Advocacy

	Welcome to the New Millenium/Pat DeLeon
	Washington Update/Ronald F. Levant

					Welcome to the New Millennium In my judgement the future of professional psychology lies totally within our own control. Psychology continues to be one of the most popular undergraduate majors. Our graduate student organization (APAGS) is more than a decade old and possesses over 41,000 members. For us to continue to thrive, however, we must ensure that we actively engage the future. Thus, it was very nice to see that during its last meeting the APA Board of Directors voted to invite APAGS to send a representative to the open business sessions of the Board as a non-voting member, for a two year trial period. Our graduate students are the future of the profession and it is very important that these colleagues become personally involved within our association’s governance. In many ways, the action of the Board reflects the thinking of colleagues across the nation. This past Fall, Jim Peck informed us that the California Psychological Association (CPA) membership voted by more than a two-thirds plurality to modify CPA’s bylaws to provide that as of this January, the CPAGS representative to the CPA Board will have full authority to introduce motions and vote. To Jim’s knowledge CPA is the first state association in the nation to include a graduate student on its board who is equal to every other member. I was also very pleased to recently learn that one of the Council of Representatives’ caucuses has taken a similar proactive policy position. Janet Matthew’s report: “The Assembly of Scientist-Practitioner Psychologists (ASPP) is one of the caucuses of the APA Council of Representatives. During the February, 1999 meeting of the caucus the ASPP Board unanimously approved the concept of proposing to APAGS the establishment of an ASPP Council Fellow. Then-ASPP President Jerome Resnick asked me, in my capacity of President-Elect, to work with APAGS on the selection of a recipient of this fellowship and then to serve as the primary mentor of this Fellow. This fellowship is in the form of a travel grant to attend the February meeting of the APA Council. Since APAGS leaders routinely attend the annual convention, it was felt that they could fully participate at that meeting as well. “The purpose of the fellowship is to encourage graduate student members of APA to learn more about the association and its governance and to participate in that governance process. This Fellow would be included in all deliberations of ASPP including its officer E-mail net, elections, and policy considerations. The ASPP Board had noted that APAGS leaders take an active part in some of APA governance but once they obtain their degrees they do not seem to be in the pipeline to continue that participation. They find themselves in the same place as the new members of Council described at the Boston meeting, when a number of them stood on the platform behind President Dick Suinn and urged Council to effectively utilize their collective expertise and energy. The difference, however, is that whereas both groups have a history of personal involvement in psychology’s governance, the former APAGS students are then removed from that involvement by virtue of the fact that they have become full members of the association. Our discussions further clarified that the APAGS agenda seldom has items referred to it expressly from the Council. Our hope is that as the ASPP Fellow discusses information with the APAGS board, they will develop legislation which can then be submitted by Council members with whom the Fellow has developed personal relationships. “This first ASPP Fellow selected by APAGS is Nabil El-Ghoroury, a student in the clinical psychology program at the State University of New York at Binghamton. Nabil spent most of the Thursday meeting of the Council in Boston in the Council chamber. He met many of the Council members as well as learning how the process worked. He asked questions about not only the overt process but the background for many of the issues. We also discussed how he might take this information back to the APAGS Board to further develop their understanding of this aspect of the APA process.” In many ways, the progressive vision of APA’s Executive Director Ray Fowler is steadily coming to maturation. The Second Session of The 106th Congress: Soon President Clinton will present his final State of the Union Address to the Congress and our nation. Over the past seven years, it has been a distinct pleasure to hear the President discuss his vision for health care reform each and every time. Last year, for example, the President urged that our nation: “...invest in long-term care. I propose a tax credit of $1,000 for the aged, ailing or disabled, and the families who care for them. Long-term care will become a bigger and bigger challenge with the aging of America, and we must do more to help our families deal with it.... America’s families deserve the world’s best medical care. Thanks to bipartisan federal support for medical research, we are now on the verge of new treatments to prevent or delay diseases from Parkinson’s to Alzheimer’s, to arthritis to cancer. But as we continue our advances in medical science, we can’t let our medical system lag behind. Managed care has literally transformed medicine in America - driving down costs, but threatening to drive down quality as well. I think we ought to say to every American: You should have the right to know all your medical options - not just the cheapest. If you need a specialist, you should have the right to see one. You have a right to the nearest emergency care if you’re in an accident. These are things that we ought to say. And I think we ought to say, you should have a right to keep your doctor during a period of treatment, whether it’s a pregnancy or a chemotherapy treatment, or anything else. I believe this. Now, I’ve ordered these rights to be extended to the 85 million Americans served by Medicare, Medicaid, and other federal health programs. But only Congress can pass a Patient’s Bill of Rights for All Americans.... Let me say we must step up our efforts to treat and prevent mental illness. No American should ever be afraid - ever - to address this disease. This year, we will host a White House Conference on Mental Health....” It is too early to predict with any sense of comfort what the President will specifically focus upon during his forthcoming and final State of the Union address. The media seems to expect that there will be an effort to expand health-insurance coverage through tax credits. Nevertheless, it is clear that during his tenure the President has had amazing success in predicting what would soon evolve. For example, his Administration was successful in guaranteeing that Americans can now keep their health insurance when they change jobs, that 5 million-plus children would have access to necessary health care (CHIP), that for the first time ever there would be federal mandates effecting private health care benefits (e.g., 48 hours of hospitalization coverage for birthing and mental health parity), absolutely unprecedented increases in the NIH budget for behavioral and biomedical research activities, and the first ever Surgeon General’s Report on Mental Health. Today the Patient’s Bill of Rights is before a House-Senate conference committee and patient medical record privacy concerns are constantly being discussed. For many of our colleagues these proposals may seem to be abstract and theoretical considerations. However, as I watch my own brother attempt to ensure that our aging parents have access to the long-term care that they require, I continue to gain greater personal appreciation for the yeoman efforts of Karen Shore and Art Kovacs to significantly modify the status quo. Our nation needs such committed visionaries. Although it is the year for Presidential partisan politics, I would venture one legislative prediction. In November, 1999 the prestigious Institute of Medicine (IOM) released it report “To Err Is Human: Building A Safer Health System.” The report indicated that each year between 44,000 and 98,000 Americans die in hospitals as a result of medical errors. These deaths due to preventable adverse events exceed the deaths attributable to motor vehicle accidents, breast cancer, or AIDS. Medication errors alone account for approximately 7,000 deaths annually, more than the number of Americans who die from workplace injuries. The increased hospital costs alone of preventable adverse drug events affecting inpatients are approximately $2 billion annually for the nation as a whole. And, hospital patients represent only a fraction of the total population at risk of experiencing a medication-related error. One survey, for example, found that physicians prescribe potentially inappropriate medications for nearly a quarter of all older people living in the community. Medication-related errors occur in nursing homes. For every dollar spent on drugs in nursing facilities, $1.33 is consumed in the treatment of drug-related morbidity and mortality, amounting to $7.6 billion for the nation as a whole, of which $3.6 billion has been estimated to be avoidable. The problem is likely to continue and possibly worsen in the future because of the number of new drugs being introduced. Approximately 48 percent of the prescription drugs on the market today have become available only since 1990. Medications are the most frequent medical intervention, with an average of 11 prescriptions per person in the United States. The IOM reported that although our nation’s health care system is a decade or more behind other high-risk industries in its attention to ensuring basic safety, it is reasonable to expect - it would be irresponsible to expect anything less than - a 50 percent reduction in errors over five years. The public response to the IOM report was unprecedented. Commission members testified before the Congress; appeared on television; and were interviewed extensively, including on the Voice of America with its 90 million listeners worldwide. In the Rose Garden the following week, the President of the American Hospital Association heralded their new medical safety campaign, in partnership with the Institute for Safe Medication Practices. President Clinton signed an Executive Memorandum directing his health care quality task force to analyze the IOM report and report back within 60 days through the Vice President as to how the Administration could implement their recommendations. He called for the federal government to lead by example (e.g., the various federal health programs were to institute quality improvements and patient safety initiatives). The Administration would convene the first national conference with state health officials to promote best practices in preventing medical errors. The IOM called upon the Congress to establish a Center for Patient Safety within the recently renamed Agency for Healthcare Research and Quality (AHRQ), thus establishing a national focus to create leadership, research, tools and protocols to enhance the knowledge base about safety. There should be a nationwide mandatory reporting system that provides for the collection of standardized information by state governments about adverse events that result in death or serious harm. Voluntary reporting efforts should be encouraged for adverse events that result in less severe consequences. Relevant legislation should be enacted addressing peer review protection and medical record privacy concerns. Perhaps most important was the call for establishing performance standards and expectations for safety - with “safety” being viewed as a integral component of “quality.” At first reading of the IOM report, one might wonder about the direct relevance to professional psychology. The relevance goes directly to society’s definition of “quality care.” As practicing psychologists, we have consistently cited that currently more than 80 percent of the psychotropic medications prescribed are “ordered” by practitioners with only minimal mental health training. Many of us have noted that “the power to prescribe is fundamentally the power to unprescribe;” e.g., to ensure that those patients who need psychotropic medications have access to the most appropriate medication and the most effective dosage levels. In making these statements, we cite studies indicating the extent to which various subpopulations (e.g., women, children, the elderly, those in rural America, etc.) do not have access to the quality of care they require. We are licensed to independently diagnose and treat. The key to appropriate utilization of medications is an accurate clinical diagnosis. These are not idle comments and the IOM report provides some very concrete policy recommendations-on a wide range of relevant issues-which are directly related to ensuring that patients receive high quality care and that our nation’s overall health care system develops a fundamentally different culture of quality and safety; e.g., the creation of a culture that encourages the identification and prevention of errors. In addressing the traditional role of state professional licensing boards, the IOM report recommends that given the rapid pace of change in health care and the constant development of new technologies and information, existing licensing and accreditation processes should be strengthened to ensure that all health care professionals are assessed periodically on both skills and knowledge for practice. The IOM noted that currently professional licensure concentrates on qualifications at initial licensure, with no requirements to demonstrate safe and competent clinical skills during one’s career. And, that there is a great deal of variation in state licensure requirements, with each state setting its own standards, measurement, and enforcement. Compared to facility licensure there was felt to be even greater variation in professional licensure. The importance of interdisciplinary care was also stressed. The IOM called for defining feasible prototype systems (of best practices) and tools for safety, including those that are both clinical and managerial. The development of and utilization of practice guidelines and defined best practices was felt to be expected. Professional associations should provide leadership, particularly utilizing their power to convene, in order to ensure that their membership appreciated this necessity. In describing the expectation that care would become increasingly interdisciplinary in nature, the example was given of the contributions of pharmacists to direct patient care. The IOM report described cases in teaching hospitals where they participate in “rounds” with residents and other staff, noting that such active participation is usually well received by nurses and doctors, and most importantly it significantly reduces serious medication errors - citing statistics that the rate of preventable adverse drug events related to prescribing decreased significantly ( 66 percent, with a control group being unchanged). And, in discussing the potential impact of advances in technology on health care, their report noted that despite the computer-based patient record being “almost here” for 45 years, it has still not arrived. Its advantages are clear: computer-based patient records and other systems give practitioners (and others) the ability to access patient data without delay at any time in any place (e.g., in an emergency or when the patient is away from home); ensure that services are obtained and track outcomes of treatment; and aggregate data from large numbers of patients, both to measure outcomes of treatment; and to promptly recognize complications of new drugs, devices, and treatments. As for licensure, the IOM noted that the National Council of State Boards of Nursing has endorsed a mutual recognition model for interstate nursing practice to encourage reciprocal arrangements between states for licensing and disciplinary action. The goal would be to make licensure more like the rules used for a driver’s license. That is, licensure is recognized across state lines, but the practitioner would still be subject to the rules of a state while in that state. It is especially important for professional psychology to appreciate the underlying policy concepts contained in this IOM report address fundamental definitions of “quality of care” throughout their discussion of the responsibilities of practitioners to be able to objectively demonstrate possessing the most up-to-date clinical knowledge, the benefits of interdisciplinary care, and the role of professional licensing boards. These are highly similar to those expressed by a Pew Commission report which we discussed almost exactly one year ago. There is a concerted policy effort at the national level to ensure objective definitions of “quality of care.” In October, 1998 the Pew Health Professions Commission, chaired by former Senate Majority Leader George Mitchell, released its futuristic report: “Strengthening Consumer Protection: Priorities For Health Care Workforce Regulation.” The Commission envisioned a future regulatory system for health professions which will undergo the following transformations to better serve the public interest: move towards national standards; significant overlap of practice authority among the health professions; new venues and participants for regulatory policy-making; integration of regulatory systems that protect health care consumers; and, increased regulatory focus on quality of care and competence assurance. Specific recommendations from the Pew Commission: 1. Congress should establish a national policy advisory body that will research, develop and publish national scopes of practice and continuing competency standards for state legislatures to implement. 2. States should require policy oversight and coordination for professional regulation at the state level. 3. Individual professional boards in the states must be more accountable to the public by significantly increasing the representation of public, non-professional members. 4. States should require professional boards to provide practice-relevant information about their licensees to the public in a clear and comprehensible manner. 5. States should provide the resources necessary to adequately staff and equip all health professions boards to meet their responsibilities expeditiously, efficiently, and effectively. 6. Congress should enact legislation that facilitates professional mobility and practice across state boundaries. 7. The national policy advisory body should develop standards, including model legislative language, for uniform scopes of practice authority for the health professions. The standards and models would be based on a wide range of evidence regarding the competence of the professions to provide safe and effective health care. 8. States should enact and implement scopes of practice that are nationally uniform for each profession and based on the standards and models developed by the national policy advisory body. 9. Until national modes for scopes of practice can be developed, states should explore and develop mechanisms for existing professions to evolve their existing scopes of practice and for new professions to emerge. 10. States should require that their regulated health care practitioners demonstrate their competence in the knowledge, judgment, technical skills and interpersonal skills relevant to their jobs throughout their careers. We would strongly suggest that we are seeing the beginning of a real movement - one that without question has major implications for the practice of psychology as we know it today. RxP- Authority For Psychology - Revisiting The Rationale, Renewing The Vision: DoD Psychopharmacology graduate Morgan Sammons will soon be returning from his Iceland assignment. [As always, the views expressed are personal and do not reflect those of DoD or the U.S. Navy.] The prescriptive authority agenda is about ensuring high quality care. Morgan’s musings to his Georgia colleagues: “Combined results of surveys taken by state psychological associations or other groups of psychologists since the early 1990s indicate that a substantial majority - over two-thirds - of respondents favor prescriptive authority for the profession. In the few surveys conducted prior to the 1990s, far greater numbers of psychologists were opposed, but in the past decade the number of those disinclined to endorse prescription privileges has stabilized at approximately 25 percent of all psychologists surveyed. It is thus apparent that opinion on the issue has consolidated, in such a way as to deliver what can be interpreted as a mandate for state associations and other groups to pursue this right.” “Legislative victories are still largely elusive, as can be expected when one profession directly challenges another for the right to expand their scope of practice into areas that have for years been, (by virtue of tradition but not necessarily of logic) the purview of one profession alone. Bills enabling psychologists to prescribe have been introduced in eight states as of this writing. One has succeeded, and others have come tantalizingly close to passing. Currently, Guam, Indiana, and certain segments of the federal sector allow psychologists to prescribe. Opposition by state psychiatric associations is understandably fierce, and continued determination is necessary to overcome their concerted opposition to the expansion of our scope of practice.” “Here we must take heart from the example provided by other non-physician health care providers. Nurse practitioners now prescribe in all 50 states, and they prescribe with complete independence in 11 - up from only four less than five years ago. Other non-physician health care providers, such as nurse anesthetists, physician assistants, and optometrists, are reaping the benefit of years of hard legislative toil in the form of dramatically increased scopes of practice. The expansion of non-physician health care providers’ scopes of practice is a phenomenon of the utmost importance in shaping the future of American health care. No other event - not managed care, not federal patient rights legislation - will redefine the face of American health care more than the rise of non-physician specialties, especially in the area of primary care. Prescriptive authority has been a key component of the success of these other non-physician specialties. It is an example that organized psychology cannot afford to forget.” “That said, several paradoxes confront those seeking to gain prescriptive authority for psychologists. Perhaps the most substantial of these paradoxes lies in the observation that, in general, American medical schools train more physicians than are needed to provide basic health care services. How can the push to add prescriptive authority to the privileges already enjoyed by psychology be reconciled with the fact that potentially excess numbers of prescribers already exist?” “The answer to this paradox is favorable to psychology’s obtaining prescriptive rights. American health care is arguably the best in the world, but it is indisputably the most expensive, largely because American physicians are expensively trained in hospital based environments, at substantial cost to the taxpayer. This model serves academic training facilities well but often does not adequately prepare physicians for practice roles where their services are most needed. Also, in spite of overall excess numbers of physicians, primary care services, especially in rural or economically disadvantaged areas, remain underserved. Finally, the profession of psychiatry has been unsuccessful in recruiting new students, and the number of American medical school graduates entering psychiatry continues to decline. This decline has become so severe that in 1997, Harold Eist, then-President of the ApA, characterized this as a “crisis,” with especially negative effects for children and economically disadvantaged adults requiring mental health services.” “Because psychologist training programs function without the benefit of the federal subsidies that underwrite graduate medical education, prescribing psychologists can be more efficiently and economically trained than their psychiatric cousins. Psychologists are better distributed in rural areas than are psychiatrists, and additional training in psychopharmacology will enable them to treat a broader, and currently underserved, range of patients.” “Much work remains to be done, but considerable progress has been made. Careful legislative action will result in acquisition of a skill that will materially aid patients with mental disorders. It will also establish psychology as a profession in the forefront of redefining a better health care system for the American people.” Pat DeLeon, Ph.D., J.D.. is president of APA and a long-time columnist with The Independent Practitioner.
		Patrick DeLeon, Ph.D., J.D. President, American Psychological Association
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