE DON’T EVER CHANGE

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

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

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

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

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

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

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

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

 

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