[DIV28SUPER] A TIME OF CHANGE, CHALLENGES, OPPORTUNITIES

Sent from my iPhone

Begin forwarded message:

From: "Pat DeLeon" <patdeleon@verizon.net>
Date: May 25, 2013, 4:50:59 PM EDT
To: "Pat" <patdeleon@verizon.net>
Subject: D55 May, 2013 column

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, 2014 is 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

 

<D55-2013.05.docx>