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Migrating Icebergs are Difficult to Stop |
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Editorial and Opinion |
Pat DeLeon |
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The Prescriptive Authority Agenda (RxP) Continues to Mature: We have been very pleased with the extent to which, over the years, professional psychology has matured and increasingly has accepted its societal responsibility to provide programmatic vision to address the pressing needs of our society. The February APA Monitor focus on “The Changing Face of Psychology Practice” is extraordinarily accurate and timely. On the cover is Robin Miyamoto, a primary care psychologist who has been active with Hawaii’s renewed prescriptive authority (RxP) efforts, and who works at the Waimanalo Health Center. [The Monitor]: “You don’t need to look into a crystal ball to see professional psychology’s future. Trends that will shape the discipline’s future have been taking form for many years and continue to evolve. Key among them is growing demand for and use of integrated, comprehensive health services that blend health and behavior, prevention, health promotion, and disease management....” In a challenge to the Hawaii Psychological Association, APA President Ron Levant noted: “The historical separation of physical from mental throughout our healthcare system is precisely the problem that my ‘Health Care for the Whole Person’ Presidential initiative was designed to solve. By collaborating with a broad range of health care organizations on a public statement on the role of psychology in health care, I hope to promote the integration of physical and psychological health care in a reformed health care system in which health care professionals team up to treat the whole person.” This January, bills were introduced in both bodies of the Hawaii State Legislature (impressively, by the relevant legislative committee chairs) which would provide appropriately trained “medical psychologists” – “with limited prescriptive authority for the specific purpose of providing care in federally qualified health centers or other licensed health clinics located in federally designated medically underserved areas.” The bill’s opening preamble notes that: “The legislature has previously authorized prescription privileges to advanced nurse practitioners, optometrists, dentists, podiatrists, osteopaths, and physician assistants. Psychologists with appropriate credentials have been allowed to prescribe medications to active duty personnel and their families in federal facilities and the Indian Health Service for years. Recently, Louisiana and New Mexico adopted legislation authorizing prescriptive authority for psychologists not limited by the service setting. Since 2000, nine psychologists in Hawaii, all native to Hawaii, have received psychopharmacological training through the Tripler Army Medical Center, Native Hawaiian Psychology Training Program. These psychologists actively collaborate with primary care physicians to provide combined therapy and psychopharmacological care of native Hawaiians at seven federally qualified health centers...” [H.B. #539 & S. B. #1239]. New Mexico’s Elaine LeVine clearly demonstrated the importance of developing true “grass roots” support from a wide range of constituency organizations. Following her lead (at Mike Sullivan’s suggestion), Robin and Jill Oliveira-Berry successfully obtained the active support of each of the community health center medical directors. The January Executive Director’s report of the Hawaii Primary Care Association informed its members that the relevant Senate and House Committee chairpersons would be introducing a prescriptive authority bill for psychologists working at CHCs, along with legislation addressing their funding requirements for the uninsured, capital projects, as well as the dental needs of adult Medicaid enrollees. The primary care world possesses its own nuances, treatment models, and value system – particularly fostering collaboration and interdisciplinary care. Responding to a concern about the role of medicine in Louisiana’s RxP legislation, John Bolter: “The law does not mandate any preceptor supervision. However, it does require ongoing collaboration and consultation with the patient’s attending or primary care physician. Dr. Hines, who authored our law and was honored at the APA Opening Session in Hawaii, was opposed to any appearance of additional supervision and felt the collaborative relationship with the patient’s physician was more than enough to offset any medical risks associated with prescribing. The law requires the psychologist to contact the patient’s physician, explain what he/she intends to prescribe and any associated course of dosage changes or adjunctive agents, as well as relevant information the psychologist may have regarding the patient’s health status (i.e., labs, physical findings, etc.). The physician must agree with the plan before the psychologist can write the prescription. If the physician has concerns, reservations, etc., the psychologist needs to resolve those expressed concerns before prescribing the medication(s). Now, this may sound difficult but I believe it will work to improve health care collaboration among physicians and psychologists, as well as improve quality of care for our patients. As you know, often there is virtually no communication between psychiatrists and other physicians and I think the patients suffer as a result. I also envision over time that psychologists in Louisiana, and perhaps elsewhere, will ultimately develop residency-like programs to assist psychologists in developing more expertise with specialized populations, such as geriatric, severely mentally ill, children, etc. The current law establishes what is the standard to be safe, very much like a medical license, and additional training helps an individual develop more expertise in an area of practice, such as a medical residency.” Successful primary health care systems respect the professional judgment and clinical contributions of all the health disciplines. Mary Beth Kenkel, former President of the National Council of Schools and Programs of Professional Psychology (NCSPP), reports that at their meeting earlier this year NCSPP formally endorsed RxP for “appropriately trained” psychologists and formally encouraged their schools and delegates to become involved in “grass roots” advocacy. “We resolve that NCSPP endorse efforts at the state and national levels to promote prescribing authority for appropriately-trained professional psychologists. APA has developed a post-licensure model curriculum for RxP training. This resolution responds to our students’ career aspirations as evidenced by APAGS endorsement of prescription privileges. Two states and one U.S. territory have achieved prescribing authority, and task forces and initiatives have begun in numerous other states. Also, several NCSPP member schools have been leaders in developing training programs. “We believe that prescribing privileges will benefit our programs in the following ways which are consistent in principle with NCSPP’s interests and mission of: Social responsibility; Better treatment options for the underserved; Enhanced and expanded employment opportunities; further integration of psychology into general health care; increasing the appeal of psychology as a profession. We recommend that NCSPP, as directed by the EC: Support and encourage schools and delegates to become involved in coordinated grassroots advocacy at state and national levels. Also, encourage schools and delegates to contribute to these efforts financially. Consider NCSPP financial support for state associations and other organizations committed to the legislative success of RxP. This support may result from proposals submitted to the EC by member schools.” [Adopted, 1/22/05]. From a public policy perspective, the maturation of professional psychology and particularly, the evolution of the RxP agenda congers up the image of a migrating Iceberg. It moves with the currents. It is very difficult to stop. The visual tip above water usually represents only one-eighth of the actual size. What one sees generally consists of snow, which is not very compact. The ice underwater at the cold core is very compact and heavy. The 21st century will be an era of educated consumers, utilizing the most up-to-date computer and communications technology to ensure that the quality of care they receive is the best possible. The behavioral sciences will become a critical element of society’s definition of “quality care.” Change is upon us and our next generation of healthcare practitioners will enter an exciting, and we predict highly rewarding, era – especially for our profession. Some time ago, Steve Ragusea reflected that in his judgment, the 10 DoD Prescribing Psychologists would eventually have a greater impact upon the future of our profession than any one of us could imagine. It was Robert Frost who once wrote: “Two roads diverged in a wood, and I – I took the one less traveled by, and that has made all the difference.” History suggests that Steve was correct and their having taken this path in our profession’s journey is proving to have made “all the difference” for psychology. An International Perspective: Former Division President “Dr. Bob” Resnick, attended the graduation of the first two DoD Prescribing Psychologists (Morgan Sammons and John Sexton) as APA President. “Dr. Bob” recently returned from the 28th International Congress of Psychology which was held almost immediately after the APA Hawaii convention. “I had not been to Shanghai, Guilin, Xi’an and Beijing since 1988. Clearly the roaring economic growth was evident as well as, unfortunately, those who are being passed over in the rush to run with the electronic economic herd. There continues to be class differences with corruption being a way of life. An example was that we wanted to go to a place where we would eat and see a local song and dance troop. Our guide said he would arrange it and we were taken to the wrong place. After much pressure, the tour guide stated he was forbidden to obtain the tickets to the show we wanted to see and his company would only get tickets to the show we did not want to see. While, we did not see the usual policy of having all westerners ‘video-taped’ for the ‘evening news,’ officials continue to describe their citizens as workers and peasants. Everywhere we went there were cottage-industries; even visiting a communal farm required a gratuity for the family as well as the tour guide. Most street vendors English was limited to, ‘hello, hello’, but it was a pleasant experience to negotiate by gesture. Most interactions left everyone pleased. “What was surprising was the changes in the cities we revisited. Shanghai in 1988 was a Chinese city still with the western sectors from colonial days. It was fascinating to move from sector to sector [English, French, Italian, German] and see the change in architecture and lifestyle. In 2004, while landing in Shanghai, the tour did not make any stops in the city but moved us 40 miles to another city with very little to see. Shanghai, however, has become the Los Angeles of the orient. Many, many skyscrapers and very polluted air. Landing in Shanghai was like landing in Los Angeles right down to the ‘gypsy-cabs.’ Guilin had entered the galloping economy; food items and tours that were part of the overall package were now ‘extra’ right down to snake wine (dead snakes in the bottle). And yes, I tried it! I am like Mikey, I try anything. So as our tour continued, the call was: ‘Let Bob try it!’ The river tour from Guilin continues to be a heart stopper!! Seeing the terra cotta warriors again was a treat and we were allowed to take our own photos and get much closer to them. “Arriving for the international conference was interesting. The conference was staged well outside Beijing at a hotel/conference center complex. But we taxied to the Forbidden City and Tiananmen Square. Most surprising was, after entering the Forbidden City, to see a Starbucks Coffee Shop! Exiting the Forbidden City into Tiananmen Square we were ‘attacked’ by dozens of vendors. Everything is negotiable even in the 5-star hotels gift shops. “John Norcross and I did a symposium on RxP to a very large audience; but not a single question or comment. Later we determined that Chinese psychology graduate students were advised to attend the conference. That may have explained the large audience with many sleeping at their seats! John and I have done many RxP symposiums around the world and what is very clear is that RxP is a developmental process and follows after issues of identity, credentialing, licensure, and insurance reimbursement have been resolved. And it may well be easier to achieve the privilege as other countries have a national license. “The Chinese were excellent hosts and we enjoyed our experience. As the Chinese culture moves more into a market based economy, it is clear, that Chinese psychology is moving with it. Talking with our Chinese colleagues in 2004 was very different from 1988. And as Margaret Meade said so many years ago, we must be mindful of cultural relativity and not judge another culture by our standards. Chinese society and Chinese psychology is gradually entering the community of nations; for that, we shall all benefit.” The Importance of a Personal Presence: In our last column, we noted that individuals who become involved in the political process at the state and local level frequently evolve onto the national scene. We pointed out that three of the four members of Hawaii’s Congressional delegation began their political involvement in our State and/or Territorial legislature. Accordingly, we urged the Division’s membership to take the time to personally visit with each of your own elected officials, at both the local and national level. Every one of us is represented by one member in the U.S. House of Representatives and two U.S. Senators. We also have the opportunity to vote for an individual in our State House and State Senate legislative bodies. The subject matter one selects for that meeting is not as important in the long run, as is the process of developing a mutually supportive relationship and open dialogue. Reflecting upon two newly elected members of the U.S. House of Representatives, columnist David Broder noted: “For all their differences, they share one bond: Both are products of their state legislatures, a background they have in common with 19 other members of the freshman class. That more than half the newcomers have this experience is significant. It means they are familiar with the give-and-take of the legislative process and the need for compromise.” Very few elected officials (or health policy experts) truly appreciate the nuances of non-physician education. In this light, we were particularly pleased to hear from Jill that: “Hawaii’s Legislature had its Opening Day ceremonies. Six of us attended the actual ceremony for the House of Representatives and then proceeded to meet with and introduce ourselves to 18 of the Senators and Representatives. The overall feel was very supportive (albeit it was opening day and everyone was probably on good behavior). Nonetheless, the chair and vice-chair of the Commerce and Consumer Affairs Committee voiced their support and intent to hear the bill which was actually a huge feat in and of itself. Robin attended a meeting today with the Medical Directors of the Hawaii Primary Care Association and they collectively signed a written letter of support. Tomorrow, June Ching is meeting with the Psychology Board in order to educate them about this year’s bill and answer some of their concerns re how the bill impacts the board’s responsibilities, etc.... At this point we are feverishly gathering the written testimonies....” The Public Hearing Process: As more of our colleagues become involved in the public policy/political process, we expect that they will come to understand the fundamental importance of being active at public hearings providing testimony. If not, at least being in attendance and afterwards sharing their thoughts with their own elected officials. Hearings are the forum in which elected officials (and the Administration) often explore broad agendas, seeking solutions to evolving consensus priorities. Rarely are the legislative results predetermined. That is why it is important to be involved – to shape one’s own professional destiny. This past session of Congress, the Joint Economic Committee held a hearing on Consumer-Directed Doctoring: The Doctor Is In, Even If Insurance Is Out, focusing upon alternatives to the traditional third-party payer health care system, hearing from innovative and entrepreneurial doctors who respond to gaps in the current medical care system. Excerpts: “I am a 51-year old board certified internist, presently practicing as an MDVIP affiliated physician in Boca Raton, Florida. I affiliated with MDVIP in order to provide my patients with comprehensive preventive care services that unfortunately can no longer be offered in a traditional primary care setting. This decision was prompted by the inability of the current healthcare environment to accommodate the necessary emphasis on wellness and prevention that I believe is essential for comprehensive preventive care. Instead, current practice, because of time constraints, focuses predominately on acute care.... Perhaps it was naive to think that the changes in medicine wouldn’t become universal. What I had not anticipated was the rapidity with which managed care, particularly in the realm of Medicare HMO’s, would take hold. Because of the generous pharmacy benefit which was then offered, these plans held great attraction for patients. Of course, the reimbursement was lower than traditional fee for service Medicare but doctors had no choice....Concomitant with declining reimbursement, overhead continued to increase. Healthcare costs for employees rose.... We attempted to cut staff but untenable delays occurred. We became more and more constrained in our efforts to be proactive with regards to healthcare, and were far more reactive.... “Last June, the New England Journal of Medicine documented that only 55% of recommended preventive care is administered, and only 52% of recommended screening is performed. It has been estimated that if a doctor, with a typical patient load of 2500 patients, complied with the recommendations of the U.S. Preventive Services Task Force, he would spend 7.4 hours a day on prevention. Only a tiny fraction of the day could then be devoted to acute care....I was on a treadmill, running at an ever-accelerating pace, desperately trying to do the best for patients with a limited resource, i.e. time...I was disappointed professionally and missed the gratification that had always been inherent in physician-patient interaction. Patients, too, were becoming increasingly unhappy.... “What was I looking for? A way to make prevention the foundation of my practice rather than an often ignored recommendation. A practice style that would allow me to dwell on exercise and nutrition, weight loss, smoking cessation and curtailment of alcohol abuse. A method to provide patients with electronic tools that would guarantee timely transfer of clinical data between providers. Planners have been talking for years about the need for a dramatic change in the delivery of primary care, but I knew of no feasible solution.... As a profession, we were awash in well-intentioned ideas, but lacking in the ability to implement meaningful change. I was ready to abandon clinical medicine.... “Hence my decision to join MDVIP, a program focused on an annual preventive care physical examination and related wellness planning, individually tailored to a patient’s needs.... What does it mean to patients who are members of a practice limited to 600 patients? It means they know that when I talk about diet and exercise I really mean it. I will urge them repeatedly, and be able to assist them throughout the year, to be more compliant with proactive preventive care initiatives. It means they will travel with a pocket CD which contains a comprehensive summary of their history, physical exam, medications.... A patient had her CD with her when she was hospitalized in Beijing, and it made an incalculable difference in her care.... My patients are thrilled. I’ve rediscovered the intimacy that traditionally had been part of the doctor patient relationship. Soon after starting my new practice, I realized that patients would share with me stories that they had never told me before.... I have come to realize that the reason I now knew was because of the changing dynamic of our relationship. I have become a friend, a confidant – a real doctor.... It is gratifying beyond description.... My relationship with my patients is special. I am their ‘doctor.’ I am not a provider chosen from an insurance company roster. My patients trust me....” |
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