Solo Private Practice: A Disappearing Frontier?

One wonders if those of our colleagues who are engaged primarily in private practice truly appreciate the magnitude of unprecedented changes that are occurring today within our nation’s healthcare environment. Ken Pope recently shared an AMA News article proclaiming: “Finances Driving Physicians Out of Solo Practice: The Business of Medicine Has Doctors Moving Into Large Groups or Employed Situations.” The Institute of Medicine (IOM) has consistently called for each of the healthcare professions to reject their traditional, and admittedly comfortable, isolated “silos,” and instead become more patient-centered and interdisciplinary-oriented in their clinical practice, research endeavors, and training. The Directors of the National Institutes of Health (NIH) have called for: “A new era when medicine will be more predictive, personalized and preemptive, through a broader scientific understanding of the fundamental mechanisms that lead to disease years before it strikes the patient.... (This) is no longer just a dream but a vision to strive for, because it can reduce disease burden and its costs while improving individual quality of life.... The treatment of cognitive decline and mental disorders continues to improve at an incredibly rapid pace.”

“From Curative to Preemptive Medicine. Historically, medicine has been reactive, and patients did not seek attention until an acute event required them to seek a doctor’s cure. Our system of care is based on managing these late events on an episodic basis – an increasingly costly and unsustainable approach. What then is the scientific vision for change? Our goal at NIH is to usher in an era where medicine will be predictive, personalized and preemptive. This trend will also require a transformation in the fundamental relationship between healthcare providers and patients, necessitating continuous participation of individuals, communities and healthcare institutions as early as possible in the natural cycle of a disease process.” With the IOM consistently reporting that it takes as long as 15 to 20 years for advances in medical technologies to be fully adopted into daily clinical practice and that there is a substantial amount of overuse, misuse, and under use of available science and technologies within today’s practice of medicine, the enormous challenge of bringing practitioners into the 21st century is clear to everyone at the health policy level. And, we also appreciate that change is always unsettling for those involved.

Ken’s report: “The ‘herding cats’ metaphor long used to describe the difficulty of organizing physicians into large groups appears to be on its way out. A survey... found a marked increase in the percentage of doctors joining large, single-specialty groups, as well as entering employed situations. The survey, covering 1996 to 2005, also found a marked decrease in the percentage of physicians in solo or two-doctor practices, as well as a large drop in the percentage of doctors who have an ownership stake in their practices. This finding was especially apparent among older physicians.... Observers say this trend is not going away anytime soon and might well reflect a growing cultural change among physicians.... A(nother) survey... finds a marked increase in recruiting by hospitals, much of it at the expense of smaller groups.... It’s not just places that employ physicians looking for doctors – it’s also doctors seeking work at places that employ physicians.” Perhaps the time has come for psychology to once again focus upon its hospital practice legislative agenda of the early 1990’s, spearheaded then by Division Presidents Mike Enright and “Dr. Bob” Resnick?

Once a Visionary, Always a Visionary: During this year’s memorable San Francisco convention, I was particularly pleased to attend the American Psychological Foundation (APF) gala where Susan McDaniel (University of Rochester) and Michael Hoyt (Kaiser Permenente) were introduced as the recipients of the APF-Cummings PSYCHE Prize, each receiving $50,000. Former APA President Nick Cummings first proposed establishing this award to the APA Board of Directors during “Dr. Bob’s” Presidency. As Nick points out, Susan has been associated with collaborative care for decades; while Michael’s work has led to the integration of behavioral/primary care throughout Kaiser Permenente’s West Coast operations. Although many of our colleagues talk about individual physicians they know who might be supportive of integrating the critical psychosocial-economic-cultural gradient of care into primary care (i.e., developing collaborative protocols with a respected psychologist), it is quite rare to hear, for example, of state psychological associations cosponsoring programs with local medical societies or with speciality societies of any of the other disciplines.
Elaine LeVine, President of Division 55 (American Society for the Advancement of Pharmacotherapy), ever mindful that supportive physicians have been critical for those states that have enacted prescriptive authority (RxP) legislation [Interestingly, for Mike Murphy in Indiana, it was a nurse who chaired the key Health Committee]: “Division 55 established a new award this year to honor a legislator or citizen, other than psychologist, who has been instrumental in moving forward the psychologists’ prescriptive authority agenda. The first winner of the ‘Visionary Leadership Award’ is Representative Josh Green, M.D. from Hawaii. Representative Green has carried Hawaii’s prescriptive authority bill that passed through the legislature, but was not signed into law by the Governor.

“Representative Green, the only medical doctor in the Hawaii Legislature, is the Chair of the House Health Committee and the sponsor of the bill. This is the first time in the twenty year history of Hawaii’s fight for prescriptive authority that the bill has been passed by both houses of the legislature. ‘It is largely due to Josh’s courageous leadership and dedication to improving health care in rural Hawaii that we have been able to get our bill passed,’ says Robin Miyamoto, President of the Hawaii Psychological Association. The bill was vigorously opposed by the Hawaii Medical Association and the Hawaii Medical Psychiatric Association. In the face of the opposition’s vocal protests and legislative pressure tactics, Representative Green responded in the press by saying, ‘They put the fear of God into people, saying it’s unsafe. What’s unsafe is for people not to have mental health coverage.’ Representative Green has also been active in promoting health care in Hawaii by sponsoring the Keiki Care Plan legislation to cover all uninsured children in Hawaii; getting sufficient increases in funding for rural care; and challenging insurance companies to do more for public health.

“Representative Green was educated at Swarthmore College and Penn State University, where he received his medical degree in 1997. After finishing medical school, Josh traveled to South Africa where he worked in missionary hospitals as a volunteer physician, treating a rural population overwhelmed by AIDS and malaria. Upon completion of his residency training in Family Medicine, Josh accepted a position in the National Health Service Corps to practice medicine in under-served areas of Hawaii. He is currently an Emergency Room Physician on the Big Island of Hawaii. Josh was elected to the Hawaii State House of Representatives on November 2, 2004 and serves as its Chair of Health, spearheading the movement to provide affordable and accessible quality healthcare for all the people of Hawaii.

“Upon receiving his award in person at our San Francisco convention, Representative Green explained to the appreciative audience that he had an opportunity to take a vacation in China, South America or San Francisco. He picked San Francisco because it was important to him to receive this award in person. He explained that he has been a long-term advocate for integrated, interdisciplinary care, but that he faced tough opposition in supporting the prescriptive authority bill. It was important to him to receive the award in person in order to be among those who appreciated his efforts as well as among those he believed in. Representative Green’s vision, belief in prescriptive authority for psychologists and caring for the underserved in his home state inspires our RxP psychologists to search for and seek the assistance of other compassionate visionaries in the United States that with their determination will move the prescriptive authority agenda forward.”

This Fall, the Health Resources and Services Administration (HRSA) called for the nomination of individuals to serve on its Advisory Committee on Interdisciplinary, Community-Based Linkages [ACICBL]. HRSA has programmatic responsibility for supporting our nation’s true Safety Net, the Community Health Center initiative, which has been the cornerstone to Hawaii’s prescriptive authority quest. HRSA funds a wide range of health professions training initiatives, including the National Health Service Corps in which Representative Green served. This particular advisory committee provides advice and recommendations to the Secretary and the Congress concerning policy, program development and other matters of significance related to interdisciplinary, community-based training grant programs authorized under Title VII of the U.S. Public Health Act. It submits an annual report describing the activities conducted during the fiscal year, identifying findings and developing recommendations to enhance the Administration’s Title VII Interdisciplinary, Community-Based Training Grant Programs. Representatives from the Geriatric Educational and Training Program and the Quentin N. Burdick Program for Rural Interdisciplinary Training are specifically being sought. Psychology is expressly recognized under the provisions of the latter program. The legislation authorizing ACICBL requires a fair balance of health professionals who represent the general population with regard to a broad geographic distribution and an evenness of urban and rural areas, along with professionals who are women and minorities.

Department of Defense (DoD) prescribing psychologist Morgan Sammons and I have been reflecting upon how during his psychopharmacology training at the Walter Reed Army Medical Center, the Fellows were exposed to the National Board of Medical Examiners (NBME) primary care exam for physicians. As the future Dean of CSPP-Alliant International University recalls, the Step Three exam is comprised of online multiple choice questions and comprehensive case studies, which use branching decision analysis to test diagnostic and treatment competency. The DoD Fellows did quite well. Perhaps in the near future, a wide range of primary healthcare training programs will be utilizing identical national examinations to obtain objective measures of the underlying competency of their trainees. The increasingly sophisticated technology of the 21st century (for example, the use of laboratory manikins and virtual reality treatment protocols) will clearly make this approach technically feasible. Will our nation’s nonphysician healthcare professions (including psychology) develop the political will to insure that organized medicine’s emotionally driven “public health hazard” allegations are ultimately put to rest? That is a question for which I expect an affirmative response. For example, in passing the Fiscal Year 2008 Military Construction and Veterans Affairs Appropriations bill, Senator Murray (Dem.-Washington) successfully offered an amendment which provides authority to transfer up to $5,000,000 from the Department of Veterans Affairs to the Department of Health and Human Services, upon a determination by the Secretary of Veterans Affairs that such action is in the national interest, for the HRSA Graduate Psychology Education (GPE) Program to support increased training of psychologists skilled in the treatment of post-traumatic stress disorder, traumatic brain injury, and related disorders. The GPE initiative has been a high priority of the APA Education Directorate under the leadership of Cynthia Belar and Nina Levitt and in my judgment, has been successfully shaping our next generation of practitioners, educators, and scientists to appreciate that psychology is one of the nation’s bona fide healthcare professions. A critical attribute of a maturing profession is possessing vision and the collective willingness to be proactive. Senator Murray’s amendment clearly demonstrates that psychology has met this test, developing necessary programmatic efforts targeting the unique and pressing needs of a special generation of citizens who have been willing to “place themselves in Harm’s Way” for all of us. Mahalo.

The White Caps of Change: During the August Congressional recess, a very interesting health policy debate began to take shape around the re-authorization of the Children’s Health Insurance Program (CHIP or SCHIP). The House, Senate, and Administration proposed dramatically different approaches – both as to level of federal financial support and the underlying governmental vs. private responsibility for providing health insurance coverage. Although it is too early to predict with any sense of certainty what might ultimately become public law, a review of the proposals included in the House Children’s Health and Medicare Protection Act of 2007 provides a template for the future. First, we should definitely be pleased that this legislation would provide for Parity for Mental Health Coinsurance under the outpatient provisions of Medicare. APA’s Marilyn Richmond has been working on this agenda since 1996, when the limited law was passed. We should also be happy with the provision that would add a new category of preventive services to the basic benefit package, including mental health services, as long as the Secretary determined them to be reasonable and necessary for the prevention or early detection of an illness or disability, taking into account evidence-based recommendations by his Preventive Services Task Force. Those attending Russ Newman’s annual State Leadership conferences will appreciate how long the Practice Directorate has been working on this agenda. Russ will soon also be affiliated with CSPP-Alliant International University. Reflecting upon the steady maturation of professional nursing, certified nurse midwives will no longer be limited to only 65 percent of what a physician receives, for providing the same care. And, the House of Representatives would provide for the coverage of Marriage and Family Therapists and Mental Health Counselors under Medicare Part B, as well as within rural health clinics and federally qualified health centers. These therapists would have to agree to consult with a patient’s attending or primary care physician, taking into account provisions for patient confidentiality. We would suggest that as psychology works within the public policy/legislative process to expand our clinical scope of practice to include prescriptive authority, arguing patient-centered and patient-determined care, efforts by some of our colleagues to prevent other non-physician practitioners from fully utilizing their training seems highly analogous to the emotional cries of “public health hazard” for which organized medicine has become so infamous. Significant changes are coming.

Aloha,

Pat DeLeon is a former APA President.