# overview of health issues



## trbell (Nov 1, 2000)

THE 108th CONGRESS CONVENES The National Elections: As the 108th Congress (2003-2004) begins, it is intriguing to speculate upon what might evolve for our nation's health care system over the next two years. The Republican party controls the Administration and both Houses of Congress, a situation similar to that which the Democrats faced during President Clinton's first two years in office a decade ago. The Republican victories are truly impressive. This was the first time since 1934 that the party of the President gained strength in both the House and Senate in a midterm election. And, for the first time in 50 years, the Grand Old Party will hold more seats in the nation's state legislatures than the Democrats will. The Senate Majority Leader has the distinction of being the first physician elected to the Senate since 1928. He is felt to be President Bush's closest ally in Congress on health issues and there are increasing indications that the Administration will be proposing a major health agenda. The time for significant change may, in fact, be upon us. Today, 41+ million Americans do not have health insurance and our nation's health care costs are again escalating faster than other segments of the economy. In 2001, health care spending soared to $1.42 trillion, the fastest annual growth in a decade. Rising health spending, coupled with the softening of the economy, resulted in health representing 14.1% of the Gross Domestic Product (GDP). Medicaid grew the fastest it has since 1993. And yet, the 2004 Presidential elections are just around the corner. The composition of the new Congress is interesting. A record number 76 women have been elected ï¿½ 62 in the House and 14 in the Senate. California's Nancy Pelosi is the first woman party leader in the House history. [We recently had the pleasure of escorting Judith Albino, President of Alliant University, over to her office, after a pleasant lunch in the Senators' dining room]. There is also a record 24 Hispanic Members in the House, 39 Black Members, and seven Asian or Native Hawaiian/other Pacific Islanders. Three Members are American Indians. The Library of Congress reports that there are nine medical doctors, three dentists, two veterinarians, an optometrist, three nurses, one pharmacist, and three psychologists. (Rep. Tom Osborne is undoubtedly considered the "major league football player, who was also a college football coach"). Law and business remain the dominant professions. 177 Members of the House and 59 Senators hold law degrees. Eighteen Members of the House possess doctoral degrees and 111 former congressional staffers now hold elected office. Mike Sullivan enthusiastically reports that not only do we have more psychologists elected to the Congress than ever before, the number of elected officials in the state legislatures with psychology training also increased, where 16 of the 20 psychologists running for state office were successful. Perhaps as a profession we are finally appreciating the importance of personal involvement within the public policy (i.e., political) process. Interestingly, however, during the most recent APA Presidential election only 20% of the eligible membership voted. We were personally very pleased that Hawaii had the highest percentage of voters at 36%, with Alaska coming in second at 33% ï¿½ being the only other state to have at least a 30% voting record. The lowest state (which we will not mention by name) had only 13%. It must have been their snow.... Democratic Legislative Priorities: On the first day of the session, the Senate Democratic leadership introduced S. 10, the Health Care Coverage Expansion and Quality Improvement Act, which addressed two party priorities: Improving the quality of health care providers deliver and Enhancing and protecting access to public and private health coverage. Included in the bill are the patients' bill of rights; mental health parity; patient safety; and various initiatives to expand and protect health coverage, including providing the states with the flexibility to provide health coverage to uninsured parents who have children eligible for medicaid and the State's Children's Health Insurance Program (SCHIP), the hallmark of President Clinton's health agenda. The mental health parity provision would prohibit group health plans that cover mental illness from providing less coverage for mental health services than for medical and surgical services. This would not, however, apply to small employers (i.e., between two and 50 employees) and would not prevent health plans from utilizing medical management of mental health benefits. In introducing the Democratic Leadership Priorities for the 108th Congress, the Minority Leader stated: "The proposals we are introducing today recognize that the American people have real concerns about their security, and that Republicans and the Bush Administration have not done enough to address those concerns. But they also recognize that security means more than national security, and homeland security. It means economic security, retirement security, and the security of knowing that our children are getting a good education, and that, if you get sick, health care is available and affordable.... It has been said that almost every problem any society faces can be solved with two things: good health, and a good education ï¿½ and we have bills in each of those areas...." Following up on the 1999 findings of Institute of Medicine (IOM), To Err Is Human, the bill would create a new national system for voluntarily reporting medical errors and patient safety incidents. New patient safety organizations (PSOs) would analyze the reported information and disseminate methods and strategies to prevent or reduce medical errors. A patient safety database and research demonstration program would be established. Grants would become available to demonstrate ways to improve patient safety and improve quality of care. The IOM reported that between 44,000 and 98,000 Americans die each year in hospitals as a result of medical errors; that deaths due to preventable adverse events exceed the deaths attributable to motor vehicle accidents, breast cancer, or AIDS; and that medications are the most frequent medical intervention, with an average of 11 prescriptions per person in the United States. The IOM further called for the establishment of feasible prototype systems (i.e., "practice guidelines" and "defined best practices"). Practitioner Mobility: The IOM also addressed the evolving issues of practitioner mobility and licensure accountability, in the context of ensuring the highest possible quality of care. In discussing current performance standards and expectations for health professionals, the IOM pointed out that these are essentially defined through regulatory and other oversight processes, such as licensing, accreditation, and certification. Standards and expectations may also be shaped by professional societies and other groups that voluntarily promulgate guidelines or protocols and sponsor educational and convening activities. The IOM found that there is, compared to facility licensure, greater variation in professional licensure. Historically, professional licensure is structured through the individual state licensing boards for each regulated profession in the state. The result is variation both within the states and across states. Within states there is generally very little coordination of management or dissemination of information among different boards. Across states, there is variation in what is required to sit for the exam, what is considered a "complaint," and in the rate at which disciplinary action is taken. There is wide variation in the rate at which state licensing boards take serious disciplinary actions against physicians, for example, ranging from 0.85 per 1,000 physicians to 15.40 per 1,000 physicians. And, there is a wide variation in the resources the states have made available for board functioning. Board action can accordingly be quite slow, with one state taking on the average more than two and a half years to resolve a case. Perhaps of even greater significance to the readership in the long term is the increasing attention being given at the national health policy level to the reality that the various professions do not have continuing assessment or required demonstration of performance after the practitioner's initial license is granted, except for physician assistants and emergency medical technicians. In general, each state is involved in initial licensure or follow-up of complaints; processes for documenting continued competence are voluntary. In 1998, the Pew Health Professions Commission, after conducting an extensive investigation of licensure and continued competency issues, recommended increased state regulation to require health care practitioners to "demonstrate their competence in the knowledge, judgment, technical skills and interpersonal skills relevant to their jobs throughout their career." They suggested that considerations of competence should include not only the basic and specialized knowledge and skills, but also other skills such as "capacity to admit errors." At this point in our history there does not appear to be a significant movement towards national (or federal) licensure; however, this possibility continues to be seriously discussed at the health policy level. It should be evident to all concerned that the ongoing explosion in capacity within the computer and communications fields and in particular, the advent of telehealth are rapidly changing the nation's health care environment. There have been increasing calls for interdisciplinary training; attention to the cultural, behavioral, and psychosocial aspects of health care; and utilization of computerized testing and simulators for training. The various professions have historically taken different approaches to the issue of licensure mobility. 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. Their underlying goal is to make licensure more like the rules used for a driver's license. That is, a practitioner's licence would be recognized across state lines and the nurse would be subject to the rules of a state while in that state. To date, organized medicine has been notably slow in addressing this evolving issue. Within professional psychology, we currently have three distinct approaches to mobility and the endorsement of CAPP and the Council of Representatives for pursuing both the enactment of the APA Model Licensing Act and other appropriate vehicles for facilitating practitioner mobility. The Association of State and Provincial Psychology Boards (ASPPB) has been working diligently. Their Certificate of Professional Qualifications (CPQ) has been discussed in numerous professional articles and at the Practice Directorate's State Leadership conferences. The American Board of Professional Psychology's (ABPP) diploma and listing in the National Register (with its extensive credential bank) are other viable options. For a most impressive map demonstrating those states which now accept listing in the National Register, the readership should go to www.nationalregister.org/mobility.html. Professional Psychology: Research and Practice, under the guidance of Division members Jay Benedict and Ron Levant, is currently developing a "special focus" on the mobility issue which is expected to be published this year. The 107th Congress: On October 26, 2002, President Bush signed into public law the Health Care Safety Net Amendments of 2002 (PL 107-251). APA was successful in having the generic term "health service psychologists" included within the definition of "behavioral and mental health professionals" for the National Health Service Corps program, which is a very nice step forward towards our acceptance within primary care. The Senate report accompanying the legislation noted while discussing rural health: "the bill would consolidate various telehealth grant programs and establish the Office for the Advancement of Telehealth (OAT). The bill also identifies OAT as the office that shall administer these telehealth grant programs. Telehealth offers great promise for improving access to specialized health care services in rural communities. By consolidating the grant programs, the committee hopes a more coordinated effort will be created to bring telehealth services to rural areas while encouraging the creation of a network of users for these services. "The legislation also would support the establishment of telehealth resource centers throughout the United States. These centers would provide technical assistance to entities interested in putting together a telehealth network. Furthermore, these Resource Centers would be available to demonstrate how telehealth technology can be used effectively in rural communities. Finally, the committee asks the Secretary to develop a definition of frontier areas to ensure that communities which are isolated will be served by the programs established by Congress ï¿½ with the highest benefit possible. A new definition of frontier is necessary to ensure that resources targeted to this area are given to the areas of greatest need. The committee strongly urges that the definition be completed within one year after the enactment of this legislation." The Senate bill included a provision which expressed the sense of the Congress that states should develop reciprocity agreements so that licensed telehealth providers can conduct consultations under the various state laws. Specifically, "TELEHEALTH. ï¿½ It is the sense of Congress that, for purposes of this section, States should develop reciprocity agreements so that a provider of services under this section who is a licensed or otherwise authorized health care provider under the law of 1 or more States, and who, through telehealth technology, consults with a licensed or otherwise authorized health care provider in another State, is exempt, with respect to such consultation, from any State law of the other State that prohibits such consultation on the basis that the first health care provider is not a licensed or authorized health care provider under the law of that State." The final version of the legislation which was signed into public law retained the "Sense of Congress" language and additionally stated: "The Secretary of Health and Human Services may make grants to State professional licensing boards to carry out programs under which such licensing boards of various States cooperate to develop and implement State policies that will reduce statutory and regulatory barriers to telemedicine." Significant change from the status quo is definitely in the wind. Interesting Development Within The RxP- Arena: We are always very interested to read the Health Policy Tracking Service News and Information, of the National Conference of State Legislatures, which after all, is the professional literature of our nation's state legislators. Mike Sullivan kindly provided us with a copy of the early January, 2003 edition which reported that: "New Mexico is still in the rule-making stage for their new law that gives prescriptive authority to psychologists under specified conditions. The New Mexico state Medical and Psychology Boards, which are tasked with developing regulations to implement the new law, have been meeting and inviting expert input on various aspects of the issues that will be addressed by the regulations. No firm decisions however, have been made yet." And, "On November 1st, the President's New Freedom Commission on Mental Health released its Interim Report assessing the nation's mental health system. In an accompanying letter to the President, the Commission concludes 'Our review of this interim report leads us to the united belief that America's mental health service delivery system is in shambles.' According to the Commission, 50% of those in need of mental health treatment do not receive it because of barriers to care...." For many of us who have been pursuing the RxP- agenda from the very beginning (including former APA President Ron Fox, Recording Secretary Ron Levant, and former Board Member Ruth Paige, for example), Access and Quality of Care have always been the driving force behind the movement. The Commission's Interim Report brings to mind the Psychiatric News article of last Fall describing efforts at the state level to address the rising costs of psychotropic drugs covered by Medicaid. The "immediate past president of the Massachusetts Psychiatric Society... (reported that) 'We need to prescribe responsibly as psychiatrists and as citizens of the state.... We came up with three prescribing practices that are costly but whose validity is not supported by a review of the literature.' They are routine and concomitant use of more than one atypical antipsychotic for more than a reasonable crossover period (60 days), use of two selective serotonin reuptake inhibitors (SSRIs) for more than 60 days, and concomitant use of five or more psychotropic medications.... (T)he work group found that as of this past January, more than 2,200 adults received more than one atypical antipsychotic at a time for more than 60 days, at a cost of $24 million; that almost 5,000 Medicaid recipients were taking more than one SSRI for more than 60 days, at a cost of more than $4.5 million; and that more than 1,100 MassHealth recipients were receiving five or more psychiatric medications in January, often from multiple prescribers." Clearly, there is a pressing need for access to the clinical judgment of highly trained prescribing psychologists. An Update From Two RxP- Training Programs: Gene Shapiro, director of the NOVASoutheastern University program received a most laudatory letter from Richard Elghammer, one of his students: "As one of the 18 psychologists who are currently enrolled in the class of 2004 (NOVA's first fly-in class), I speak from experience when I say this is a unique opportunity to learn neuroscience. The format of the two-year program consists of 10, six day segments of classes at NOVA, where we fly in from all around America to receive classroom training. Each summer is devoted to practicum, in our own communities, where we receive hands-on training with patients who require psychotropic medications. NOVA's program is not a diluted down crash course in 'psycho-pharm-lite.' This is a well developed, intense program with depth, leading to a diploma (M.S.) in Clinical Psychopharmacology. "An additional bonus for me has been taking my wife and children on great vacations in South Florida. One evening, after an especially hard day in the classroom, my five year old daughter, Ellen, asked 'Daddy, do you have to go back to school each day? We had such a great time building sand castles and swimming, can't you take a day off?' 'No,' I replied, thinking to myself, 'How can I instill in my children the importance of learning and education?' Maybe by setting this example. A last note - psychologists who are members of their respective state psychological associations receive a significant tuition reduction by NOVA to attend the program." Matt Nessetti, director of The Psychopharmacology Institute (TPI): "Our postdoctoral program in psychopharmacology is an internet based program consisting of 28 courses and 492 hours of didactic training, an 80 hour pathophysiology practicum, and a one year/100 patient preceptorship. Each student is guided through materials consisting of web-based presentations (over 5000 slides in all), required readings from textbooks for each course (through a cooperative arrangement with Lippincott, Williams, and Wilkins texts are available at a discount), internet based resource materials, an ongoing list serve, regular journal article dissemination, advocacy updates, individualized consultation, and closed book proctored examinations. The final course is the PEP PREP which is entirely dedicated to assisting the student in passing the APA College's PEP exam. TPI has seen a steady increase in the number of students taking courses since the passage of New Mexico's prescribing law for psychologists. TPI is an APA approved provider of continuing education for psychologists. The entire cost of the program is under $8000 and discounts, scholarships, and student financial aid are available. [www.nmhc-clinics.com/pages/TPI/ppp.html]. We have been particularly pleased with Matt's willingness to reach out to our Guam colleagues so that they can effectively implement their law in the near future.Pat DeLeon, former APA President ï¿½ Division 42 ï¿½ January, 2003a psychologist's perspecive so biasedtom


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