 |
The Law of Unintended Consequences |
||||
|
Professional Practice |
Pat DeLeon, Ph.D., J.D. |
||||
 |
|
||||
|
The Institute of Medicine (IOM) has reported on several occasions that the time lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of about 15 to 20 years. The IOM has further pointed out that even today, many medical technologies are being used inappropriately and that between 30 and 40 cents of every dollar spent on health care is spent on the costs of poor quality, a figure which represents slightly more than a half trillion dollars a year. As far back as 1975, wide geographical variations in quality practice had been documented and these have been replicated in a series of studies across the country over the last 30 years. At the same time, the IOM also notes that: “Health care delivery has been relatively untouched by the revolution in information technology that has been transforming nearly every other aspect of society.” “Claims that health care is unique and therefore not susceptible to a transfer of learning from other industries are not supportable.” Accordingly, as the technological revolution begins to provide our nation’s health policy experts and those who “pay the bill” with the capability to systematically measure what truly represents “quality of care” (including the psychosocial aspects), practitioners of all disciplines must expect increasing pressure to document that they are not only practicing in an ethical manner, but that they are also practicing according to predetermined standards (i.e., “best practice” protocols and/or “empirically-supported treatments”). The signs suggesting this far-reaching evolution are increasingly evident. And, they exist within the public policy (i.e., political) context of ever-increasing health care costs and rising number of uninsured Americans. The societal interest in ensuring that the health care industry is accountable, and thereby cost-effective, is steadily increasing. The Wall Street Journal: “The percentage of Americans without health insurance shot up last year after falling the previous two years, and some policy experts fear the insurance gap will widen. An estimated 14.6% of Americans – 41.2 million – went uninsured in 2001, up from an upwardly revised 14.2%, or 39.8 million, in 2000, according to a Census Bureau report.... The new statistics and bleak prospects for improvement likely will fuel the debate about the future of the nation’s health-care system and what reforms are needed. To that end, the Robert Wood Johnson Foundation enlisted former presidents Gerald Ford and Jimmy Carter, along with the U.S. Chamber of Commerce, the AFL-CIO and others, to launch a national campaign to focus attention on those who lack health coverage – and come up with a solution. ‘Not having health insurance is a leading cause of personal bankruptcy, destroying the dreams of thousands of families,’ says Risa Lavizzo-Mourey, president-designate of the foundation.... “With last year’s reversal, the plight of those without health coverage could once again emerge as a dominant political theme, as it did in the early 1990s amid a raging debate over President Clinton’s failed universal-coverage plan. Although some in Congress had vowed to address the matter this year, it fell off the radar screen as lawmakers bickered over higher-profile health-care matters, such as providing a prescription-drug benefit under Medicare, the federal program for the elderly and disabled. When the issue has come up, deep philosophical differences have prevented anything from getting done. “Health and Human Services [HHS] Secretary Tommy Thompson says the report supports the need to help more Americans get insurance quickly, and he pressed for Congress to pass President Bush’s tax-credit proposal. ‘He is proposing more community health clinics, health credits and more freedom for states to extend insurance to those who need it.’” Last year, during the House of Representatives deliberations on the Fiscal Year 2002 Appropriations bill for HHS, the Appropriations Committee noted: “Within the total provided, $5,000,000 above the budget request is to provide evidence based mental health outreach and treatment to the elderly. By the year 2010, there will be approximately 40 million people in the U.S. over the age of 65 and more than 20 percent of them will experience mental disorders. Only a small percentage of Older Americans who require assistance currently receive specialty mental health services for reasons which include stigma, denial of problems, access barriers, lack of coordination between mental health and aging networks. The funding provided is intended to begin to address this problem.” The funds were retained during the subsequent House-Senate conference. This Fall, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse (NIDA) jointly announced: “...a unique intra-agency agreement to expedite the application of findings from treatment research into clinical application. The $1.5 million agreement between NIDA and SAMHSA’s Center for Substance Abuse Treatment (CSAT) will help ensure that findings from NIDA’s treatment research will be quickly and readily available to practitioners around the country. Dr. Glen R. Hanson, NIDA Acting Director, says, ‘This collaborative effort puts into place a system whereby health care providers can be more rapidly alerted to new and improved medications and behavioral therapies with which to treat patients for drug abuse and addiction.’ SAMHSA Administrator Charles G. Curie noted that ‘This partnership is a significant step in our efforts working with the National Institutes of Health to define and develop a ‘Science to Services’ cycle and to reduce the time between the discovery of an effective treatment or intervention and its adoption as part of community-based care. Today, the Institute of Medicine tells us it can take up to 20 years.’ “Under the agreement, NIDA will provide funding to support CSAT’s Addiction Technology Transfer Centers (ATTC), a network comprised of 14 independent regional centers and a national office charged with increasing the knowledge and skills of addiction treatment practitioners and fostering alliances to support and implement best treatment practices. The purpose of the agreement is to enhance effort to disseminate and apply findings from NIDA’s National Drug Abuse Treatment Clinical Trials Network (CTN) as well as other NIDA-supported studies to practitioners served by the ATTCs. Grants totaling almost $6 million were awarded... to add three nodes – Northern New England (covering 5 states), New Mexico, and Arizona – to NIDA’s CTN. The network is now comprised of 17 research nodes around the country. These nodes are conducting a variety of research protocols on behavioral, pharmacological, and integrated behavioral and pharmacological treatment interventions in 27 states at 120 community treatment sites. More than 3,500 patients are participating in these studies. The CTN is designed to determine treatment effectiveness across a broad range of community-based treatment settings and diversified patient populations.... this intra-agency agreement will mutually augment the outreach and impact of both NIDA and CSAT’s efforts to ensure that science-based findings are incorporated into clinical practice. ‘And the most important beneficiaries... will be those individuals in treatment and recovery from substance abuse disorders.’” The Webpage for the Florida Mental Health Institute notes that researchers at the University of South Florida’s Louis de la Parte Florida Mental Health Institute have been awarded a 5-year, $5.5 million federal grant to establish a national Center for Evidence-Based Practice focused on the needs of young children with challenging behaviors. This is being funded by the U.S. Department of Education, Office of Special Education Programs and will be housed in the Institute’s Department of Child and Family Studies, chaired by Bob Friedman who recently testified before President Bush’s New Freedom Commission on Mental Health. It is the third national center at the de la Parte Institute related to children’s behavioral health. It was not that long ago that Marty Seligman, during his Presidency of APA, was calling for exactly this type of federal investment in demonstrating quality psychological care. The Centers for Medicare and Medicaid Services (CMS) has similarly announced a solicitation for evaluating quality care. CMS cited an IOM report which: “found that quality-related problems can result in waste and lead to inefficiencies, directly conflicting with incentives designed to reduce costs. Therefore we need a more direct alignment between the compensation method and quality improvement initiatives, especially for individuals with chronic illness who account for a significant portion of Medicare spending. The PGP [Physician Group Practice] demonstration provides the opportunity to identify, test, and evaluate aligning health care providers compensation models with quality improvement goals in the Medicare fee-for-service environment.... The PGP demonstration will provide a unique reimbursement mechanism through which providers are rewarded for coordinating and managing the overall health care needs of a nonenrolled, fee-for-service patient population. It offers an opportunity to test whether a different financial incentive structure can improve service delivery and quality for Medicare patients, and ultimately prove cost-effective.... [It] superimposes new incentives on traditional fee-for-service reimbursement that are more in line with those used by managed care organizations and other commercial payers. In addition... [it] includes explicit incentives for process and outcome improvement. Performance on both process and outcome quality indicators, together with cost savings, will be used in the calculation of performance bonuses.... Bonus payments will be allocated between efficiency improvements and documented improvements in processes and outcomes. Bonus payments will be made to a single entity (health care group). The entity is responsible for allocating any bonus payments among affiliated organizations.” [Eligible Organizations: Health care groups with at least 200 physician full-time equivalents.] Just Wondering Out Loud: It is difficult not to enthusiastically embrace any proposed improvements in our nation’s health care system. And yet, upon further reflection, one begins to wonder if our practitioner colleagues are really ready for the revolutionary changes that might perhaps be “right around the corner”. What could be the practical implications of the recent AMA News article -- “Harm Flows From Simple Errors: The next step will be proposing solutions for error reduction in the family physician’s office”? The IOM estimates that four of ten U.S. households had Internet access as of August 2000, and that 90 percent will have access by 2010 or before. Clearly this has made it possible to informally keep in contact and share ideas with colleagues as never before. APA Board of Directors member Carol Goodheart and I “chat” from time to time. Carol is in Mexico; I am in our nation’s Capitol. Most recently we have been thinking about the potential growing problems for practice if adherents for the Empirically-supported treatments/ Evidence-based treatments movement continue their efforts to restrict treatment to this small subset of possibilities. Apparently there is even talk in some circles that it should be unethical to offer anything but CBT approaches based on empirical data. It is hard to believe that those who might take such a rigid stance appreciate the clinical contributions of psychoanalytic, feminist, family systems, humanistic, etc. approaches to dealing with very real human problems. Clearly the potential exists for the insurance industry (i.e., those “paying the bill”) to jump on this bandwagon and perhaps even misuse the data to restrict treatments. Both Carol and I are thankful that Russ and the Practice Directorate are quite aware of this issue and are exploring ways to address our underlying concern. Carol has also been “chatting” with President-Elect Bob Sternberg and was very pleased to share how supportive Bob is of having a symposium during the forthcoming Toronto convention within his Presidential tract, including both practitioners and scientists. This could become a very nice catalyst for bringing the various camps within APA together in a collaborative and highly productive manner. It might even result in a far reaching publication that would reach many more colleagues than ever attend one of our annual conventions. RxP- Authority Continues To Mature: We were pleased to recently receive from Asher Pacht, Director of Professional Affairs for the Association of State and Provincial Psychology Boards (ASPPB), a copy of ASPPB’s Guidelines For Prescriptive Authority. “As a matter of policy, ASPPB neither endorses nor opposes the current movement within many psychological organizations to promote prescription privileges for psychologists.” Nevertheless, those of us supportive of the RxP- evolution should be extraordinarily pleased with their visionary guidance, which very nicely parallels APA’s recommendations. “In an effort to maintain as much consistency as possible, jurisdictions that have statutory provision for prescription privileges for psychologists are urged to follow... these guidelines in writing regulations for the certification of individuals for prescription privileges.... Certifying individuals for prescriptive authority should be separate from and in addition to the generic license.... Candidates for certification should have been licensed already by a state or province for the independent practice of psychology at the doctoral level, and have the necessary training and experience as a health service provider.... Education and training for prescription privileges should be at the postdoctoral level. A minimum of three hundred hours of didactic instruction... is required.... Consideration should be given to the fact that many licensed psychologists are licensed for prescription privileges in another profession, e.g., nursing. For these individuals, part or all of the didactic requirements should be waived.... ” From a public policy perspective, this is a major step forward and especially significant in that it is addressed to public agencies, with the primary responsibility of protecting the public. There are also increasing signs that the APA Practice Directorate’s RxP- “Southern Strategy” is steadily expanding. From the far Northeast, New Hampshire Psychological Association Executive Director Kristen Singleton reports that they are submitting RxP- legislation this year. In the far West, Rochelle Jennings recently returned from a most productive RxP- meeting in the State of Washington. And in our nation’s most Southern state, David Weiss, chair of the Hawaii Board of Psychology, reports that the licensing board voted unanimously to provide testimony in support of the concept of RxP- privileges. Equally intriguing was a Senior Editor’s Note (i.e., editorial) Mike Sullivan received from Product Marketing Today: “Are you ready for the new prescriber landscape?” “There was a time when the only health care practitioners in the United States with prescriptive authority were physicians and dentists. Pharmaceutical marketers could concentrate on refining and directing their marketing, sales, and educational efforts at these specific audiences. Today, the traditional boundaries governing who may and who may not prescribe are in a shambles – and they are morphing at head-spinning speed. Some analysts predict that by 2005, as many as five or six new categories of nonphysician health care providers will have either full or partial prescriptive authority in nearly every state in the country. Why this sudden paradigm change, and which nonphysician groups are making the most headway? Revolution or Evolution? In 2002, more than 30 states are expected to consider bills to grant prescriptive or independent practice rights to nonphysicians, including nurse anesthetists, nurse midwives, optometrists, podiatrists, chiropractors, psychologists, and pharmacists. Even alternative medicine practitioners in some states are pushing for permission to treat any condition as long as there is informed consent by the patient.... Although New Mexico is the first and so far the only state to extend prescriptive authority to psychologists, similar legislation may be passed this year in Alabama, Illinois, and Tennessee. In states where psychologists are not making much headway in gaining prescriptive privileges, such as New Jersey, they are enrolling in advanced-degree nursing program that will certify them as advanced practice nurses, thus allowing them to prescribe drugs. In Georgia, the pressure to expand the prescriptive role of nonphysician providers is particularly intense this year... What is a pharmaceutical product manager to do? Do you begin promoting to these new nonphysician providers as vigorously as you promote to doctors, dentists, PAs, and NPs – and at what risk to your relationships with traditional prescribers? Are you allowed to sample these new prescribers? Should you add... the American Psychologist... to your media schedule? Should you plan sales training modules to help your reps understand the ‘new’ demographics and prescribing patterns of... psychologists...? Will you need new – and different – educational programs and materials to meet the specialized learning and recertification needs of these professionals? What should you do about pharmacists who now have the authority to convert a prescription for your drug to that of a competitor?” Dramatic change is definitely in the winds. An Entirely New Focus: In our judgment, the key to the outstanding success of Elaine and Mario has been their constant focus on addressing the true needs of their constituency (e.g., the citizens of New Mexico). In all my years in APA governance, I have never seen such sincere grass roots support expressed by members of the general public for what is essentially a psychology agenda. It is a truly an outstanding tribute to both of them and to their colleagues in the New Mexico Psychological Association. What we would propose is that those dedicated to the RxP- agenda explore how they (and their state psychological associations) can clinically contribute to the mission of their own local community health centers. The federal community health centers program began in 1965 as a demonstration initiative of President Lyndon Johnson’s War on Poverty. The President’s Fiscal Year 2003 budget reports that nationwide, health centers presently serve 11.75 million Americans at more than 3,400 recognized sites. And, as we indicated earlier, the President has asked for a significant increase. Forty percent of health center patients are children and adolescents under the age of 20; 59 percent of patients are female. In Hawaii, 39.4 percent of all federally qualified health center patients are on Medicaid, while nationwide 40 percent are uninsured. Sixty-one percent are other than White. John Myhre, a Native Hawaiian psychologist, has been working closely with Hawaii’s health centers. This Fall, four of his physician colleagues wrote to their State elected officials: “This letter is to request that we organize a community health center bill that gives our Native Hawaiian Psychologists the ability to be reimbursed for their services in a primary care clinic and the right to prescribe the necessary medications for their mental health patients.... In Waianae alone, these doctors have become very valuable members of our primary care clinics seeing over 2000 patient contacts this year at the Waianae Coast Comprehensive Health Center. Again, this program is of such importance to community health centers and to the care of Hawaiians, that we are in fact asking you to help draft/support a bill to change the legislation required to completely support a valued Native Hawaiian healthcare service opportunity.” The Executive Director of one of our most rural centers wrote: “...Being of Native Hawaiian descent, these doctors are versed in culturally sensitive patient care. As providers that are linked by video teleconferencing... they can, and have accessed a vast resource of some of the most cutting edge integrated mental health treatments available. They have recommended hundreds of psychopharmacological prescriptions in the primary care clinic... and have proficiently managed the care of our patients.... These services fill a critical void of a previously unmet community need.... Gone is the artificial divide between mental health and physical health when combined into integrated health that holds patient wellness as it’s pole star of care.” Aloha, Pat DeLeon |
||||