EVEN INCREMENTAL CHANGE TAKES TIME

SAMHSA's FY' 2014 Budget:  It is always instructive to review the budget priorities of those federal agencies which address the needs of our profession's beneficiaries.  The Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) noted that her FY' 2014 budget "prioritizes essential investments in mental health and substance abuse infrastructure and innovation as the nation comes to terms with its long-standing neglect of these public health issues.  I believe this request reinforces SAMHSA's efforts to help the nation understand and act on the knowledge that behavioral health is essential to health – that emotional health and freedom from substance abuse are necessary for an individual, a family, a community or a nation to be healthy."  Her total budget request is $3.572 billion, including $130 million to support the President's plan to protect America's children in the wake of the tragic events of December 14, 2012 in Newtown, Connecticut.  Approximately $63 million is targeted for states to work with providers to increase enrollment and to maximize third party reimbursements for substance abuse and mental health services.  An additional $21 million is to identify and bring to scale evidence-based practices to promote mental health and to prevent and treat mental illness.  Funding is also requested to implement the National Strategy for Suicide Prevention and to begin a new program focused on trauma and women, Grants for Adult Trauma Screening and Brief Intervention.  $130 million will ensure young people and the adults who work with them know how to recognize mental illness and find a clear pathway to care.  This includes funding for Project AWARE (Advancing Wellness and Resilience in Education), providing Mental Health First Aid training, and fostering comprehensive state-school-community partnerships to prevent violence, promote mental health, and facilitate referrals to treatment.

            The Administration firmly believes that individuals and families cannot be healthy without positive mental health, freedom from addiction, and the absence of abuse of substances.  Prevention, treatment, and recovery support services for behavioral health are essential components of health service systems and community-wide strategies that work to improve health status and lower costs for individuals, families, businesses, and governments.  The presence of substance abuse and mental illness exacerbates the cost of treating co-morbid physical diseases and results in some of the highest disability burdens in the world.  SAMHSA's vision – * Behavioral Health is essential for health.  *Prevention works.  *Treatment is effective.  And, * People recover from mental and substance use disorders.  Being aware that the sense of shame and secrecy associated with mental illness and addiction prevents too many Americans from seeking help, President Obama directed the Secretaries of the Departments of Health and Human Services and Education to launch a national dialogue about mental illness with young people who have experienced mental illness, members of the faith community, foundations, and school and business leaders.  SAMHSA collaborated with public and private partners to facilitate this National Dialogue on Mental Health in order to raise awareness and reduce negative attitudes.   APA's Norman Anderson and Give An Hour's Barbara Van Dahlen were invited to participate in this historic White House Conference.

            Barbara's Reflections:  "On June 3 President Obama held an unprecedented event at the White House: a National Conference on Mental Health.  The day-long gathering featured speeches by both the President and Vice President, as well as a series of panels – one of which, moderated by Secretary of Health and Human Services [HHS], Kathleen Sebelius, I had the honor of serving on.  The attendees for the conference included members of consumer and advocacy groups, representatives of the major mental health associations (American Psychological Association, American Psychiatric Association, National Association of Social Workers), and several celebrities, including Glenn Close and Bradley Cooper, who came because they care about ending the stigma associated with mental illness.  This was a premier event that took months to coordinate.  It brought together all of the stakeholders – from within the government and from communities across the country – with the goal of raising our nation's consciousness about the mental health issues that affect one in four Americans.  Oddly, while the White House was packed with TV cameras and journalists on June 3, the event itself received very little national coverage….  There has been no follow up and seemingly no interest about an issue that affects us all – directly or indirectly – at some point in our lives.  According to the National Institute of Mental Health: * An estimated 26.2% of Americans ages 18 and older – about one in four adults – suffer from a diagnosable mental disorder in a given year.  (And) * Mental disorders are the leading cause of disability in the United States and Canada."

            One particularly exciting initiative in the SAMHSA budget highlights a program for which Senator Mark Begich introduced the authorizing legislation -- the Mental Health First Aid (MHFA) bill.  MHFA helps the public identify, understand, and respond to the signs of mental illness and addiction disorders.  Specifically, the program: teaches the warning signs and risk factors for schizophrenia, major clinical depression, panic attacks, anxiety disorders, trauma and other common mental disorders; teaches crisis de-escalation techniques and provides trainees with a 5-step action plan to help individuals in psychiatric crisis connect to professional mental health care.  Since violence is not limited to college and school campuses, the audience for the training includes emergency services personnel and other first responders, police, human resource professionals, teachers and school administrators, faith leaders, parents, veterans, etc.  Widespread dissemination of the Mental Health First Aid curriculum is expected to reach 750,000 individuals who work with youth, including how to talk to adolescents and families experiencing these problems so they are more willing to seek treatment.  SAMHSA funding, combined with that from the Departments of Education and Justice, will be used to support competitive grants with the goal of making schools and communities safer and providing mental health literacy training, along the model of traditional First Aid projects for physical accidents.

            Three of SAMHSA's strategic initiatives are closely aligned with APA priorities that Katherine Nordal has discussed at her annual State Leadership Conferences over the past several years.  * Ensuring that the behavioral health system (including states, community providers, and peer and prevention specialists) fully participates with the general health care delivery system in the adoption of health information technology (HIT) and interoperable electronic health records (EHRs).  * Realizing an integrated data strategy and a national framework for quality improvement in behavioral health care that will inform policy, measure program impact, and lead to improved quality of services and outcomes for individuals, families, and communities.  And of special interest to APA President Don Bersoff, * Supporting America's service men and women – active duty, National Guard, Reserve, and veteran – together with their families and communities by leading efforts to ensure that needed behavioral health services are accessible and that outcomes are positive.

            Having been supportive of the Minority Fellowship Program (MFP) since its inception in 1973, I was pleased to learn of SAMHSA's request for $5 million to provide stipends to graduate students in order to increase the number of culturally competent behavioral health professionals who would provide direct mental health and/or co-occurring substance abuse services to underserved minority populations.  Currently minorities represent 30% of the nation's population and are projected to increase to 40% by 2025; yet only 23% of recent doctorates in psychology, social work, and nursing were awarded to peoples of color.  SAMHSA intends to utilize the existing infrastructure of the MFP to expand the focus to support master's level trained behavioral health providers in the fields of psychology, social work, professional counseling, marriage and family therapy, and nursing and thereby increase the number of providers who are available to provide clinical services to the underserved, at-risk children, adolescents, and populations transitioning to adulthood, in an effort to increase access to, and the quality of, behavioral health services for this age group.

            Change Always Takes Time:  In 2006, the Institute of Medicine (IOM) released its report "Improving the Quality of Health Care for Mental and Substance-Use Conditions."  The IOM concluded: "Improving our nation's general health and the quality problems of our general health care system depends upon equally attending to the quality problems in health care for mental and substance-use conditions….  Dealing equally with health care for mental, substance-use, and general health conditions requires a fundamental change in how we as a society and health care system think about and respond to these problems and illnesses.  Mental and substance-use problems and illnesses should not be viewed as separate from and unrelated to overall health and general health care."  Each year more than 33 million Americans use health care services for their mental and substance-use illness (M/SU).  Treatment can be effective.  M/SU problems and illnesses occur with a wide array of diagnoses and varied severity, with many people requiring only a short-term intervention to help them cope successfully.  However, as with general health care, despite what is known about effective care for M/SU conditions, numerous studies have documented a discrepancy between M/SU care that is known to be effective and the care that is actually delivered.  One landmark study demonstrated that people with alcohol dependency were found to receive care consistent with scientific knowledge only about 10.5% of the time.  The IOM called on institutions of higher education to "facilitate the development and implementation of core competencies across all M/SU disciplines (and) place much greater emphasis on interdisciplinary didactic and experiential learning and bring together faculty and trainees from their various educational programs" – one of the underlying tenants of the Patient Protection and Affordable Care Act.  Similarly, the Secretary of HHS should "provide leadership, strategic development support, and additional funding for research and demonstrations aimed at improving the quality of M/SU health care."  The 21^stcentury will be an era of patient-centered, interdisciplinary, integrated care which is significantly impacted by the unprecedented advances occurring within the communications and technology fields (i.e., EHRs and comparative effectiveness research) which readily allows cross-diagnostic, cross-population, and cross-provider objective comparisons.

            Over the years, I have always wondered why it seems that even beneficial change takes so long to accomplish.  Harvey Fineberg, President of the IOM, recently proffered a highly relevant and thoughtful observation in JAMA – "The Paradox of Disease Prevention: Celebrated in Principle, Resisted in Practice."  "Why is prevention such a difficult sell?  This puzzling question surfaces daily in clinical practice and public health, and it intrudes on policy makers wanting to make scientifically sound, evidence-based policy decisions.  Because prevention is so deeply embedded in US culture, the relative neglect of preventive medicine seems paradoxical."  This is a critical issue that Senator Inouye and his colleagues grappled with for over four decades.  As the treatise notes, there are many possible explanations for prevention's low priority: future success is invisible, there is a lack of clinical drama, the long delay before concrete rewards appear, commercial conflicts of interest, and statistics have little emotional effect upon individual lives.  Perhaps the key is that "incentives for prevention are often misaligned in a system designed to treat disease after it occurs.  A key policy goal in health reform is to better align financial incentives with superior care, often including prevention.  Too often still, the benefits of prevention do not accrue to the payer.  Until incentives are aligned with health and not just diagnosis and treatment, true health care reform will be delayed….  In the end, prevention is truly worth the investment to make a difficult sell just a little easier and to put everyone on the road to a healthier future."  Yet, as Barbara pointed out after the historic White House event, there is "seemingly no interest about an issue that affects us all – directly or indirectly – at some point in our lives."  Without question, the SAMHSA FY' 2014 budget request is most timely.

            Transformational Change:  This spring, Lt. General Patricia Horoho, U.S. Army Surgeon General, testified before the U.S. House Appropriations Committee describing the Army Medicine story.  "Since 1775, America's medical personnel have stood shoulder to shoulder with our fighting troops, received them at home when they returned, and stand ready today when called upon to put their lives on the line to care for our wounded Soldiers.  While the wounds of war have been ours to mend and heal during a period of persistent conflict, every day our Soldiers and their Families are kept from injuries, illnesses, and combat wounds through our health promotion and prevention efforts; are treated in state-of-the-art fashion when prevention fails; and are served by an extraordinarily talented medical Force.  We are at our best when we operate as part of a Joint Team.  It is our collective effort – Army, Air Force, and Navy – that saves lives on the battlefield….  Our Army is charged with being prepared to face tomorrow's challenges, remaining relevant for the future ahead of us.

            "The reality is that after more than a decade of war, our Military and our Nation face a time of significant changes and challenges.  Army medicine is impacted by both the National healthcare conversation and the direction of the Military Health System….  The Army Medicine 2020 strategy is a Call to Action that contains the vision, strategic imperatives and way ahead for Army Medicine to move from a healthcare system to a System for Health….  By moving from a disease model to a health model, we can impact health on a National level.  The health of the military and the health of the Nation are not separate discussions….  This is a Call to Action – Healthcare in the United States is at a turning point, and the Military Health System has an opportunity to lead the Nation away from the status quo.

            "In 2012, the Army lost 183 soldiers to suicide.  These tragic losses affect all those left behind, including fellow Soldiers, Families, and communities….  We must eliminate the perceived stigma of asking for help.  This is not simply an issue isolated to the medical community to recognize and resolve….  Our challenge regarding military suicides is to move forward in a coordinated, multifaceted, and National approach.  It will take a team effort….  Army Medicine is advancing a culture shift by encouraging every Professional Soldier to develop a mindset that drives them to optimize their own health in order to improve performance and resiliency.  There must be an effective way to change mindsets, not just dictate behaviors.  As Army Medicine continues to open the aperture, we must look at where health is truly influenced.  Long term success in Army Medicine lies in our ability to effectively impact the 'Lifespace.'  It is in the Lifespace where the choices we make impact our lives and our health.  We understand the patient healthcare encounter to be an average interaction of 20 minutes, approximately five times a year….  The health of the Total Army is essential for readiness and prevention is the best way to health.  Prevention – the early identification and mitigation of health risks through surveillance, education, training, and standardization of best public health practices – is critical to building and sustaining health and resiliency in Army populations and is the foundation for military success.

            "Behavioral Health.  The longest period of war in our Nation's history has undeniably led to physical, mental and emotional wounds to the men and women serving in the Army – and to their Families.  The majority of our Soldiers have maintained resilience during this period.  However, the stresses of increased operational tempo are evident in the increased demand for Behavioral Health Services and increased suicide rate….  While physical injuries may be easier to see, 'invisible wounds' such as mild traumatic brain injury, depression, anxiety, and post traumatic stress (PTS) also take a significant toll on our Service Members.  And yet, to the individuals who suffer from these wounds, and those who care for them, they are anything but invisible.  One of the most challenging areas of wartime medicine is PTS treatment.  We have discovered that with the right treatment, most will go on to live productive, fulfilling lives.  Military research shows that 15% of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans develop PTS.  PTS is treatable; 80% of those with PTS have remained on Active Duty.  Army Medicine continues to move the model of behavioral healthcare delivery outside of the brick and mortar MTFs [military treatment facilities] through behavioral health initiatives, such as Embedded Behavioral Health (EBH).  We demonstrated success by looking at ways to bring healthcare and education to the foxhole, which allows us to increase accessibility, visibility, and ultimately trust, while decreasing the stigma and time spent away from the unit.

            "Behavioral health problems, mild traumatic brain injury, and suicide, while often described as 'invisible wounds of war,' are not unique to a theatre of combat or to the military population – they are National issues.  As a Nation, there are opportunities for us to partner and to lead the way in breaking the silence – to encourage those who struggle with behavioral health issues to receive help.  The Army and Army Medicine are actively engaged in reducing stigma and upholding our responsibility to raise national awareness regarding mild traumatic brain injury and mental health conditions including PTSD.  We anticipate the need for mental health services will only increase in the coming years as the Nation deals with the effects of more than a decade of conflict.

            "We must never lose sight of the fact that the most important unit in the Army is the Family unit.  Our Families, including those outside of the nuclear family setting, have demonstrated unprecedented strength and resilience, quietly shouldering the burdens of our Nation's wars….  Army Medicine is currently setting the conditions to better understand the Army Family both within and outside of conventional patient care settings.  Impacting the Lifespace of our Army Families will not only improve the strength, performance, and readiness of the Soldier, but also establish an example for our Nation on a way forward to improve the health of communities….  Our military families – the children of our men and women in uniform – have a different story to tell compared to their peers outside of the military.  I want the story of the military Family to resonate throughout the Nation's history as an example of resilience – demonstrating the powerful impact that can be felt when we invest not only in the Soldier, but in the individuals, old and young, who support our heroes."  [General Horoho is the first woman and first non-physician to serve as DoD Surgeon General.]

            Reflections on Retirement -- One of Psychology's True Visionaries:  "HA!  When I decide to retire, I will disappear.  I have no desire to hang on past that time.  My youngest graduated from medical school Saturday and he is headed to Emory University to begin his seven year neurosurgical residency.  My oldest and her husband are both practicing physicians here in town (OB and ID respectively), my middle daughter was awarded her master's degree in nursing two weeks ago and is starting to teach in an RN program locally, and my youngest daughter is a master's degree social worker employed by one of the large general med-surg hospitals locally where she is the ICU/ER social worker.  I will simply ride off into the sunset and turn everything over to the next generation (Jim Quillin)."  Aloha,

Pat DeLeon, former APA President – Division 29 – August, 2013

 

THRIVING IN UNSETTLED TIMES – PERSONAL INVOLVEMENT IS THE KEY

The Wisdom Of Visionaries:  With the public sector facing an increasingly likely sequestration, including furloughs and decreased training resources, and with those within the private sector having to navigate the rough waters surrounding President Obama's far reaching Patient Protection and Affordable Care Act (ACA), it is important to reflect upon the wisdom bestowed by Katherine Nordal at this year's exciting State Leadership Conference.  Proclaiming to her 500+ colleagues in attendance: "The clock is ticking towards full implementation of the law [ACA] and January 1, 2014 is coming quickly.  ButJanuary 1^st is really just a mile maker in this marathon we call health care reform.  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us.  Many of our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  These are factors that create 'value-add' for psychologists on health care teams and in integrated, interdisciplinary systems of care.  No one else is fighting the battles for psychology… and don't expect them to."  Public service colleagues do bring "value-add" to those whom they serve.  Now we must collectively educate those who establish our nation's health policies and advocate for appropriate recognition.  We must also be willing to aggressively embrace change.

            This summer, I was invited to participate in the Canadian Psychological Association's 74^th annual convention in which CPA President Jennifer Frain passionately urged her colleagues to take control of their own professional destiny by becomingpersonally involved in the public policy/political process with her inspirational opening address "Supporting Canadian Psychology: Advocacy Required."  The following day, the Honorable Justice Edward F. Ormston, of the Consent and Capacity Board (an independent body created by the provincial government of Ontario to conduct public hearing under the Mental Health Act), similarly invoked "A Call to Arms: A Discussion of Why the Timing is Right to Reclaim the Role of Psychologists in Treating Mental Illness and to Access Public Health Funding."  The political and health care structure of Canada is without question considerably different than that of the United States.  However, the needs of our clients and the potential contributions of our profession are strikingly similar and challenging.

It was back in 1974 that the Canadian Minister of National Health and Welfare, Marc Lalonde, visionarily proclaimed: "For these environmental and behavioural threats to health, the organized health care system can do little more than serve as a catchment net for the victims.  Physicians, surgeons, nurses and hospitals together spend much of their time in treating ills caused by adverse environmental factors and behavioral risks….  While it is easy to convince a person in pain to see a physician, it is not easy to get someone not in pain to moderate insidious habits in the interests of future well-being….  It is therefore necessary for Canadians themselves to be concerned with the gravity of environmental and behavioural risks before any real progress can be made."  Our nation's mental (i.e., behavioral) health care providers of all disciplines must come to appreciate that what our visionary colleagues to the North are calling for is, in essence, our training and clinical expertise. We must now make sure that society appreciates the significant "value-add" of our perspective and expertise.  Hope springs eternal and we were very pleased to learn from APA's Heather Kelly that the SPSSI Policy Workshop, which is being cosponsored by APA and a number of divisions, was "over-applied for by paying participants by a couple of hundred young graduate students and early career psychologists!  And there is space for only 40… wow.  There will be lots of young people there."

            This June, I also was invited to attend the 3^rd annual NUKA System of Care Conference sponsored by Southcentral Foundation (SCF) of Anchorage, Alaska.  SCF is an Alaskan Native owned, nonprofit health care organization serving nearly 60,000 Alaska Native and American Indian people living in Anchorage, Matanuska-Susitna Valley, and 60 rural villages in the Anchorage Service Unit.  It is built around the value of shared responsibility; ensuring systems are respectful and culturally appropriate and strive to achieve excellence in "customer-owner" satisfaction, connecting the Native Community with services that benefit everyone.  By accepting clinical and financial responsibility from the Indian Health Service for serving its beneficiaries, SCF obtained the necessary flexibility to craft clinical services that would be most cost-effective.  Their inpatient utilization rate has dramatically declined, while "owner" (i.e., patient) satisfaction and health status indicator measures impressively improved.  SCF has also been able to develop innovative training programs; their dental extender model (which was subject to litigation by the ADA) was included in the ACA and their Traditional Healing Clinic and Family Wellness Warriors initiatives wonderfully reflect the patient-centered holistic ideals of President Obama's vision.  The underlying NUKA system is both a capitated system (i.e., bundled reimbursement), as well as possessing the ability to obtain fee-for-service reimbursement.  Their experience has been that to truly provide quality care, they cannot let short term financial rewards override long term wellness initiatives which ultimately contain costs.  One concrete example which is particularly relevant to the Alaskan Native and Native Hawaiian populations:  A provider can be reimbursed for providing a child with an audiology evaluation and referral; however, if there are no speech therapists available, what has really been accomplished?

At the conference there were health leaders from around the country (including several from other nations), and an impressive presence from the VA.  Don Berwick, former Acting Administrator of the Centers for Medicare and Medicaid Services (CMS), was the keynote speaker.  He presented a vision of how dramatically our nation's health care system was changing.  Unprecedented change is clearly inevitable and, as Katherine keeps emphasizing, will be unsettling, if not downright painful for many.  One of his most memorable slides graphically depicted how an extraordinary weather event had destroyed almost all of the bridges in a small rural nation, except one built by the U.S. government.  Very impressive.  However, the river had significantly modified its course, so it no longer was flowing under the still standing bridge.  Over and over the underlying message presented was that for acute health care needs (such as immediately following an automobile accident), we have the best health care system in the world.  However, for the 80+% of health care needs, it is the patient (in SCF's case, the "owner") who really determines the course of care.  Accordingly, the relationship between patients and providers is critical to ensuring quality health care.  Providers have to be willing to give up their historical "hero" roles and become educators/coaches if they want to be effective.  They have to learn to listen to the patient's journey and accept them where they are.  Systems have to continuously seek and respond to owner feedback.  For most health care providers and training institutions this is a fundamentally new perspective.  The senior leadership from the VA clearly listened.  We shall see if they can ultimately make a real difference for our nation's veterans who really do "own" the VA.  SCF received the well-deserved 2011 Malcolm Baldrige National Quality Award for performance excellence; an honor which was established by the Congress in 1987 in memory of the late Department of Commerce Secretary as the highest level of national recognition for performance excellence.

            What's Past May Well Be Prologue:  During the late 1970s, following up on impressive testimony by former APA President Nick Cummings and Joan Willens, the Senate Finance Committee seriously explored including psychology under the "physician" definition of Medicare and developing a process by which those mental health services which would eventually met the Food and Drug Administration standard (i.e., were safe, effective, and appropriate) would be fully reimbursed.  Recently, APS's Alan Kraut, along with Steve Breckler and Lynn Bufka of APA, participated in discussions chaired by the leadership of the NIMH regarding the possibility of an Institute of Medicine (IOM) study on the now apparently timely topic of psychotherapy standards, efficacy, effectiveness, etc.  The ACA calls for health care delivery system reforms and innovations that rely heavily upon incorporating health (including behavioral and mental health) services within budgeted (i.e., "closed") systems such as Accountable Care Organizations and Medical Homes, as well as utilizing electronic health records (EHRs) which ultimately will allow cross-population and cross-provider comparisons.  At the same time, mental health parity is expected to be provided.  Reflections of the current thinking by senior health policy experts:

Without traditional fee-for-service transactions to keep track of utilization and access, these newly developing systems of care will rely on performance measurement to monitor how patients are treated and require objective outcome successes (such as lowered blood pressure readings, successful diabetes management, etc.).  Accountability will increasingly take the form of linking performance measures to economic rewards such as shared savings.  Behavioral health performance related to pharmacological management of patients is simpler and better developed than is the measurement of psychosocial treatments.  As a result, treatment has increasingly shifted away from psychosocial care possibly to the detriment of patient well-being.  Unfortunately, the mental health field has lagged behind in the development of measures to allow one to track whether the content of provided psychosocial treatment is consistent with evidence-based treatment and what clinical science has shown to work.  It is critical therefore to develop better ways to promote effective psychosocial therapies to counter the pressures to limit access to these types of care and to develop better ways to monitor the quality of care being provided through psychosocial services.

            The process by which psychosocial therapies are currently validated and coverage determinations are made is highly variable based largely on policies developed by payers, including private insurers, and public payers such as CMS, the VA, state Medicaid programs, etc.  In addition, there are a wide range of disciplines and levels of training that claim to provide effective psychosocial treatments.  Variation exists in the levels of scientific evidence used to make coverage determinations, the types of studies and outcome measures used, and the evidence needed to determine the necessary dose and duration of treatments under differing conditions.  Further, there are no standards in place to ensure treatment fidelity based, for example, on providers' training or performance metrics for providers.  How does one know what actually transpired during therapy?  As a result, it is difficult for consumers and payers to understand what they are buying.  This uncertainty reasonably creates skepticism regarding the value of the average psychosocial service.  By default, this reinforces a traditional "medical model" of care which many non-physician providers feel is simply inappropriate.  This inherent skepticism is likely to be especially present within the newly proposed ACA organizations that must manage care under a finite budget.

            The Mental Health Parity and Addiction Equity Act was intended to address special limits on access to behavioral health care services.  However, without accepted and endorsed quality standards for psychosocial care, emerging health care systems may be highly reluctant to promote appropriate use of these treatments.  To facilitate a balanced approach to care that is consistent with the mental health parity directive and to track its effect on access to care and appropriate utilization of services, the quality standards developed must feed into existing accountability arrangements, including the quasi-public entities that have already demonstrated leadership on endorsing, reporting, and maintaining performance measures (for example, the National Quality Forum, the National Committee for Quality Assurance, etc.).

The IOM has an impressive record of addressing complex health policy issues such as this in an open, transparent, and interdisciplinary manner.  The leadership of the NIMH similarly has an outstanding history of looking to the future.  Addressing the controversy surrounding the publication of the new DSM V, the NIMH Director and the President-Elect of the American Psychiatric Association jointly stated: "What may be realistically feasible today for practitioners is no longer sufficient for researchers.  Looking forward, laying the groundwork for a future diagnostic system that more directly reflects modern brain science will require openness to rethinking traditional categories….  This is the focus of the NIMH's Research Domain Criteria (RDoC) project.  RDoC is an attempt to create a new kind of taxonomy for mental disorders by bringing the power of modern research approaches in genetics, neuroscience, and behavioral science to the problem of mental illness."  The contemplated IOM study could represent a very important step in this process -- perhaps as was envisioned in the late 1970s.  The 21^st century will be an era of provider accountability.  Aloha,

Pat DeLeon, former APA President – Division18 – July, 2013

 

EXCITING OPPORTUNITES FOR THOSE WITH VISION

    During my tenure on Capitol Hill, one of the most interesting federal agencies, often overlooked by psychology, was the Centers for Disease Control and Prevention (CDC).  What psychology brings to society's most pressing needs often falls within its jurisdiction.  When Rodney Hammond was there, the Director proffered that: "child maltreatment is a serious public health problem with extensive short- and long-term health consequences.  Abused children often suffer physical injuries, including cuts, bruises, burns, and broken bones.  In addition, maltreatment causes stress that can disrupt early brain development, and extreme stress can harm the development of the nervous and immune systems.  As a result, children who are abused or neglected are at higher risk for health problems as adults, including alcoholism, depression, drug abuse, eating disorders, obesity, sexual promiscuity, smoking, suicide, and certain chronic disorders.  Fortunately, there is a growing body of evidence that documents the effectiveness of primary prevention strategies….  (I)ntegrating behavioral health approaches into primary care systems can be an important component of health reform (10/23/09)."

            The CDC Fiscal Year 2014 budget highlights several behavioral and psychological initiatives which should be of considerable interest to our state associations (SPAs).  CDC has a long history of working closely with public and private agencies to explore mutually shared programmatic interests.  Why not with SPAs?  This year, for example, in response the nation's epidemic of obesity: "CDC is currently in the process of collaborating with national groups, and in FY 13 entered into a Memorandum of Understanding (MOU) with the Culinary Institute of America to educate volume food service leaders on strategies to increase the number of healthy and tasty menu options for children and adults."  Addressing the issue of falls among older adults, CDC uses: "the public health model and focusing on primary prevention, CDC uses the best available scientific data to identify effective fall interventions and to determine the optimal strategies to promote widespread adoption of proven programs.  CDC develops, disseminates, and supports proven strategies that prevent older adult falls.  This is done through research, capacity building, dissemination, and implementation of evidence-based programs, and by developing resources to help healthcare providers incorporate fall prevention into clinical care."  Both of these priorities are fundamentally behavioral.

            "CDC's mission, simply put, is to keep Americans safe and healthy where they work, live, and play.  Our scientists and disease detectives work around the world to put proven prevention strategies to work, track diseases, research outbreaks, and respond to emergencies of all kinds.  CDC works with partners around the country and world… preventing the leading causes of disease, disability, and death."  The range of behavioral issues CDC addresses is impressive: gun violence, rape prevention and education, smoking, community transformation, racial and ethnic approaches to community health, preventing motor vehicle crashes, AIDS/HIV, teen pregnancy, Alzheimer's disease, and promoting breastfeeding to new mothers.  Focusing upon its success in addressing chronic diseases, which are the leading causes of death and disability in the nation, CDC notes the importance of environmental approaches to promote health and reinforce healthful behaviors.  Close to Rodney's heart, CDC described its enhanced capacity to collect child maltreatment mortality data and its efforts to engage parents, communities, and states in ensuring child well-being and preventing child maltreatment.  It's Core Violence and Injury Prevention Program provides support to states to prevent all forms of violence.

            SLC:  At this year's exciting State Leadership Conference (SLC), Katherine Nordal highlighted for the 500+ colleagues in attendance that: "The clock is ticking towards full implementation of the law [President Obama's Affordable Care Act (ACA)] andJanuary 1, 2014 is coming quickly.  ButJanuary 1^st is really just a mile maker in this marathon we call health care reform.  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us.  Many of our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  These are factors that create 'value-add' for psychologists on health care teams and in integrated, interdisciplinary systems of care.  No one else is fighting the battles for psychology… and don't expect them to."

            Hawaii:  Beth Giesting, Healthcare Transformation Coordinator for the State of Hawaii: "We were fortunate to get a State Innovations Planning grant.  Heading toward the half-way mark I can say we've made a lot of progress and learned a lot.  Among our lessons -- there's a lot of support in the health care community for this organized effort and general agreement on what needs to be done.  On the other hand, there is so much infrastructure that needs to be put in place, especially in HIT, before we can do a lot we need to do.  You won't be surprised to know that the most intractable problem that pops up everywhere concerns behavioral health – it is among the top issues for avoidable ER and inpatient use, a big unmet need for the VA, a major concern for the public safety system, in short supply and confusing of access for kids, adults, and the elderly.  Obviously, we need to do something about the behavioral health workforce shortages.  Also in our plan is trying to figure out ways to support expansion of FQCHCs and have them collaborate with the Native Hawaiian Health Centers to provide case management."  There are numerous opportunities for those with vision and who get involved.  Aloha,

 

Pat DeLeon, former APA President – Division31 – June, 2013

 

LEADING THE WAY IN UNCHARTERED WATERS

USUHS:  Since January, 2012 I have had the privilege of serving on the faculty of the Uniformed Services University of the Health Sciences (USUHS) and have been very impressed by the professionalism and dedication of the graduate students and faculty in nursing and psychology.  The Psychology Department hosts a weekly seminar exposing the broader university community to a wide range of behavioral expertise.  Steven Brewer's report: "Combat and Behavioral Health – The USUHS Medical and Clinical Psychology Department provided another informative seminar recently.  This time the topic was the behavioral health of soldiers and marines after a decade of combat.  The presenter was renowned military researcher Carl Castro, U.S. Army Colonel and the current director of the Military Operational Medicine Research Program at Fort Detrick, Maryland.  To provide perspective for his discussion, Col. Castro began by discussing the context of combat-related PTSD and how it differs from other types, perhaps due to the extensive training provided prior to deployment.  This prior training makes the traumatic event expected and not unanticipated.  The prior training may also allow reaction to occur 'automatically' and allow the person to not freeze.  The symptoms themselves may also be beneficial in the combat environment for survival of self and protection of others, especially when the environment will provide repeated exposure to the traumatic events, rather than a single instance.

            "The key points of Col. Castro's presentation were made through the Lessons Learned from a decade of combat.  The first Lesson Learned is 'Combat impacts the mental health and well-being of Soldiers and Marines.'  Service members in a Brigade Combat Team assessed at three months after returning from a year in Iraq had a three-fold increase of PTSD.  The risk increased proportionately with the increase of combat engagement and even perceived danger.  Even 12 months post-deployment saw a significant increase in angry and aggressive behaviors.  The second Lesson Learned is 'Not all Soldiers are at equal risk for mental health problems.'  The risk is greatest for those serving in direct combat, such as Infantry units, compared to those who serve in combat support (CS) or combat service support (CSS), such as Signal units.  While it is important to note that the CS and CSS service members do still see an increase in symptoms and mental health disorders during deployments, the risk increases directly with combat exposure.  Those who served in high combat were most likely to show symptoms of anxiety, depression, PTSD, and other mental health disorders.

            "The third Lesson Learned is 'Leadership is important for maintaining Soldier mental health.'  Soldiers with high perceptions of leadership were less likely to screen positive for a mental health problem compared to those with low perceptions of leadership.  In fact, the percentage of positive mental health problems was lower in High Combat/ High Leadership groups (17%) than it was in Low Combat/ Low Leadership groups (20%), indicating the importance of good leadership to mental health.  The fourth Lesson Learned is 'Mental health training works.'  For instance, Battlemind Training (BMT) is an evidence-based skill development model that uses examples relevant to service members, has a team focus, and builds on existing strengths.  Those who received BMT reported significantly fewer PTSD symptoms at three months post-deployment compared to those who received the standard stress education training.

            "The fifth Lesson Learned is 'Mental health 'resetting' following a year-long combat tour takes more than 12 months.'  Many units that deploy for 12 months are then authorized a 12-month 'dwell time' to reset before possibly deploying again.  However, the evidence shows that symptoms of depression, anxiety, and PTSD often increase over the 12-month period.  Service members have little time to deal with their mental health issues, as the dwell time includes many deployment related activities, including training and preparation for the next deployment.  The sixth Lesson Learned is 'Longer and multiple deployments are likely to lead to more mental health issues.'  Intuitively, it makes sense that symptoms do not get better by multiplying the trauma which caused the symptoms.  The evidence bears out this thought, for both 12- and 6-month deployments.  The last Lesson Learned is 'Every combat Soldier and Marine will face moral and ethical challenges.'  The combat arena is a difficult one for people to understand unless they have been there, and the decisions that must be made can be challenging to an individual's personal code of ethics.  The findings indicate Soldiers who screened positive for a mental health problem or who had high levels of anger were twice as likely to engage in unethical behavior on the battlefield compared to those Soldiers who screened negative or who had low levels of anger.  Soldiers with high levels of combat were more likely to engage in unethical behaviors than Soldiers with low levels of combat.

            "The next step is to use the Lessons Learned to improve the mental health of those who serve.  The primary means appears to be focusing on the junior leadership, including non-commissioned and commissioned officers.  We must also work on the recovery and return-to-duty both after and when mental health issues arise.  Relationship building among peers, mental health providers, and leaders is critical to improve the facilitation of mental health services.  Finally, the transition from the combat arena to home is difficult.  Some service members return to an active duty post; others, such as the Reservists, are transitioned to their civilian life with little time to make the conversion.  Families often suffer from confusion and a sense of helplessness when mental health symptoms appear.  As we move into the future, we must ensure we are providing the best care we can to those who have served 'in harm's way.'"

            "Retirement":  Prior to USUHS, I served with the late-U.S. Senator Daniel K. Inouye for 38+ years, retiring as his chief of staff.  One of the most interesting initiatives was the directive by the conferees on the Fiscal Year 1989 Appropriations bill that DoD establish a "demonstration pilot training project under which military psychologists may be trained and authorized to issue appropriate psychotropic medications under certain circumstances."  Morgan Sammons and John Sexton (both U.S. Navy) were the first to graduate from this program at the June 17, 1994 ceremony held at Walter Reed, attended by then APA President Bob Resnick.  These two trailblazing colleagues unequivocally demonstrated that psychologists can learn to safely and cost-effectively provide high quality psychopharmacological care.  Military psychologists should be proud of their historical accomplishment and now also affirmatively assist other colleagues in obtaining this important clinical responsibility within the VA, and throughout the civilian sector.

            The Civilian Sector:  During the past year significant progress has been made in two of our larger states.  In New Jersey, Bob McGrath reports: "The New Jersey RxP bill passed our Assembly on April 29, 2013 despite strong opposition from several of the medical societies.  Though they fielded five lobbyists on the day of the vote, they had no argument against the bill other than the usual claims that the training is insufficient and patients would be 'harmed,' without presenting a shred of data to support their position.  Next we move on to the Senate.  It's a remarkably expensive undertaking, and we can use any help we can get."

In Illinois, Beth Rom-Rymer: "We have had a remarkable 14 months.  On March 6, 2012, the Illinois State Senate Public Health Committee passed our RxP bill out of Committee by a vote of 6-4.  With our lobbyists, we made the critical decision to spend the next 12 months educating our psychologists and legislators around the state on RxP issues; training Illinois psychologists in becoming effective advocates for RxP; and reaching out to mental health associations, social service organizations, law enforcement agencies, hospitals, mental health centers, physician groups, etc. to educate about, and advocate for, RxP.  We have been very fortunate to work with strongly committed and dedicated legislative chief sponsors, including the Senate President ProTem Don Harmon.  On March 12, 2013, our RxP legislation passed out of the Senate Public Health Committee by the unanimous vote of 8-0 with one abstention.  On April 25th, we overwhelmingly passed out of the Senate by a vote of 37-10 with 4 abstentions.  On May 7th, our Senate bill was placed in the House Executive Committee.  Over the next several days, we were continually conferring with our lobbyists over the advisability of calling our bill.  We made the strategic decision that we wanted to take more time to work with our Representatives so that the vote would reflect an informed understanding of the issues.  We will be working very closely, over the next several months, with our legislators and all of our third party groups around the state.  We are very fortunate that although this legislative session has concluded on May 31st, we are in the first year of a two year sequence.  We are, therefore, able to build on all of our terrific accomplishments, to date, and focus on the House.  We are also in productive discussions with the Governor's Office.  We are looking toward achieving passage during our next legislative session in the spring of 2014."  From the littlest of Acorns, those with vision see mighty Oaks.  Aloha,

 

Pat DeLeon, former APA President – Division19 – June, 2013

THE RAPIDLY CHANGING HEALTH CARE ENVIRONMENT

As we begin to focus upon our forthcoming annual APA convention, to be held in Hawaii, we should reflect upon the challenge issued by Practice Directorate Executive Director Katherine Nordal at this year's exciting State Leadership Conference (SLC) to get personally involved in our state association's legislative efforts.  "The clock is ticking toward full implementation of the law [President Obama's landmark Patient Protection and Affordable Care Act (ACA)] and January 1, 2014 is coming quickly.  ButJanuary 1^st is really just a mile marker in this marathon we call health care reform.  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us.  The details of ACA implementation vary from state to state, and so do the key players….  I want to highlight an important new development within APA, the Center for Psychology and Health.  The Center includes a new Office of Health Care Financing, which will address challenges such as ongoing implementation of new psychotherapy billing codes and seeking new CPT (Current Procedural Terminology) codes that will adequately capture the work of psychologists in integrated care settings.  Dr. Randy Phelps is heading up this office….  Yes, the clock is ticking toward January 1, 2014.  But remember, we're not running a sprint.  Health care reform is a marathon – we're in it for the long haul.  New models of care and changes in health care financing won't take shape overnight.  We can't hope to finish the marathon called health care reform if we're not at the starting line.  Fortunately, many psychology leaders have embraced our call to action."  SLC and our annual conventions have always been the highlight of the psychology year for me – such collective energy, vision, and enthusiasm.  Katherine has a wonderful gift of vividly capturing the most critical agendas: This year, "Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  No one else is fighting the battles for psychology… and don't expect them to."  Last year, "If we're not at the table, it's because we're on the menu.  And I quite frankly don't want to be on anybody's plate to be eaten."

            Randy's Vision:  "APA launched its new Center for Psychology and Health under the direction of CEO Norman Anderson in January.  One component of that Center is a new Office of Health Care Financing (OHCF), which we are currently setting up and will be directed by me.  First, some background.  As Norman has indicated in a number of venues, the purpose of the new APA Center for Psychology and Health is to vigorously pursue Goal Two of APA's Strategic Plan: Expand psychology's role in advancing health.  The Center pulls together top leadership, staff, and major initiatives across all of APA to focus the association's efforts on four inter-related challenges outlined by Norman towards achieving this goal.  They are: 1) Workforce, education and training challenges; 2) Influencing how we are viewed by policy makers, the scientific community, other disciplines and the public; 3) Addressing how we view and define ourselves; and, 4) What Norman calls the 'getting included, getting paid' challenge.  There is, and has been, a tremendous amount of work by APA on each of these challenges, and we will keep the membership informed.

            "Specifically regarding the 'getting included, getting paid' challenge, hopefully you're aware of the ongoing advocacy by the APA Practice Organization to legislatively define psychologists as 'physicians' in Medicare, gain inclusion of psychologists in every state's Medicaid system, and legally challenge inappropriate insurance practices and parity violations.  The new OHCF was created to augment those efforts, and will work in close partnership with Katherine and APAPO, although it will be housed in APA's Executive Office.  Getting included as providers in all primary care and integrated care settings, playing a key role in inter-professional treatment teams, participating in Accountable Care Organizations (ACOs), etc., are all necessary, but not sufficient, steps to insuring our future.  For example, if you (or your institution) are not being reimbursed for your services in the existing fee-for-service (FFS) system or in the newer care delivery models, you are at risk of being replaced by those who are reimbursable, or by lower cost providers.

            "The AMA Strategy:  Our strategy is to directly target this issue in the most critical national venues where financing policies and mechanisms are translated into actual reimbursement realities.  The American Medical Association (AMA) is one of those venues, so a primary activity of the new OHCF for the immediate future is to coordinate and expand APA's involvement with the AMA.  Their processes play a very direct and powerful role in shaping this country's health care financing policies and provider reimbursement levels – in both the public sector and the private health care market.  The Center for Medicare and Medicaid Services (CMS) uses the AMA's recommendations to set the fees paid in Medicare.  And, these Medicare fees become the benchmark for reimbursements in other federal programs such as TriCare (DoD) and Medicaid and, very importantly, the commercial insurance market.

            "So how does the AMA influence the public and private reimbursement system throughout the country?  The AMA owns and runs the confidential and proprietary process through which all health care procedures in the U.S. are described and then assigned a billing code (which is then used for reimbursement in virtually all payment systems), known as the Current Procedural Terminology (CPT) system.  APA is a player at the AMA CPT Committee, and was represented there by Tony Puente from 1994-2008.  In 2009, Tony became the first psychologist elected as a voting member of its governing body, the AMA CPT Editorial Panel.  Since then, Neil Pliskin has represented APA at CPT.  The AMA also owns and controls the highly confidential process by which 'work values' are determined for all CPT codes; i.e., for all health care procedures from surgery to psychotherapy and beyond.  That committee is known as the Resource-Based Relative Value Update Committee or 'RUC.'  Jim Georgoulakis is the APA representative to the AMA RUC, and has held that seat for a decade and a half.

            "So the AMA defines the procedure codes used by all health care providers, including psychologists, and also assigns a valuation ('RVU') to each procedure.  CMS bases its fees on the RUV recommendations of the AMA, so this is where 'value' translates to reimbursement dollars.  Commercial carriers and other federal programs then use the CMS fee schedule as a benchmark in setting their rates.

            "APA's Game Plan:  As I noted, APA has been a player for many years at the AMA CPT and RUC through our volunteer representatives.  But with pressures to transform the health care system accelerated by President Obama's ACA, it is critical for APA to kick its CPT and RUC involvement up a notch to be at the table even more actively.  And while these processes are central to maintaining the existing fee-for-service (FFS) system in health care, the move to newer financing models such as 'bundling' and 'global payments' will still rely on current fees as the building blocks to value the contribution of individual team members.  So psychology cannot afford to neglect this arena for both the present and the future.

            "To that end, we are working very intensively at the CPT and RUC with colleagues Tony, Jim, and Neil on issues that affect both 1) mental health services by psychologists and 2) the delivery of psychological services in physical health and integrated care settings.  The immediate priorities of the OHCF in each of those two domains are:  Mental Health Codes -- * Complete the AMA RUC survey process for the three remaining CPT codes in the new mental health CPT code set that went into effect January 1^st for the entire public and private mental health system.  CMS is using an interim fee schedule, and will not release its final fees for all mental health codes until that survey work is completed.  * Work with the AMA and the other mental health societies to develop an 'extended service' psychotherapy code for trauma, PTSD, and other treatments that extend beyond 60 minute sessions, because there is no code available in the new mental health code set.  Codes for Integrated Care -- * Lobby CMS for permission to re-survey (through the RUC system) the existing Health and Behavior CPT codes, used for psychological treatments associated with physical disorders.  Those codes are currently valued at 30-40% below the comparable mental health codes.  * Participate in the AMA's ongoing development of reimbursement codes for care coordination, transitional care, team conferences, etc.  Psychologists are currently not reimbursable for these activities, and are not yet at the AMA table where they are being developed."

            Health Resources and Services Administration (HRSA):  Having finally completed deliberations on its very contentious Fiscal Year 2013 budget, the Administration recently submitted its request for Fiscal Year 2014.  Administrator Mary Wakefield, who has participated in Cynthia Belar's Education Directorate Advocacy Breakfast: "Thanks to ACA, HRSA has an even broader role.  Combined with first of its kind initiatives like the National HIV/AIDS strategy, HRSA's mandate continues to grow.  Working with our DHHS partners, HRSA is responsible for 50 individual provisions in the health care law.  These generally fall into three major categories.  * Expanding the primary care safety net for all Americans – especially those who are geographically isolated, economically disadvantaged or medically vulnerable – for example, through expansion of the Health Center program.  * Training the next generation of primary care professionals, while improving the diversity of the workforce and re-orienting it toward interdisciplinary, patient-centered care.  HRSA does this through targeted support to students and clinicians and grants to colleges, universities and other training institutions.  * Working with its partner agencies, HRSA is expected to greatly expand prevention and public health efforts to catch patients' health issues early – before they require major intervention; to improve health outcomes and quality of life; and to help contain health care costs in the years ahead.  Our FY 2014 budget request places a strong emphasis on investing in programs that improve access to health care in underserved areas and allows the Health Resources and Services Administration to take important steps towards implementing healthcare reform and improving healthcare access for underserved populations.  We are determined to work with our DHHS and other healthcare partners to assure the health of the Nation."

            As a result of the continuing diligent efforts by Cynthia Belar and Nina Levitt, the HRSA budget request includes $2,892,000 for the Graduate Psychology Education (GPE) program, which was the level provided in FY 2012 (with a slight increase in FY 2013).  This APA sponsored program funds accredited health profession schools, universities, and other public or private nonprofit entities to plan, develop, operate, or maintain doctoral psychology schools and programs and programs in mental and behavioral health practice to train psychologists to work with underserved populations.  The program is designed to foster an integrated and interprofessional approach to addressing access to behavioral health care for vulnerable and underserved populations.  Fifty-five percent of graduates were underrepresented minorities and/or from disadvantaged backgrounds and 29% report practicing in a medically underserved area.  In support of the program, HRSA noted that mental disorders rank in the top five chronic illnesses in the U.S. and that the National Alliance on Mental Illness reported approximately 6%, or one in 17 Americans suffers from a serious mental illness.  Serious mental illnesses cost society approximately $193.2 billion in lost earnings per year.  Individuals suffering from a serious mental illness earned at least 40% less than people in good mental health, confirming that mental disorders contribute to significant losses of human productivity.  Over the years, we have come to appreciate that the federal government is much more sympathetic to paying for clinical services rendered by practitioners when it has supported their training.

            The Office for the Advancement of Telehealth (OAT) would receive $11.5 million, which was also its level in FY 2012.  Funds would be provided for two grants under the Licensure Portability Grant Program, as well as associated technical assistance and evaluation activities.  OAT anticipates that 204 communities will have access to adult mental health services and 239 communities will have access to pediatric and adolescent mental services by FY 2014.  The OAT programs are viewed as an integral component of the overall DHHS Improve Rural Health Care Initiative to expand the use of telecommunications technologies that increase access to and improve the quality of health care provided to rural and underserved populations.  Telehealth programs strengthen partnerships among rural health care providers, recruit and retain rural health care professionals, and modernize the health care infrastructure in rural areas.

            Very Timely Steps -- Division 31:  "APA Division 31 and Division 42 received a CODAPAR grant to create a specific digest of the laws of each State, and then create State specific electronic health record (EHR) templates.  All APA member psychologists will have access to the laws and templates.  It should assist in the implementation of the ACA provisions that will require EHR use among integrated healthcare professionals.  Check the Division's website for the grant proposal and additional information.  To gain access, go directly to:http://www.apadivisions.org/division-31/membership/health-record-templates.aspx.  The State specific EHR templates comply with the laws of each jurisdiction.  The States have had an opportunity to have their digests and the templates reviewed through the volunteer efforts of their member experts on the ethics/law.  Each State's vetted materials are now posted at the Division 31 Community website so that all APA members will have access to these free resources [Andy Benjamin, Division 31 Past-President]."

            Intriguing Incremental Steps:  Those involved in shaping APA's Guidelines for the Practice of Telepsychology, which is a collaborative effort by APA governance entities, the Insurance Trust, and the Association of State and Provincial Psychology Boards (ASPPB), have taken notice of the parallel evolution of the notion of an "E. Passport" by ASPPB.  This would address a number of issues surrounding interjurisdictional telepsychology practice and ASPPB is currently seeking public comment on their preliminary proposal.  "The primary objective of every regulator within the field of occupational regulation should be public protection.  Regulators typically achieve public protection by establishing licensing standards, engaging in complaint resolution, and by facilitating education.  A central consideration in evaluating the effectiveness of any proposed Telepsychology standard, guideline, or regulatory language is its ability to ensure that the practice of psychology is done competently and at the minimum standard of acceptable and prevailing practice.  In essence, by asking, 'Will this solution to Telepsychology protect the recipients of the psychological services?'"  The ASPPB Telepsychology Task Force is considering the E. Passport proposal as such a mechanism to monitor and regulate interjurisdictional telepsychology practice.  This goes directly to the underlying issue of licensure mobility which, with the advent of technology and integrated health systems, must be effectively addressed in a timely manner ifpsychology is to remain competitive within the global health care environment.

            Clinical Pharmacy:  "Reciprocity of pharmacy licensure is possible across all the states, Puerto Rico, and the District of Columbia and is facilitated by a national licensure transfer process and a national jurisprudence exam.  There is no multi-state compact, however, as in nursing.  The National Association of Boards of Pharmacy (NABP) provides these national mobility resources as a service to member state boards of pharmacy and to licensees.  NABP also provides the Model Pharmacy Practice Act and updates it regularly.  The Model Act addresses key issues, including the regulatory framework for collaborative drug therapy management agreements between pharmacists and physicians, nurse practitioners, and other prescribers, Collaborative drug therapy management facilitates pharmacists' patient management activities which include the initiation, modification, and cessation of medication (June, 2011)."  Pharmacy's visionary approach proactively addresses the complex issues surrounding providing telehealth services by their profession.  Aloha,

Pat DeLeon, former APA President – Division 42 – June, 2013

 

A TIME OF CHANGE, CHALLENGES, OPPORTUNITIES

 As we excitedly observe from afar the evolving progress of our colleagues in New Jersey and Illinois, we should appreciate that historically where our profession has been able to have prescriptive authority (RxP) legislation enacted, it has been where a few have been sufficiently committed to made this their highest personal priority, demonstrated by never being "distracted" by other interesting events such as our annual APA conventions and state leadership conferences (SLCs).  The public policy/political process is a very personal one where success only comes with vision, persistence, and commitment.  As State Advocate Guru Mike Sullivan constantly reminds us, change is always the result of individual participation and that there are only a few who have been willing to become actively engaged.  Those who succeed have focused on society's real needs (i.e., envisioning a "higher agenda" beyond mere "turf issues").  Over the years we have also come to appreciate that substantive change always takes time; often far longer than one would initially predict, regardless of its ultimate benefit.  And, that change is very unsettling for many.

            State Leadership Conference (SLC):  During this year's extremely exciting APA State Leadership Conference (SLC), Practice Directorate Executive Director Katherine Nordal made clear to the over 500 attendees that unprecedented change is coming, particularly with the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA), and that it will be at the state and local level where the most critical implementation decisions will be made.  "The clock is ticking toward full implementation of the law and January 1, 2014is coming quickly.  But January 1^st is really just a mile marker in this marathon we call health care reform.  We're facing unchartered territory with health care reform and there's no universal roadmap to guide us.  The details of ACA implementation vary from state to state, and so do the key players.  There are challenges for the states.  A principal example is expansion of Medicaid.  Millions of consumers are expected to move into the Medicaid system as ACA is fully implemented.  We must pave the way for psychologists to provide services to the swelling ranks of Medicaid recipients.  To do that, we need to confront barriers to our participation and reimbursement.  Medicaid programs in 16 states do not recognize private sector psychologists as providers.  For those that do, many place conditions and restrictions on psychologists' participation.  One restriction involves requiring physician referral for psychological services.  And as of 2010, only 25 state Medicaid programs utilized health and behavior codes.  APA created these codes more than 10 years ago to facilitate our involvement in integrated systems of care and allow reimbursement for interventions that target physical disorders – such as diabetes, chronic pain, and cardiac disease.

            "One of the first steps in positioning for reform is for practitioners to recognize that they bring numerous professional skills and strengths to integrated care settings.  These are factors that create 'value-add' for psychologists on health care teams and in integrated, interdisciplinary systems of care.  And that's what many of our practitioners increasingly will need to promote: the value and quality they can contribute to emerging models of care.  We are a highly educated and talented discipline, and we need to identify and create opportunities to make others aware of the skills and strengths we can contribute to health care.  I believe that if we are not valued as a health profession, it will detract from our value in other practice arenas as well.  So regardless of how we feel about the current state of our health care system, psychology must take its seat at the table and contribute to the solutions needed to fix our ailing system.  No one else is fighting the battles for psychology… and don't expect them to.  We need to look at our advocacy broadly as taking advantage of any opportunity to help others understand and appreciate the value of psychology and psychological services.  It's not enough to have a good message.  We also need good messengers.  Health care reform is a marathon – we're in it for the long haul.  New models of care and changes in health care financing won't take shape overnight.  For two years in a row at SLC our theme has been health care reform, and we've focused on the critical need for psychology to get engaged.  We can't hope to finish the marathon called health care reform if we're not at the starting line.  Fortunately, many psychology leaders have embraced our call to action."  Katherine has always been a staunch supporter of prescriptive authority.  In our judgment, obtaining RxP is critical to psychology's future as an independent health care provider.

            Integrated Care:  One of the defining features of the ACA is its emphasis upon increasing access to team-based, interdisciplinary, integrated patient-centered primary care.  Accordingly, it will be interesting to see the extent to which visionary psychologists come to appreciate that the ongoing battles today between organized medicine and the Advanced Practice Registered Nurses (Doctors of Nursing Practice) are very much about psychology's future, especially at the state level.  It is estimated that the number of Nurse Practitioners will nearly double by 2025; from 128,000 in 2008 to 244,000.  A similar trend exists for Physician Assistants; where the number was 40,469 in 2000, increasing to 83,466 in 2010.  A thought provoking article in the New England Journal of Medicine notes: "In Virginia, after prolonged negotiations that engaged the Medical Society of Virginia and the Virginia Council of Nurse Practitioners, the state legislature unanimously enacted a 'compromise' struck by the two organizations in March, 2012.  The law stipulates that nurse practitioners must work as part of a patient-care team led and managed by a physician, and they must adhere to scope-of-practice limits as applied to them.  The law expands from four to six the number of nurse practitioners who can be supervised by a physician, and it recognizes telemedicine as a legal form of oversight when nurse practitioners practice in different locations.  The boards of medicine and nursing in Virginia jointly drafted regulations implementing the law.  The AMA promotes the Virginia law as a model that other states should consider, but the American Association of Nurse Practitioners believes the law places Virginia out of step with national trends."

Timely?  We would remind the readership that on June 17, 2011 proposed regulations for Community Mental Health Centers (CMHCs) seeking federal support (i.e., Medicare and Medicaid reimbursement) were promulgated that would require "a psychiatric evaluation, completed by a psychiatrist or psychologist with physician counter signature, that includes the medical history and severity of symptoms."  As a condition of participation, the "CMHC must designate a physician-led interdisciplinary team that is responsible, with the client, for directing, coordinating, and managing the care and services furnished for each client.  The interdisciplinary treatment team is composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and therapeutic needs of CMHC clients."  The envisioned physician-led interdisciplinary team would provide the care and services, with the CMHC designating a psychiatric registered nurse, clinical psychologist, or clinical social worker, who is a member of the interdisciplinary team, to coordinate the care and treatment decisions with each client, in order to ensure that each client's needs are assessed and that the active treatment plan is implemented as indicated.  Clearly the underlying policy issue being posed for psychology is: Whether our clinicians should be considered independent providers or allied health physician extenders?

Transformational Change is Necessary:  The various reports issued by the Institute of Medicine (IOM) over the years should alert psychology, as Katherine Nordal has emphasized at SLCs, that what we as psychologists and data-oriented behavioral scientists believe should be a priority for our nation's health care system is often unappreciated (or simply not understood) by those who establish clinical and programmatic priorities, and particularly the all-important reimbursement systems.  "Health care in America has experienced an explosion in knowledge, innovation, and capacity to manage previously fatal conditions.  Yet, paradoxically, it falls short on such fundamentals as quality, outcomes, cost, and equity.  Each action that could improve quality – developing knowledge, translating new information into medical evidence, applying the new evidence to patient care – is marred by significant shortcomings and inefficiencies that result in missed opportunities, waste, and harm to patients….  In short, the country needs health care that learns by avoiding past mistakes and adopting newfound successes….  The entrenched challenges of the U.S. health care system demand a transformed approach.  Left unchanged, health care will continue to underperform; cause unnecessary harm; and strain national, state, and family budgets.  The actions required to reverse this trend will be notable, substantial, sometimes disruptive – and absolutely necessary.  The imperatives are clear, but the changes are possible – and they offer the prospect for best care at lower cost for all Americans [IOM]."  We would suggest that psychology's maturing RxP quest and our active clinical participation in the evolving integrated models of care substantially reflect this underlying societal charge.

Divisional Visionaries:  The RxP evolution is transformational and will make a substantial different in the lives of many individual patients, as well as our health care system's definition of "quality care."  Psychology has a societal responsibility to address the critical psychosocial-cultural-economic gradient of care.  As Katherine proffers: If not psychology, who?  During the Illinois legislative hearings, former Division President Bob McGrath submitted  testimony:  "I am writing in support of awarding appropriately trained psychologists in Illinois the authority to prescribe.  Any decision about scope of practice for a profession requires balancing the goal of maximizing freedom of choice/access to care with that of public safety.  In this case, the empirical record clearly supports the proposed expansion in scope.

"First there is a clear shortage of specialty mental health prescribers.  No one can argue with this assertion.  Studies consistently demonstrate that 60-80% of all medications for mental disorders are prescribed by primary care physicians.  These physicians are dedicated, conscientious, and caring, and they have valiantly filled the gap created by the lack of appropriate  psychiatric services.  However, they are diagnosing and treating mental disorders with little or no formal training in the diagnosis of mental disorders or in alternatives to medication.  It is no surprise then to find they rely heavily on medications, even when such medications should not represent the first-line treatment.  The result is over-medication and unnecessary medication.  Allowing appropriately trained psychologists to prescribe would substantially increase the population of specialty mental health prescribers, increase the proportion of such prescribers who are familiar with circumstances in which alternatives to medication are superior, and reduce costs associated with using a physician as the primary prescriber.

"This argument only makes sense if prescribing psychologists are safe, and there the record is clear.  Psychologists will only be allowed to prescribe after having completed at least five years of graduate training in psychology, becoming licensed as a psychologist, completing an additional three years of medical training, and becoming licensed as a prescriber.  Consider that in five years a physician becomes licensed to prescribe over 4000 medications and participate in any medical procedure from childbirth to surgery.  In contrast, a psychologist who wants to prescribe spends three years learning approximately 100 medications (including their interactions with other drugs) and the small set of medical procedures relevant to their prescription (e.g., reading lab test results, performing and interpreting a physical examination).

"However, the case for psychologists as safe prescribers is not just logical; it is also data-based.  Psychologists have prescribed for more than 20 years in the U.S. military; they have written hundreds of thousands of prescriptions in two U.S. states where psychologists can prescribe (Louisiana and New Mexico); they have served as prescribers in the U.S. Public Health Service and Indian Health Service.  In all that time, not one complaint has ever been lodged against a prescribing psychologist.  What is particularly telling is that not one physician has ever complained about the performance of a prescribing psychologist to a licensing board.

"I am the Director of the M.S. Program in Clinical Psychopharmacology at Fairleigh Dickinson University.  Fairleigh Dickinson is one of three institutions designated by the American Psychological Association as meeting the association's guidelines for preparing psychologists to prescribe.  So far, Fairleigh Dickinson has graduated over 100 psychologists with a master's degree in clinical psychopharmacology.  We have graduates who have prescribed in the military, in the Public Health Service, in the Indian Health Service, and in the states where psychologists are currently authorized to prescribe….

"Psychologists are a highly trained, ethically bound profession.  We do not enter into the obligations of being a prescriber frivolously.  The fact that we have designed a curriculum that requires three additional years of medical training after completion of the doctorate reflects a profession that perceives the role of the prescriber with great caution.  Allowing psychologists to prescribe in Illinois will improve access to care without reducing public safety.  I hope you will look beyond the emotional appeals of its opponents, and recognize it is the logical choice."

            Reflections:  RxP:  Jerry Strauss reported on the September, 2008 Louis Stokes VA Medical Center Psychology Service first annual all day conference open to VA and community psychologists titled "The RxP Movement in Psychology and Implications for Treating Patients with HIV and Tobacco Abuse."  Participants included former Division President Morgan Sammons and APA's Randy Phelps.  "The conference was well attended by VA psychologists, psychology postdoctoral fellows and interns, and community psychologists; most of whom are very interested in the prescriptive authority movement for psychologists.  This event may be the spring board for initiating a Psychopharmacology Training Program at the Cleveland VA.  Stay tuned."  A review of the feedback subsequently received from the trainees and postdocs was quite informative.  A number felt that: "Many of the sessions focused on the diagnoses and situations where psychologists with prescription privileges could play a vital role.  The speakers presented support for psychologists receiving prescription privileges and showed how prescription privileges for psychologists would lead to fully integrated care."  And also, "I felt the sessions that spoke about prescription privileges were one sided.  I felt like I was at a sales pitch for prescription privileges in that only the pros were presented.  It would have been nice to hear both the pros and cons.  The cons seemed to arise from the audience, not the presenters."

Retirement:  Floyd Jennings is one of the first recognized prescribing psychologists, his expertise resulting in formal recognition in the Indian Health Service (IHS) Santa Fe hospital by-laws in the 1980s.  "My hunch, albeit mere speculation, is that the quality of life post-retirement for psychologists is related to the degree to which investment in professional activities became the principal and deciding focus of personal identity for the person.  That is, for persons – like myself – who invested far too much in professional activities to the detriment of development of personal areas of interest, retirement is a death sentence in the very near term; for one asks, either consciously or unconsciously, 'Is this all there is?'  Thus, speaking solely for myself, therefore, I had decided to 'work' in some fashion until I infarct and expire.  My mind continues to be active, even more so than in the past; and I write more, and think more about policy and long-range issues than short-term, tactical matters.  To be sure, I am building in far more time for travel and those experiences for which I have longed; but nonetheless, continue to function in an employed fashion (the first such opportunity in decades) and the county appears in no hurry to discharge me.  One wag said, 'Why?'  You are now vested and we might as well continue to get some use from you…!"  Aloha,

Pat DeLeon, former APA President – Division 55 – May, 2013