As the Democratic and Republican Presidential primaries get seriously underway, we would expect that issues surrounding the delivery of health care in our nation will receive significant attention in the media. Although we would predict they will probably not yet become “defining differences” among the candidates. At some point in our professional lives, however, this will change. The Institute of Medicine (IOM) recently published a slightly different, although definitely thought provoking, perspective on the public policy process: “The story of human civilization is the story of knowledge: its pursuit and application. Nowhere is this more evident than in efforts to improve people’s health and well-being. The detailed observations of the ancient Egyptians led to cultural practices of hygiene and diet that would place them ahead of many developing nations today. The Greek medical schools of the fifth century B.C. began paving the way for the modern scientific pursuit of medicine and put the fundamentals of human biology on paper.... In each age of medicine, an increase in knowledge has led to improved public health. The work of great scientific minds has been bolstered, supported, and amplified by public policy, public opinion, and national action. Without massive infrastructure investments during World War II, for example, penicillin would have remained an interesting lab experiment. The decisions that guide and shape these advances are profoundly important and often politically charged. Today, health care sits at the top of the nation’s agenda. Issues such as the rising cost of health care and emerging threats such as avian flu and bioterrorism have created new challenges to the health care system. Meanwhile, advances in stem cells, nanotechnology, and genomics have brought the ethics of medicine further into the arena of politics, creating increasingly complex challenges for policy makers and scientists alike. Against this backstop, the need for independent, evidence-based information and analysis has become even more important.”
“Quality of Care: A Health Professional Duty - Health care is a vast enterprise that now accounts for more than one in every seven dollars spent in the U.S. economy. Despite spending that dwarfs that of every other country in the world, more than 15 percent of Americans had no health care insurance in 2005, and the United States lags behind dozens of other nations on health measures such as infant mortality and life expectancy. Despite striking scientific advances and new therapies, too often the quality of care that every citizen deserves is not delivered. Is it possible to attain a high-quality health system that functions well for every American and that is efficient and affordable in its operation? How will the nation cope as new technologies and an aging population add to the pressures on the system?”
Of specific interest to psychology, the IOM has also highlighted two fundamentally behavioral science agendas: “Mental or Substance-Use Problems: Quality of Care - Each year more than 33 million Americans receive health care for mental or substance-use problems and illnesses. The diagnoses and severity of mental and substance-use problems vary widely - from distress caused by a life-changing event to severe depression to physical dependence on alcohol. These conditions are the leading cause of combined disability and death in women, and the second highest in men. Effective treatments do exist for many of these problems, and they continually improve. However, as with general health care, deficiencies in the way these treatments are delivered prevent many from receiving appropriate care. This has serious consequences for people who have the conditions; for their loved ones; for the workplace; for the education, welfare, and justice systems; and for the nation as a whole.... Evidence-Based Medicine - The IOM is founded on the principle of using sound scientific evidence to drive policy and research. The health of Americans has greatly benefited from the rapid growth of medical research and technology over the years, but multiple studies have shown that too few of the medical services supported by the strongest evidence are actually delivered and that far too much health care spending is devoted to activities that do not improve health. In fact, little time or money has been invested in understanding the advantages of different interventions. This gap in knowledge will continue to increase as the pace of technology development quickens and the benefits of genetic research and other revolutionary areas of inquiry evolve into therapies and medications. Bridging this divide is fundamentally important to the efforts to improve the efficiency and efficacy of health care in America.”
How personally involved have Division 42’s practitioners been in the crucial public policy (i.e., political) process? Presently on the division’s “e-mail highway” there is considerable discussion regarding the importance of contacting one’s own congressional representatives in order to prevent the projected 10.1 percent reduction in Medicare reimbursement. Collectively, we seem to finally appreciate that Medicare often sets the standard for the private sector; that if the federal government reduces its reimbursement rates, the private sector will soon follow. The U.S. Senate Finance Committee, which has jurisdiction over Medicare and Medicaid, estimates that it would cost $30 billion to avoid the 2008 reduction, as well as the additional 5 percent reduction scheduled for 2009. Clearly, this should be a high priority for all practitioners, regardless of their professional discipline. And yet, from another perspective, the annual scramble to prevent Medicare reimbursement reductions almost seems to be rearranging the deck chairs aboard the RMS Titanic.
The Congressional Budget Office (CBO) 2007 Long-Term Outlook for Health Care Spending: “Spending on health care in the United States has been growing faster than the economy for many years, representing a challenge not only for the government’s two major health insurance programs - Medicare and Medicaid - but also for the private sector. As health care spending consumes a greater and greater share of the nation’s economic output in the future, Americans will be faced with increasingly difficult choices between health care and other priorities.... The goal of the projections in this study is to examine the implications of a continuation of current federal law, rather than to make a prediction of the future. Under that assumption, however, federal spending on health care would eventually reach unsustainable levels. In reality, federal law will change in the future....
“(T)he premise that CBO chose was that Americans will ultimately demand changes to the system to prevent their consumption of other goods and services from declining in real (inflation adjusted) terms. In other words, CBO’s projections assume that to avoid a reduction in real consumption of items besides health care, employers, households, and insurance firms will change their behavior in a variety of ways (potentially including higher cost sharing, increased utilization management, reduced insurance coverage by employers, and greater scrutiny of new technologies based on evidence of their comparative effectiveness) to slow the rate of growth of spending in the nonfederal part of the health system. The projections also assume that, even in the absence of changes in federal law, some of the measures adopted to slow growth in the rest of the health care system will moderate spending growth in Medicare and Medicaid and that regulatory changes at the federal level and policy changes at the state level will help to slow cost growth in those programs. The results of CBO’s projections suggest that in the absence of changes in federal law:
- Total spending on health care would rise from 16 percent of gross domestic product (GDP) in 2007 to 25 percent in 2025, 37 percent in 2050, and 49 percent in 2082.
- Federal spending on Medicare (net of beneficiaries’ premiums) and Medicaid would rise from 4 percent of GDP in 2007 to 7 percent in 2025, 12 percent in 2050, and 19 percent in 2082.
The main message of this study is that, without changes in federal law, federal spending on Medicare and Medicaid is on a path that cannot be sustained. In itself, higher spending on health care is not necessarily a ‘problem.’ Indeed, there might be less concern about increasing costs if they yielded commensurate gains in health. But the degree to which the system promotes the population’s health remains unclear. Indeed, substantial evidence exists that more expensive care does not always mean higher-quality care.... Over the past 30 years, total national spending on health care has more than doubled as a share of GDP.”
An Opportunity To Make A Real Difference - On A Global Basis: Ellen Garrison, APA Senior Policy Advisor and a former Society for Research in Child Development (SRCD) Fellow: “Participation in federal advocacy can be a transformative experience, in some ways like that of psychotherapy. Psychologists who set out on their first visit to Capitol Hill often do so with great trepidation but return with an overwhelming sense of empowerment. This should come as no surprise.... After all, elected officials and their staff are typically welcoming, since they want to meet and hear directly from their constituents about critical issues. Also, we would anticipate from the research literature that the psychologists would perform well, given their moderate level of arousal (a.k.a., anxiety!). Individual psychologists and the field of psychology as a whole have much to contribute to addressing the challenges facing our nation - including strategies to reduce health disparities, prevent suicide, promote the mental and behavioral health of students on college campuses, or respond to terrorism, hate crime, and other forms of violence. Psychologists can also educate members of Congress and their staff about the role of psychology in promoting overall health and positive development across the lifespan and for diverse populations. And psychologists also need to engage in advocacy efforts to benefit the field and the individuals whom we serve - for example, in support of mental health parity or in opposition to Medicare cuts.
“There are many different ways to get involved in federal advocacy. A good place to start is to read the policy-related articles in the Monitor on Psychology and to visit the government relations Web sites of APA’s Public Interest, Education, and Science Directorates, as well as the APA Practice Organization (APAPO), which can be accessed at www.apa.org/ppo. This will provide you with up-to-date information on key legislative and regulatory initiatives in a broad range of areas, as well as access to A Psychologist’s Guide to Participation in Federal Policymaking and the Public Policy Advocacy Network (PPAN). Through membership in PPAN, you will learn of legislative issues and late-breaking developments where your outreach to congressional offices is urgently needed.
“At the APA convention, for example, you may have the chance to participate in a federal advocacy training program as part of an APA division or governance group, which includes a didactic session on Congress, the ‘how tos’ of conducting a hill visit, an issue briefing, and actual meetings on Capitol Hill. There are also opportunities to visit your elected officials on Capitol Hill or in their local or district offices when the Congress is in recess. APA and APAPO government relations staff can help to facilitate these critical connections. They also arrange for APA members to contribute to the development of legislation, participate in congressional briefings and hearings, and serve on federal agency panels, among other activities.
“For those psychologists who would like to gain direct experience in federal policy making, APA offers the Congressional Fellowship Program. Since 1974, a total of 108 psychologists have worked on Capitol Hill as a special assistant with a member of Congress or congressional committee for a year-long APA Congressional Fellowship experience. Fellows attend an eight-day orientation program in congressional and executive branch operations, which includes guidance in the congressional placement process and a year-long seminar series. Fellows conduct legislative or oversight work, which may include assisting in congressional hearings and debates, preparing briefs, and writing speeches. Fellows have worked most frequently on issues related to health, education, mental health reform, and children and families. (See www.apa.org/ppo/fellows for more information about APA policy fellowships and internship programs.) Many of our Fellows have maintained their connection with APA following the Fellowship year and have assumed leadership positions in APA governance (including serving on the Board of Directors) and divisions, as well as in state psychological associations. Our APA Congressional Fellows describe their experience as life-changing and continue to encourage other psychologists to participate in the program. So make that phone call to a congressional office, meet with a member of Congress or his/her staff, attend the Fellows annual symposium at the APA convention, and/or embark upon a year-long congressional adventure yourself. Now is the time to take action and make a difference.”
On An Individual Basis: Jim Meredith, former Department of Defense (DoD) prescribing psychologist: “As a prescribing psychologist in the Air Force I spent considerable time in clinics in which I was the only prescribing provider with both psychologists and social workers referring patients to me for medication evaluations. In a public care setting where there was no financial incentive for keeping patients, that meant that most of the patients that I judged could benefit from medication were transferred to me for both their medication and therapy needs. In some cases the referring therapist wanted to keep the patient for therapy and I did the periodic med checks. I didn’t find this burdensome because it was rare and was quite similar to what I would do with patients with whom I had stabilized on medication and had finished active therapy. I would use the med checks as a relapse prevention opportunity and felt that it was a real benefit to my patients to be able to do that.
“As a result of receiving these medication referrals from my non-prescribing co-workers the majority of the patients I saw ended up being on medication. I kept records of my prescribing pattern over 10 years and ended up prescribing medication to around 15 to 20 percent of my patients, and when you add in a similar percentage from each of the other providers the result was a caseload most of whom I prescribed to. If this had occurred in a private practice setting, I can see where instead of inheriting the patient I would only be doing the medication for a substantial number of patients and doing much less psychotherapy. Every psychologist will probably have a different tolerance level for this and as they reach their limit of ‘medication only patients’ would then begin to do what psychiatrists have to do - develop wait lists that depend on finishing with one medication patient before accepting another.” Aloha,
Pat DeLeon, former APA President - Division 42 - December, 2007
