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A Maturing Profession in Challenging Times |
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Advocacy |
Pat DeLeon, Ph.D., J.D. |
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Having been involved in the public policy (i.e., political) process for slightly more than three decades, I have been genuinely pleased with the steady maturation of our profession. We are beginning to appreciate that we can make a difference to society. Last Spring at the annual State Leadership conference Russ Newman reflected: “The Conference has grown significantly over its 20 year history. It began with a handful of psychologists interested in moving psychology forward and who understood the importance of the national organization working hand in hand with the State, Provincial and Territorial Associations. It is now a gathering of over 500 leaders in the profession.... The focus of this year’s conference is perhaps best described as more attentive to our own resilience in the wake of many challenges and uncertainties.... The theme of the conference was specifically chosen to reflect a stance of resolve and confidence that we as a profession are headed in the right direction. That is not to say we should be without self-reflection and self-evaluation. Yet, in our roles as leaders of the profession, we must demonstrate both perseverance and resilience in the face of significant challenges.... [Prior to Louisiana’s RxP- success] What is perhaps the most telling feature of the prescription privilege movement is that for the entire period from 1986 to 2002, a total of 13 states had filed legislation, usually no more than one or two a year. In 2003, there are 12 states simultaneously pursuing legislation. As important as it was to get that first state law passed, it is equally important to get the second law enacted. Organized psychiatry continues to cling to the argument that New Mexico was a fluke, an anomaly, and that no other state would repeat this ‘mistake’ by the New Mexico legislature. We need to remove this misconception to which they cling by making new laws a trend rather than an isolated event.... “While the problems of increasing numbers of uninsured and rising healthcare costs are clear, there is no clear or agreed-upon solution to these problems anywhere on the horizon. This is not to say there are no proposed solutions. In fact, there are reform proposals starting to pop up. For example, many of the Democratic Presidential hopefuls have, or have promised, proposals to reform this country’s healthcare system.... One common thread running through many of the proposals for reform is the desire to have consumers play a bigger and more central role in their healthcare decisions. Not coincidentally, this thread is appearing at a time marked by an abundant supply of health information available on the Internet and an increasing influence in the healthcare system by Baby-Boomers who have followed the path of empowerment virtually all of their lives.... A consumer-directed health plan is intended to give employees greater choice and more control over decision-making. Managed care and gatekeeping are not part of (this); these are replaced by Internet-based support tools that provide information about services and healthcare professionals to the employee and by vesting power in the individual consumer to make decisions about his or her own healthcare. It is assumed that when armed with information and choice, consumers will make good healthcare decisions in their own best interest.... It is virtually impossible to know which, if any, of these ideas will gain traction beyond partisan posturing in advance of the 2004 Presidential elections. The best news in all of this, though, is the apparent increase in energy and discussion of comprehensive reform for a health system recognized by virtually all to be in crisis.... “The most salient question for us, given the uncertainty of healthcare reform is: What is the best strategy for organized psychology? It won’t come as a surprise at this point that the Practice Directorate believes the best strategic option is to stay the course that we’ve worked in recent years to chart. How does this strategy translate for us? First, we must continue to press for mental health parity.... Second, we must continue our efforts to educate decision-makers (and the public as well) about the important role of psychological services in preventive care.... Third, mental health and psychological services cannot continue to be kept so separate from physical health services in our healthcare system.... Fourth, we must continue to press to hold managed care companies accountable.... Fifth, we must continue to assure that the value of psychological services is recognized by policy makers, as well as the public.... “We have State, Provincial and Territorial Associations, practice divisions and a graduate student organization all working together towards a common purpose.... We have elevated our information technology capability and launched the practitioner portal in an effort to further strengthen the sense of community among practitioners. What we are trying to accomplish for psychology is not easy, not without obstacles, and not without challenges. It will take time for us to get from here to there. But the course has been charted and the means to travel the course effectively built. I urge us to stay that course and continue leading psychology forward.” The 21st Century will undoubtedly be an era of educated consumers who will utilize technology in an unprecedented fashion to ensure that they and their loved ones receive high quality health care in a cost-effective fashion. Last summer, the PEW Foundation reported that approximately 80 percent of Americans who use the Internet have searched the Web to seek out health information, with most saying doing so helped improve their quality of care. Involvement in the public policy process provides one with an appreciation for how long it actually takes for legislative enactments and changed paradigms to have a concrete impact. Mike Sullivan and I have long ago learned that at both the state and federal level, possessing a long term vision, being patient; and most importantly, being present is absolutely necessary for success. The public policy process is seemingly timeless, moving at its own pace. At this year’s State Leadership Conference, Russ noted the past year saw implementation of the HIPAA [The Health Insurance Portability and Accountability Act of 1996] Privacy and Transaction rules around the country and the development of the Practice Organization’s information technology infrastructure. “In related developments, APApractice.org has been redesigned to make the portal more user friendly, and we have launched a biweekly electronic newsletter as well.... But now I want to turn our attention ahead to the future and away from the past. It is no great prediction that practicing psychologists will continue to confront a healthcare system that is simply not working. Health professionals will continue to be devalued by corporatized health care, and health services will continue to be commoditized. Reform may be in the offering, although what form that will take is anyone’s guess.... Perhaps you recall our last year’s discussion of staying the course led us to conclude that our current focus, from which we should not veer, is to identify and magnify for all to see the utility and effectiveness of psychological services. Building strategic resilience and our capacity to be innovative should not interfere with this focus. In fact, I believe it will help us better achieve it. By being innovative, we can find more aggressive ways to promote psychology and psychological services to consumers and third party payers. By being innovative, we can find additional creative ways to utilize the Congress, the legislatures and the courts to assure access to quality psychological services. By being innovative, we can take advantage of the developing trend in this country to recognize the importance of lifestyle for physical health and physical illness. By being innovative, psychology can capitalize on the next iteration of incremental reform which will likely target chronic disease management in an effort to provide more efficient and effective care. By being innovative, we may even be able to change the paradigm so that good physical health is subsumed under the larger umbrella of good psychological health. And by being innovative, we can find new ways to incorporate technology to make practicing psychology easier and to better serve our patients. Although I won’t try to predict the future.... I see a profession that consistently gets a jump on change. But perhaps most importantly, if we are able to build our strategic resilience, I see a strong and vibrant psychology that is constantly making its future rather than just defending its past.” I would suggest many of us are just beginning to experience the impact that technology and far-reaching federal legislation, such as HIPAA, will ultimately have upon our personal and professional lives. Russ’ vision is extraordinarily important. On April 27, 2004 President GW Bush addressed the importance of health information technology during an event in Baltimore, Maryland. Health policy experts project the adoption of a national health information network could result in savings of $87 to $140 billion annually, while resulting in higher quality health care. Utilizing electronic records and billing triggers HIPAA requirements. “The President -- Yesterday I talked about ways for us to make sure America stays on the – stays a leader in the world, particularly when it comes to technology and innovation. That’s what we want. We want to lead. We’re not interested in following. America is a nation where the entrepreneurial spirit is strong, where the focus of the Government, in my judgment, is right. We’re willing to spend research money.... The way I like to kind of try to describe health care is, on the research side, we’re the best. We’re coming up with more innovative ways to save lives and to treat patients. Except when you think about the provider’s side, we’re kind of still in the buggy era.... “(T)he health care industry is missing an opportunity, if patients, in order to make sure they get quality care, have to carry files from one specialist to the next. It’s like IT, information technology, hasn’t shown up in health care yet. But it has in one place, in one Department that you’re about to hear from, and that’s the Veterans Department. So here’s what we’re here to talk about. We’re here to talk about how to make sure the Government helps the health care industry become modern in order to enhance the quality of service, in order to reduce the cost of medicine, in order to make sure the patient, the customer, is the center of the health care decisionmaking process. And we’ve made great progress. There’s a role for the Federal Government. One thing is, the Federal Government has got to make sure the privacy rules are strong. You’re going to hear us talk about electronic medical records, and that’s exciting. But it’s not so exciting if you’re a patient who thinks somebody could snoop on your records, to put it bluntly. I’m not interested in having my – well, it’s too late for me. My medical records are pretty well known.... “Tommy Thompson... – the Secretary of Health and Human Services – is a strong advocate about the spread of IT throughout the health care industry. I think he’s got – I know he’s got the proper perspective of the role of the Federal Government in encouraging not only the Federal agencies but the private sector to adopt these strategies in a way that is positive for the American consumer and cost-beneficial for society.... (W)e’re doing some smart things at the Federal Government, and the Federal Government can lead because we’re spending a lot of money in health care. We’re a large consumer on behalf of the American people. Think about it: Medicare, Medicaid, veterans’ benefits, Federal employee health insurance plans. I mean, there’s a lot of money going through the Federal Government, and therefore it provides a good opportunity for the Federal Government to be on the leading edge of proper reform and change.... “It’s estimated that they spend $8,000 per worker on information technology in most industries in America, and $1,000 per worker in the health care industry. And there’s a lot of talk about productivity gains in our society, and that’s because companies and industries have properly used information technology. If properly used, it is an industry-changer for the good. It enables there to be a better cost structure and better quality care delivered, in this case in the health field. And yet, the health care industry hasn’t touched it, except for certain areas.... I know the veterans who are here are going to be proud to hear that the Veterans Administration is on the leading edge of change.... The taxpayers’ money is being well spent.... “The goal I set is, most people ought to be covered within a 10-year period. It’s not like in 10 days or 10 months. This is something that is going to take time to get there.... And so the reason why we’ve started this process now is we want to encourage insurance companies and State Governments, doctors organizations, AMA and others, to understand the great benefit for the American people by implementing information technology in the health care field. By introducing information technology, health care will be better, the cost will go down, the quality will go up, and there’s no telling whether other benefits will inure to our society. In other words, when we get this done – and we will, because America is a land of doers and entrepreneurs; our job is to set the goal and then to encourage and incent people to achieve the goal – but when we get this implemented, America will remain on the leading edge of technological change. This is the kind of innovation that’s practical and makes sense, that will keep us to be the leader in the world.... I look forward to working with people to achieve this objective. I want to thank those up here who are doing a good job... you all have made us proud.” The next day the President signed Executive Order 13335 - Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator. A View From New Mexico “Like most of us, my reaction to the news that Governor Kathleen Blanco signed the Louisiana RxP Bill into law was one of jubilation. It brought back memories of March 2002, when New Mexico Governor Gary Johnson signed our Bill. Comments from legislators, state officials, and citizens in New Mexico concerning Louisiana’s RxP have been extremely positive and supportive. Our opponents can no longer point to New Mexico as an anomaly. Other states can now become more confident and assertive in their quest to obtain RxP. Though the statutes in New Mexico and Louisiana are somewhat different, many of the strategies in passing the legislation were similar. RxP proponents now have two successful models from which to draw upon in order to convince their legislative and executive branches of state government to do the right thing. That is, help to provide safe and effective quality car to individuals in need of mental health treatment. “What the Louisiana Medical Psychologists accomplished was nothing short of phenomenal. Quite possibly, it may be one of the most successful political lobbying efforts in the history of psychology. One of the most impressive aspects was how our colleagues were able to organize and develop a grass roots advocacy group that surpassed NAMI. A feat that helps to define for other states the hard work necessary to accomplish the goal. In addition, the political fund raising component of their strategy is unparalleled in our profession. Whereas, in New Mexico we had to rely on the generosity of colleagues around the country, in Louisiana, the 50 Medical Psychologists reached deep into their own pockets to move the mountain. “In my opinion, the most satisfying aspect of the Louisiana law is the stipulation that the Board of Psychologist Examiners is responsible for implementation and regulation. As you know, in New Mexico, it has been a joint effort between the Psychology and Medical Boards; a condition that has created numerous problems and delays for us. Hopefully, the Louisiana Medical Psychologists can move quickly to implement their edict. We in New Mexico stand along side APA and our Louisiana colleagues, ready, willing, and able to assist other states obtain RxP. The writing on the wall and the domino effect has begun [Mario Marquez].” Public Policy Reflections Recently there has been considerable discussion on several list-serves regarding whether those engaged in pursuing prescriptive authority at the State level should seek to incorporate into their bills the specific requirement that advanced training in clinical psychopharmacology must be at the masters degree level. The APA model statute does not require this, deferring instead to the judgment of the individual State licensing boards. The four States and Territories (New Mexico, Louisiana, Guam, and Indiana) that have already enacted RxP- provisions appear quite comfortable possessing broad authority to require a masters degree or evidence of “equivalent” education, as long as passage of a relevant national examination is also documented. Admittedly, however, none of the licensing boards have formally promulgated their implementing regulations at this time. Jan Ciuccio reports that approximately 60 colleagues have taken the APA College of Professional Psychology’s Psychopharmacology Examination for Psychologists (PEP), with the numbers expected to increase with Louisiana’s success. I personally do not believe that one can reasonably argue that RxP- training programs which are university-based necessarily provide better didactic training than our free-standing initiatives. Perhaps, when greater numbers of graduates have taken the PEP we will eventually have objective data to resolve this issue. Although it has been very difficult to obtain accurate information as to the total number of graduates, there can be no question that significant numbers of well trained (and oftentimes highly vocal) colleagues would be disenfranchised if a formal graduate degree were legislatively or administratively required, unless licensing boards adopted a grandfathering provision. And yet, from both a public policy and historical perspective, I would predict that a masters degree will ultimately be required. Laws are enacted by legislators, not by health care providers. In the Congress the dominant professions continue to be law and business. Fifty-nine Senators possess law degrees. Our society is genuinely comfortable with trusting accredited institutions of higher education to develop new training models and ultimately new professions. The increasingly intense debate surrounding the purported safety (or lack thereof) of Web-based pharmacies, notwithstanding their cost-savings, underscores the importance of this “comfort factor” for elected officials and society at large, whenever unfamiliar entities attempt to significantly modify the status quo. There is no question in my mind that given the intense emotions surrounding the RxP- debates, requiring formal university-based training would provide a significant comfort level for elected officials and those citizen interest groups that become involved on psychology’s behalf. In so many ways, the underlying arguments remind me of psychology’s gradual movement towards embracing APA accredited internships, rather than relying upon freestanding placements. During that evolution, our federal colleagues played a significant role when the Veterans Administration made this a requirement for employment. Unfortunately, educational institutions (regardless of professional discipline) generally do not accept outside training as the equivalent of their course work. There is a limit on the number of course hours that can be accepted for transfer. Thus, as psychology moves towards requiring a formal masters degree, we must not ignore the very real potential for colleagues to be adversely effected. Nevertheless, given the movement within the health care environment towards national licensure (i.e., licensure mobility), the advent of telehealth, and computer technology’s impact upon patient care, I expect the outcome to ultimately be beyond psychology’s control. Non-university based training programs (regardless of discipline) will find a niche providing quality continuing education credits or developing affiliations with academic institutions (as in New Mexico). This is notwithstanding that it has often been our profession’s practitioners who have moved education into the forefront of evolving clinical practice. I share this perspective appreciating that the timing of any evolution is never as certain as might be expected. Aloha, |
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