Health Care Reform Blog

by Kathleen Ashton, PhD, ABPP

I was privileged to present with Div. 38 on "Ethics in Hospital Settings" at the 2016 APA Convention with colleagues Amy Sullivan, PsyD, and Marilyn Stern, PhD. I hope it was among the many programs I attended that were relevant and helpful to practitioners. Here are highlights of some of the issues discussed. Look for more in the next edition of the "Cambridge Handbook of Applied Psychological Ethics" (book chapter in press).

Top 15 Recommendations for Best Ethics Practices in Integrated Care Settings

1. Obtain both verbal and written informed consent.

2. Clarify with whom the information will be shared.

3. Clarify the purpose of the referral and what types of recommendations may be made.

4. Clarify the information that will be included in the electronic health record (EHR).

5. Keep information included in the EHR factual, behavioral and relevant.

6. Maintain an EHR with both accessible mental health and medical notes to enhance patient care.

7. Encourage other health care providers to respect the sensitivity of psychological information.

8. Use an audit system as part of EHR to avoid unnecessary viewing of patient records.

9. Limit discussion in multidisciplinary team meetings to relevant details.

10. Consider issues such as cultural competence and health care literacy.

11. Reassess informed consent regularly, making it an ongoing conversation.

12. Clarify the role of supervisees and the level of involvement of supervisors.

13. Clarify the roles of third parties such as family members, interpreters or other supports.

14. Work with multidisciplinary teams to provide the psychological perspective and balance maleficence versus beneficence.

15. Consult with colleagues, relevant ethical guidelines, state rules and regulations, state boards of psychology, state psychological associations, the American Board of Clinical Health Psychology, bioethics teams and legal counsel regarding ethical concerns.
    

by Kathleen Ashton, PhD, ABPP

I am energized and excited having just returned from APA convention in Denver.  What a great city and venue. I loved the Blue Bear but not the altitude sickness.  I thought the   2016 convention was an exceptionally strong program, with many beneficial programs for APA Practice Organization (APAPO) members .  Some of the programs that I found particularly enjoyable were related to working in integrated care and hospital settings.  I attended a terrific program on psycho-oncology with Barb Andersen and Shawna Ehlers that highlighted how research and practice come together in specialty integrated care.  Some other stellar programs included “Negotiation Strategies in Hospitals with Kate Brown and Robin Henderson,” “Leadership Strategies in Academic Medical Settings with John Linton” and “Demonstrating Psychology's Value.”  I was privileged to present with my good colleague Amy Sullivan on “Ethics in Hospital Settings” where we had a great audience despite the early hour.   I enjoyed the opportunities to connect with other psychologists at the division social hours and informally between programs.  I definitely came back with lots of ideas and contacts.

Practice was also visible in the exhibit hall, where the Practice Directorate showed how the APAPO helps with the “game of life of a practitioner,” and the APAPO political action committee (APAPO-PAC) raised over $20,000 toward advancing issues important to practicing psychologists (Thank you to all who contributed to this important advocacy effort!)   If you did not get a chance to contribute at convention, please visit the APAPO-PAC website. APAPO-PAC donors were invited to a reception (students donating $20.16 included), which highlighted the work that the Governance Relations is doing on the behalf of practicing psychologists and their patients, including work on the Medicare Mental Health Access Act and bipartisan Mental Health Reform Bill.

At opening session, our APA President Susan McDaniel highlighted health treatment (including mental health treatment) as a human right and shared her presidential integrated health initiatives. Our interim CEO, Cynthia Belar, also noted the importance of the APAPO in promoting issues for psychologists, where the APA focuses on science and education of   psychology.

The Committee of State Leaders (CSL) was also active at convention, providing an excellent program on social justice advocacy as part of state psychological associations . I was proud of Michael Ranney, my executive director of the Ohio Psychological Association (OPA), who discussed some of OPA's social justice work including statements on conscience clause, Black Lives Matter and suicide in African American men.  Erica Wise and Sally Cameron from North Carolina discussed their important work on the “bathroom bill,” and Jo Linder Crow and Doug Haldeman discussed working on conversion therapy and conscience clause legislation in California.  Great information about policy making, practicalities and building alliances for other state associations.

CSL also held a lunch meeting where we discussed the upcoming   changes to State Leadership Conference  (SLC) given the financial challenges to the APAPO and APA.  I am grateful to the work of APA staff, including Dan Abrahamson and Susie Lazaroff, to find creative and cost-effective strategies to keep the SLC viable.  This important opportunity for state leaders to share ideas and information, connect with other leaders and advocate for professional psychology on the Hill is invaluable.  Although there will be increased cost sharing for state and participants, the conference essentially will remain the energizing experience it has been for the past 34 years.

I also saw many of the APAPO Committee for the Advancement of Professional Practice (CAPP) candidates at convention. As a reminder, voting for your APAPO leadership on CAPP is open currently until Sept. 30. You should have received an email with instructions; please visit the website.  Do not forget to vote and make your voice heard; this is a great opportunity for members to have a more engaged voice in leadership.  If you haven't received an email, check your spam/junk mail and make sure you are an APAPO member

Despite the above opportunities, I would love to see the APAPO more visible at convention, and I am interested in members' feedback about the best ways to accomplish this.  Some ideas may include:

• APAPO exhibit booth/membership booth.
• Meet your legal/regulatory team event.
• APAPO ribbons to recognize members.
• APAPO CAPP candidates forum.
• APAPO social hour.
• Better promotion of collaborative division programming.
• Increased interaction with divisions with heavy practice emphasis.

The next APAPO CAPP meeting is Sept. 8-11. I look forward to further discussion about membership models/dues structure and will provide members with an update with my September blog entry.

Kathleen Ashton, PhD, ABPP

One of APA Practice Organization's (APAPO) goals is to promote psychologists in integrated health care systems and help them transition into integrated care positions from more traditional practices.  The recent regional integrated care summits sponsored by APAPO ( including the upcoming Midwest Forum in Chicago on June 24 ) are a great example of APAPO's initiatives.  Topics covered will include “Alternative Practice Models,” Working with Payers to Foster Better Care and Demonstrate the Value of Psychology,” “Risk Management and Legal Considerations in Integration,” and “How Psychologists and Physicians Can Communicate and Collaborate More Effectively.”

As a psychologist who has practiced in integrated care for most of my 12-year career, and as I consider transitioning to a new integrated care area, I've been thinking about what makes it work and some of the challenges.

• Integrated team.   Psychologists may be referred within a health care system and located separately, co-located but functioning separately or fully integrated into the team.  My experience is the more fully the psychologist is integrated into the team, the better patient outcomes.  This includes regular integration into meetings, face-to-face discussions regarding patients and coordinated scheduling for patients.
• Staff privileges.   Being recognized as a doctoral provider on par with the rest of the medical staff is key.  Some states/hospitals have rules about this; psychologists as doctorally trained professionals should be seen as colleagues rather than “ancillary staff.”  This can mean better access to research/conference funds, better benefits and more leadership opportunities.
• Flexibility .  Be available to the medical staff/team when needed.  Being able to see patients on the fly in an exam room, by request the same day is important.  Creativity when it comes to office and group space may help you to function better in a hospital environment.
• Outcomes measures. Psychologists have an advantage with their research training, and integrated care is a great place to use these skills.  Showing how psychological treatment positively influences medical outcomes can make your work meaningful to the rest of the team and likely to be tied to economic advantage as health care reform continues.
• Understanding the biopsychosocial model. Good understanding of the medical area you are working with is important as well as the psychological and behavioral factors that affect the condition.  Shadowing the team members, doing background reading and coursework and attending key scientific meetings will help you to be more effective clinically and work with the team.
• Take advantage of teaching opportunities. Psychologists who are part of resident education, in-services for staff and continuing medical education have the opportunity to share their expertise, increase awareness of psychological factors affecting medical care and improve understanding of how they can serve patients.
• Cultural competence .  Psychologists bring a strong understanding of the strengths and the unique needs of diverse populations, which is an asset in the integrated care setting.
• Interpersonal skills.   As a member of a team, it is important to value every discipline and piece of the system.  Learning to navigate the intricacies of hospital politics is essential to success.
• Stay current.   Whether presenting research, attending national conferences or keeping up with journals in your field, psychologists in integrated care must be aware of current trends and be able to apply new knowledge to clinical care.
• Know your reimbursement.   Psychologists are often the odd ducks in a medical model.  They need to understand how their salaries are determined and how their services are reimbursed.  They should be familiar with tracking metrics like CPT codes, RVUs, amount billed, amount collected, PQRS and trends in value-based reimbursement.  It is not the only thing their worth is measured by, but it can be a problem if ignored.

Check out these resources and professional guidelines for integrated care:

• APA Guidelines for Practitioners  
• Guidelines for Psychological Practice in Health Care Delivery Systems
• APA Center for Psychology and Health

It is important for psychologists to be aware of the changes in how providers will be paid for their services. For example, Centers for Medicare & Medicaid Services intends to shift 50 percent of all reimbursements to “value-based” models, and many insurers plan to follow suit.

What exactly are “value-based payments” and how will this effect psychologists? This is an important question that will be important to understand. The main driver of these changes is the general agreement that the current fee-for-service model is financially unsustainable in the health care system and may not produce the best patient outcomes.

The article, “The Future Includes Value-based Reimbursement,” discusses the notion that fee-for-service “pays for more care rather than good care” and details the shift towards reimbursement based on standardized quality measures. Two emerging payment models are highlighted — “global payments” and “bundled payments.” Global payments are a per-patient-per-month model, which includes bonuses based on quality measures, while bundled payments is a model based on pre-determined payments that cover the average cost of all services required for a person's specific episode of care and includes bonuses for providers who achieve certain outcomes at lower-than-expected cost.

While complex and potentially confusing, these models are sure to gain traction and impact all of those who provide health care services. The article concludes with several concrete ways in which providers can prepare for the advent of value-based payments.

Jon Marrelli, PsyD and Lubna Somjee, PhD
Co-chairs, Div. 31 Health Care Reform Task Force

In Part 1 we explored the importance of why patients ought to be asked about quality of care they receive.  In contrast, this subsequent article, “The ACA and Patient Satisfaction: Does It Improve Care?” discusses some of the criticisms of patient satisfaction surveys, suggesting that payments tied to patient satisfaction understate the importance of improving patient health outcomes.

Accountability is useful; however, are we truly taking into account the complexities surrounding measuring good care?  While this article focuses on Medicare, note that Medicare will inform the private insurance companies as they currently work to develop similar measures for behavioral health both within and outside of hospital settings. The links within the article provide a more in depth analysis as well.

While patient satisfaction scores are garnering much attention around health care given that scores will become increasingly tied to reimbursements, there seems to be little attention to what role these may play in the work of psychologists and how this affects the professional of psychology specifically.

We will start to explore this issue on the blog in a two-part series, contrasting both sides of the debate.

Why is Patient Satisfaction Important?

Patient satisfaction is considered an essential component of patient-centered care and is, indeed, a cornerstone of the Triple Aim — widely considered to be the blueprint that must guide our health care system's transformation. The Triple Aim involves improving the U.S. health care system across three domains simultaneously — improving the patient's experience of care (satisfaction), improving the health of populations and reducing the per capita cost of care. Given that patient's feelings of satisfaction are now considered an important indicator of service quality, there is intense interest in obtaining, measuring, rating and making decisions based on how patients perceive the care they receive.

The article, “Measuring Patient Satisfaction: A Bridge Between Patient and Physician Perceptions of Care,” discusses the importance of why patients ought to be asked about the quality of care they receive. Stay tuned for Part 2 of this series, in which we will explore several of the criticisms of patient satisfaction tools and scores.

The article, “Small and Solo Family Practices Provide Critical Services,” discusses alternate models of health care delivery, specifically focusing on small and solo practices. It claims that although there has been a trend towards consolidating and joining larger organizations, those in solo practices serve a vital function. The data on consolidation are not clear cut. While the article focuses on physicians, many of the concepts apply. It begs the questions: Could similar alternate models also be developed by and for psychologists in the future? Are there other potential models, delivering the triple aim, outside of patient-centered medical homes and accountable care organizations?

The Div. 31 Health Care Reform Task Force would like to share with our readers a presentation developed by APA, “Show Me the Change: Removing Barriers Within Medicaid to Psychological Services in Light of Health Care Reform and Medicaid Expansion,” which highlights the many barriers to Medicaid reimbursement. In addition, it addresses the efforts that APA/APA Practice Organization and APA Legal and Regulatory Affairs have made to advocate for psychologists within the Medicaid program across numerous states, including reimbursement for psychology interns and a case study of one state psychological association's efforts to improve Health and Behavior codes for psychologists within the state.

A brief article on Medscape.com identifies the cuts that will affect the Affordable Care Act (ACA). Given the enacted 2015 congressional funding that runs through September 2016, cuts may have an impact down the line on reimbursement and adequacy of provider panels, as well limits on choices of products within the ACA exchange.

Lubna Somjee, PhD, and Jon Marrelli, PsyD
Co-chairs, APA Div. 31 Health Care Reform Task Force

Healthcare professionals are moving towards telehealth as more and more platforms are being designed specifically for healthcare needs. Definitely helpful in remote rural areas where patients may not have adequate access, assuming there is consistent internet access. However, there is also a downside to telehealth.

Do you think telehealth should be utilized by more psychologists? Read about a program in Arizona and decide if and when telehealth might be useful for psychological services as well - and how we may shape this new technology.

Lubna Somjee, PhD and Jon Marrelli, PsyD
Co-chairs, APA Div. 31 Health Care Reform Task Force

A recent article in Behavioral.net discusses how change in healthcare is steadily occurring, "and it will be based on increasing healthcare quality and lowering the cost of care." How do we measure quality in psychotherapy? How does one measure the quality of, say, the therapist? The article raises the point that most therapists believe their skills are above the average, yet they often neglect to actually measure their effectiveness, and patient self-report questionnaires may not be a reliable indicator either. "The question today is whether we dare to measure results...if we don't measure results, we will be treated as an undifferentiated ancillary service, alongside real interventions that have a demonstrated value."

Read the full article.

Does the profession as a whole support defining and measuring our own quality? If not, are there pockets within the profession that do? And what is the current state of measuring clinician and psychotherapy effectiveness? We welcome your thoughts on the matter and encourage you to become active leaders in promoting the profession in this era of healthcare reform.

Jon Marrelli, PsyD and Lubna Somjee, PhD
Co-chairs, APA Div. 31, Healthcare Reform Task Force

We are moving away from fee-for-service and heading towards value-based payments as a way to decrease healthcare costs. Other measures in place include narrowing provider panels and increasing deductibles and co-pays. As a result, it will require insurance companies/payors and healthcare professionals (HCPs) to work together much more closely than they have previously. Some HCPs are willing to do this, and others are attempting to become the payers themselves. A survey of CEOs found that the vast majority believe that increased collaboration between providers and payers is inevitable, "but that doesn't mean the future financial interests of these oft-warring parties will align."

Regardless, changes are rolling out regarding how we are paid and how we provide healthcare services. It would be beneficial for psychologists to attempt to help shape these value based payments as private insurance companies develop their models relating to mental health. Have psychologists found that they were successfully able to negotiate and collaborate with different payor systems? If so, please share your thoughts.

Recently, the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) released a two-page workforce analysis for professional psychology for the years 2012 through 2025.

Among the findings:

• In 2012, there were 188,000 psychologists, with one-third self-employed.
• From 2012 to 2025, the demand for psychologists is projected to grow by 10 percent.
• The supply of psychologists appears to be declining.
• The supply of psychologists between 2012 and 2025 will fall short of demand.

The U.S. government analysis seems to run counter to the beliefs that some psychologists have that the demand is shrinking yet the number of psychologists is increasing.

We wonder if this report aligns with what most psychologists believe about the workforce trends in psychology and also whether the analysis leaves out other important factors that are impacting our field during this transformational time in health care.

Please feel free to share your views.

Jon Marrelli, PsyD & Lubna Somjee, PhD
Co-chairs, APA Div. 31, Health Care Reform Task Force

Given the focus on metrics and patient satisfaction tied into reimbursement, we are finding there may be costs associated with keeping patients "happy" but not necessarily healthy. Below are two brief articles about how patient satisfaction surveys can lead to bad medicine. Given psychology's role in developing measures and conducting/conveying research, learning more about patient satisfaction becomes paramount. The federal expectations call for partnering with professional organizations, as well as working with insurance companies within our state.

The articles suggest:

• A new report by the Hastings Center suggests patient satisfaction surveys that Medicare uses to assess healthcare providers are seriously flawed. The authors question whether the government should be relying on them in quality initiatives such as value-based purchasing.
• The bioethicists also worry that focusing on patient satisfaction as an independent goal has made it "ripe for commercialization" and resulted in a boom of profit-making businesses.
• The current metrics used to rate, rank and evaluate hospital quality continue to undergo scrutiny as the field of quality measurement advances in health care. Improvements are more frequently gained on easily tracked process measures, like using checklists and giving discharge instructions. Still, many have questioned whether focusing on those priorities will lead to improvements in patient outcomes such as lower mortality and lower readmission rates or result in unintended consequences.

The articles referenced above are: "Bioethicists say patient-satisfaction surveys could lead to bad medicine," and "The hidden costs of incentivizing patient satisfaction."

Helen L. Coons, PhD, ABPP, discusses how psychologists can fit into the world of integrated health care. The Affordable Care Act prioritizes the triple aims to increase access to comprehensive, coordinated health care for children and adults across the life span; improve patient outcomes; and reduce costs to the nation's health care budget. This article (PDF, 30KB) highlights practice opportunities in primary care, specialty and community medical settings; health promotion and prevention; as well as innovative ideas for health psychology services in community and corporate locations.

Given trends toward the integration of mental health services into primary care settings, a recent overview on behavioral health supervision and training in primary care is especially timely. The Collaborative Family Healthcare Association blog post, "Supervision in Primary Care," begins as follows: "As the demand for behavioral health providers skilled in the provision of brief, targeted, and population-based assessment and intervention within primary care continues to grow, so does the need for a model of supervision that promotes the acquisition of clinical skills and professional development in this area."

The author provides a handy grid on the training/supervision needs of beginning, mid-level and advanced clinicians, which may be a helpful guide for those who supervise psychologists in expanding practice areas such as primary care settings.

Lubna Somjee , PhD and Jon Marrelli , PsyD
Co-chairs, Health Care Reform Task Force

The article, "Texas Physicians to Benefit from First-Of-Its-Kind Organization Created by Texas Medical Association, Blue Cross and Blue Shield of Texas", outlines an interesting model created specifically for independent practitioners to keep up with changes in health care without being part of an accountable care organization or a patient-centered medical home. We continue to wonder if psychologists, especially those in independent practice, can develop their own innovative models that may benefit them in similar ways, as pay for performance becomes the norm for behavioral health services. We encourage professionals to continue to collaborate, innovate and develop new models that support the role of psychologists. Those familiar with TMA (Texas Medical Association) PracticeEdge or similar efforts should contact us and share your thoughts.

Lubna Somjee, PhD or  Jon Marrelli, PsyD
Co-Chairs, Health Care Reform Task Force

The article, "Power to the Patient: Health Apps, Data & Biosensors Redefine Healthcare" outlines the different ways that technology is impacting medical care, ranging from facilitating communication between clinicians and patients to monitoring patient health remotely. It is likely that the use of technology will spread to behavioral health care as well. What are some ways that psychologists can begin to explore using technology more wisely — before it is done for us?

Lubna Somjee, PhD and Jon Marrelli, PsyD
Co-chairs, Div. 31 Health Care Reform Task Force

With the ongoing decline of the solo practitioner across health care, and the increasing consolidation of practices into larger and larger systems, this timely article is worthy of attention. Written from the point of view of a physician who is in private practice, and whose father before him ran a private practice, the author presciently describes the some of the dilemmas facing the new generation of doctors in a health care system that is shifting "from physician-employer to employed physician."

One of the author's observations: "I can only speculate that newly-trained doctors must learn to be more comfortable with managerial oversight from both physician and non-physician executives. Skill-sets such as effective team building, employment contract negotiation and the ability to co-manage are likely more relevant now than in prior generations, where self-employed physicians predominated."

Although written from a physician's point of view, much is applicable to psychologists as we navigate health care reform.

The Journal of the American Medical Association article, "Designing Smarter Pay-for-Performance Programs," focuses on designing more useful models of Pay-for-Performance Programs (P4P). An October 2008 APA Monitor on Psychology article, "Putting Patients First," seems to be pro P4P, warns it is coming soon and states that psychologists need to partner with other mental health professionals and work with insurance companies in their states to develop sound models.

We are curious to hear whether psychologists have been able to do this within their states or whether they are in the process of doing this effectively? Should psychologists partner with the American Medical Association's Physician Consortium for Performance Improvement given this organization seems to makes significant decisions regarding P4P? Please send comments to Lubna Somjee and Jon Marrelli.

The New York Times article, "Race Is On to Profit From Rise of Urgent Care," highlights the striking rise in urgent care centers nationally, now representing a $15 billion industry with as many as 9,000 centers across the country. This makes urgent care centers one of the fastest growing segments in health care.

The article provides a general overview of urgent care centers, while highlighting the ambivalence that many feel such centers represent. While the centers afford convenience (no appointment needed, evening/weekend hours available, less costly than ER or primary care), there is concern about the quality and the erosion of the patient-doctor relationship. Although mental health services do not appear to be offered at urgent care centers currently, one wonders if it is only a matter of time before acute mental health services are offered and, if so, will psychologists explore this emerging new area of the health care market and should they? Please join the debate.

Lubna Somjee, PhD and Jon Marrelli, PsyD
Co-chairs, Health Care Reform Task Force

Discussion has occurred recently about how state exchanges may seek to standardize the insurance products that they offer, in terms of benefits, provider panels and so forth. However, debate runs rife as to how how they might attempt to streamline and standardize their products. Please see the article, "State Health Insurance Marketplaces Look To More Standardized Plans for 2015," that outlines how some state exchanges are beginning to look at this issue. Is this another opportunity for your SPTA to work with the state exchanges, perhaps in coalition with other mental health and medical professional groups? Consider contacting the exchanges and providing input about benefits, provider panels, the benefits of having robust mental health services, as well as the costs associated with not having widely available services as it relates to mental health and medical issues. 

Lubna Somjee, PhD and Jon Marrelli, PsyD
Co-Chairs, Health Care Reform Task Force

The California Psychological Association's (CPA) Division of Clinical and Professional Practice (Div I)and the CPA Health Care Reform Task Force present a one-day workshop, "Creating An Integrated Primary Care Practice: What To Do & How To Do It," which will take place on June 28, 2014, from 9 a.m. to 4 p.m. The workshop features Christine Runyan, PhD, ABPP, a nationally known practitioner, author and educator in the field of integrated health care. Register today.

Changes in the healthcare landscape are requiring psychologists to advocate in ways we never have before. Advocacy efforts will require all psychologists to advocate in numerous ways locally, at the state and national level. Dr. Karen Postal has generously provided free access to this overview of 360 degree advocacy approach that was published in The Clinical Neuropsychologist. It is a compelling example of advocacy in action that many psychologists can adapt and use going forward. Please see Dr. Lubna Somjee's interview of Dr. Postal about this approach.

Lubna Somjee: Katherine Nordal, Executive Director of the APA Practice Organization gave a shout out to the 360 Degree Model of Advocacy in her Keynote speech at the State Leadership Conference. What is 360 Degree Advocacy?

Karen Postal: The 360 Degree Advocacy model is a structured method of coordinating advocacy efforts that works by sharing best practices from previous, similar advocacy efforts, and involves key state and national decision makers from the beginning. This results in rapid, high impact advocacy.

The structure of the 360 Degree Advocacy teams facilitate targeted, rapid action by placing individuals with experience from previous successful efforts along with key state/ regional organizational decision makers on a 360 Degree Advocacy team. While many advocacy efforts stall while a plan of action developed by a group of advocates is “sold” to leadership of SPTAs or national organizations critical for its implementation, the 360 Degree Advocacy team composition creates “buy in” from the beginning as organizational leaders actively participate in developing the plan.

LS: What led your group to develop this model?

KP: In 2012 the major national neuropsychology organizations got together and realized that our advocacy was inefficient. We were duplicating each other's efforts, we didn't replicate each other's successful strategies, and we had less impact acting alone. The Inter-Organizational Practice Committee was born, with delegates from the American Academy of Clinical Neuropsychology/ American Board of Clinical Neuropsychology, the Society for Clinical Neuropsychology (Division 40 of APA), the National Academy of Neuropsychology, and the American Board of Professional Neuropsychology. The IOPC developed this model in the two years we have been working together.

LS: Can you tell me more about how the model works?

KP: Here's how the model works with neuropsychology. Other specialties of psychology could do something very similar.

The 360 Degree Advocacy model is activated when a practitioner/ neuropsychologist learns of a critical practice or advocacy issue. The neuropsychologist informs the practice and advocacy committee of his/her national neuropsychology organization (e.g., AACN, APA D40 or NAN). The matter is discussed in committee and if appropriate the practice and advocacy chair (who is also a delegate to the IOPC) refers the issue to the IOPC.

IOPC delegates share information about current or past advocacy efforts in the area of concern. In this way, the IOPC identifies previously successful advocacy efforts carried out in parallel circumstances in other areas of the country. The IOPC recruits neuropsychologists who participated in other advocacy efforts to participate on a 360 Degree Advocacy team, along with local neuropsychologists (typically those individuals who brought the issue to attention) and SPTA/ regional neuropsychology leaders. State level providers carry out action with input from the 360 Degree Advocacy team. The result is a rapid advocacy response, using best national practices, with buy in and “boots on the ground resources” from local clinicians and state level leaders. The model can also be triggered when a SPTA, regional neuropsychology association, or national neuropsychology organization learns of a practice, access, or legislative threat or opportunity .

LS: Can you tell us about some recent successes with the model?

KP: In June of 2013, First Coast Services, Inc., the regional Medicare carrier for Florida, Puerto Rico, and the Virgin Islands, announced that it was revising its local coverage determination (LCD) for neuropsychological services. Alterations to the number of hours considered typical for neuropsychological assessment, which ICD-9 codes would demonstrate medical necessity, and the scope of neuropsychology services, were among the proposed changes in the LCD draft that was released. These changes were very unfavorable for psychologists and neuropsychologists in the region. The IOPC put together a 360 degree advocacy team which included the SPTA president and Executive director of the effected state, decision makers from each of the IOPC member organizations, and national experts who had experience in fighting LCD changes. The result was a letter signed by all of the national neuropsychology organizations, and the SPTA outlining requested changes. Just about every single one was adopted in the new LCD. Our article talks more about this.

LS: Any new advocacy in the works?

KP: Yes, we now have a 360 degree advocacy team that is fighting changes in the LCD for National Government Services. This is the largest team ever compiled, consisting of the SPTA president of 11 states, as well as two regional neuropsychology organizations, APAPO legal experts, and the IOPC leaders. So far, we have had a huge success. We will be announcing details soon.

LS: Any last thoughts?

KP: I want to encourage SPTA leaders to read the article, and think about implementing similar targeted advocacy efforts. We think this model will work for rehab, clinical, really any specialty advocacy effort. The key is figuring out who key decision makers are, and who already knows what they are doing from previous, similar advocacy efforts, and get those people together to make things happen.

Bio: Karen Postal, PhD, ABPP-CN

Karen Postal is the president-elect of the American Academy of Clinical Neuropsychology. She is the immediate past president of the Massachusetts Neuropsychological Society and a past president of the Massachusetts Psychological Association. Dr. Postal sits on the Medicare NGS Clinical Advisory Committee and the American Psychological Association's Advisory Group on State Implementation of Health Care Reform. She is the founding chair of the Inter-Organizational Practice Committee, a super-committee of the advocacy chairs of the American Academy of Clinical Neuropsychology, the National Academy of Neuropsychology, Division 40 of the American Psychological Association, and the American Board of Neuropsychology.

Dr. Postal is a board certified neuropsychologist and a lecturer at Harvard Medical school where she teaches postdoctoral fellows in neuropsychology. She has a lifespan private practice in Andover, Mass., dedicated to helping people think better in school, at work, and throughout later life.

The article, "Population Health: The Risks & Rewards," primarily focuses on population health rewards. It is a useful reminder about what health care providers, as well as psychologists, can expect to grapple with during the next few years. The article defines population health, how provider reimbursement is changing and will continue to change, and the need for clinical integration.

As the new co-chairs of the Div. 31 Health Care Reform (HCR) Task Force, we are eager to roll up our sleeves and get to work. As we have been witnessing, the landscape of health care has been changing rapidly, and there are more changes yet to come. Given how health care is rolling out on the ground, the impact on our field, and ultimately the people we serve, it is clear that psychologists will need to work together en masse if we are to survive and thrive in this new health care environment. 

As chairs, our hope is to provide you with links, posts and comments regarding the changes in health care that are important, inspiring, thought provoking and at times even provocative. 

There are numerous psychologists developing innovative ideas to thrive within HCR - psychologists who are developing important advocacy efforts. Important conversations are also being held on key legislative, professional and training issues impacting our field. We feel confident that if we can all come together and share ideas, pool advocacy efforts and work together to help each other, we can continue to help those we serve to the best of our ability. 

To connect psychologists and pool key information that they will need to know/have access to, our task force will be working on three main initiatives throughout the course of the year: 

1. We will post regularly on the Div.31 HCR Blog. This blog will continue to be a place where all SPTAs can go to obtain information regarding HCR including developments, advocacy efforts and ways to navigate HCR. Please feel free to contact us if you feel there is information that may be useful to share with other SPTAs through the blog. 
2. During the year we are planning to develop an HCR online library that contains information that psychologists can refer to and use within their own States. This might include templates outlining certain advocacy efforts, innovation in relation to private practice, information regarding the Affordable Care Act, training to work within integrated care settings and so forth. Again, feel free to contact us with information that might be useful to include in our online library. 
3. Our task force is planning on developing an HCR email list whereby representatives from SPTAs who are involved in HCR can share important information in a timely manner. 

The more we can pool information and share ideas, the more psychologists can access information that can help them in their work, and at the state level. We look forward to working to inform and connect STPAs on matters pertaining to health care reform. 

Lubna Somjee, PhD and Jon Marrelli, PsyD
Co-chairs, APA Div. 31 Health Care Reform Task Force

Adam Benton, PhD, describes changes in the Arkansas payment system for healthcare providers as follows: 

1. In a nutshell, Arkansas Medicaid is completely revamping the way it reimburses, the rates it reimburses, and services that are billable through Medicaid. It is exploring national averages for payments and offering payment for many services that it currently does not reimburse but that research suggests are effective, such as psycho-education. 
2. The intent of Medicaid's reforms is to create a Medicaid behavioral health system that rewards higher quality of care while reducing cost. The proposed system will create three new entities that will help manage and coordinate the mental health needs of Medicaid patients. Many of these processes and functions are still being defined. The new entities include Patient Centered Medical Home, Behavioral Health Home, and Independent Assessors. In their own roles, each entity will be responsible for ensuring that patients get quality care and that providers communicate with each other. 
3. Medicaid is switching from a "fee for service" model to "episodic payment packages" for its more expensive mental health problems. In this switch, providers and agencies who treat patients more efficiently than the average, will receive a share of the financial gain. Those whose average cost per client group (grouped by diagnosis) is higher than the state average will share in the financial risk.  As you may know DHS has already implemented an episodic payment structure for ADHD, and has designed packages for ODD, and Comorbid ADHD / ODD. ArPA was involved in the design of all three models. Last I heard, the ODD and Comorbid packages were held up in congress. My view of these three models is that the ADHD model will probably work sufficiently. It provides ample range of services and may be financially beneficial for a lot of providers, but is slightly restrictive in the amount of funds allowed for treatment. The ODD and Comorbid packages are generous in the services offered and designed to reflect what research suggests is good treatment for these conditions, such as family therapy, teacher consultation, parent education, and parent training.
4. Starting in July of 2014 Medicaid patients will be assigned to a Patient Centered Medical Home, or PCMH, who will be reimbursed not only for providing medical services but also for managing and coordinating services provided by other clinicians, such as psychological or speech therapy.  The PCMH will most likely be the patients current PCP. 
5. All patients will maintain their PCMH while still receiving outpatient care to private practices, local clinics, or community health centers, but hopefully with increased communication between providers, since the PCMH will be reimbursed for coordinating care. The PCMHs will function like case managers and will be reimbursed at a rate between $1 and $30, for each patient per month.
6. Mental health services will be divided into three tiers of available services to be reimbursed by Medicaid.  Tier 1 will include the vast majority of patients seen for mental health services. Tier 2 will include those with higher levels of severity and Tier 3 will be those with the greatest need for services.  At each Tier, Medicaid patients will have access to all the services available in the previous Tiers and then additional services, such as residential treatment, respite and therapeutic communities for those in Tier 3.
7. All Medicaid patients will have access to Tier 1 services without prior authorization. Those needing more services than allowed for Tier 1 will progress to Tier 2 and will have to be evaluated by an Independent Assessor, and an Independent Care Plan will be created. The Independent Assessment will be conducted by a contracted organization who provides assessment only, no treatment.  The assessment will measure functional impairment, not diagnostic clarification. Medicaid will release the proposal and seek bids for this new entity, "Independent Assessor." 
8. Most community providers will function under Tier 1. Tier 1 services include individual therapy, group therapy, marital/family therapy, multifamily group therapy, psychoeducation, mental health diagnosis, interpretation of diagnosis, substance-abuse assessment, psychological evaluation, psychiatric assessment, and pharmacological management. No prior authorization needed, although the services will have a limit. The larger organizations, with hospitals, day treatment, and substance abuse treatment, will likely be Tier 2 and Tier 3 sites.
9. All patients, regardless of Tier, will have access to Crisis Services and hospitalization. Although hospitalization will put in place an immediate referral for the Independent Assessment, placing them in Tier 2 or 3, and assigning them to a Behavioral Health Home (BHH), which will function like a mental health-specific care coordinator. At such time, the patient will have a PCMH to coordinate medical needs and BHH to coordinate mental health needs. DHS will release criteria for agencies to apply for BHH status.
10. The DHS committee charged with making reforms remains open to ideas, concerns and discussions. They have a large team at DHS and an outside organization, the McKenzie Group on the project. They hold public forums for anyone interested in attending, in addition to our core workgroup meetings and other focus groups among stake-holders.

For additional information, see Arkansas Payment Improvement Initiative. This article is posted in full on our clinic website for anyone interested. 

Adam Benton, PhD 
Licensed Psychologist 
ArPA Vice President-Elect 
Telephone: (501) 812-4268

Michael Goldberg, PhD, Acting Director of Professional Affairs for the Massachusetts Psychological Association (MPA), has provided this update regarding a recent legislative victory in the battle for transparency in the use of "proprietary" guidelines to approve or restrict benefits for neuropsychological care of patients. Congratulations to our colleagues in Massachusetts for effectively advocating for transparency in the decisions made by health plans in the medical necessity criteria they use to determine access to care for patients. Follow the progress of this bill.

In 2010 Elena Eisman, Karen Postal and I debriefed after a meeting with BCBSMA related to their implementation of new medical necessity criteria that they purchased from McKesson, a large out of state corporation. BCBSMA refused to give us information about these criteria citing that they were "proprietary." We believed that they were using these criteria to justify unreasonable restrictions in access to legally mandated neuropsychological services. At that meeting I proposed a legislative initiative to combat this by requiring "transparency" from the health plans in the medical necessity criteria that they use.
 
MPA worked with House Representative Ruth Balser, PhD (Psychologist-Democrat-Newton), to file legislation to require such "transparency" from health plans for all health care services. This legislation: 

1. Required health plans to make the criteria available to providers, even if they were proprietary. 
2. Required that any adverse determinations or other denials for coverage must be made by a provider in the same licensure category as the ordering provider.
   
   Thanks to immense grass roots advocacy by Karen Postal, PhD, Andi Piatt, PhD, and others the legislature and governor acted favorably on our initiative. The legislation was eventually worked into Chapter 224 of the Acts of 2012 (the health care reform law), which was passed.
    
   This has been four years in the making; final implementation of this legislation reflects a great victory for us and will give us one more tool to combat unfair practices by health plans in preventing access to behavioral health services. 

In their article, “Moving Towards Population Health Management What You Need to Know,” the members of the New York State Psychological Association Health Care Reform Taskforce discuss how primary health care is adopting the “practice-based population health” model, which assumes that medical providers are responsible for improving the overall health of the population they manage, and not just for treating individual patients who come to them for care.

Glenn Ally, PhD, a consulting psychologist in Louisiana who provides services at a hospital in addition to maintaining a private practice, shared his approach to negotiating hospital fees on the Div. 42 email list recently. He graciously permitted Div. 31 to repost his response to provide information to psychologists who negotiate fees for hospital-based consultation and testing services. As psychologists look for integrated care practice opportunities, they can benefit from learning from colleagues' experiences in fee negotiation for specialty services. 

As first posted on Div 42's email list, Dr. Ally wrote:

I've always negotiated contracts based upon my private practice hourly rates. I say rates because I give them the range...my hourly rate for psychotherapy, my hourly rate for testing, my hourly rate for forensic work, and my hourly rate for deposition. I indicate that I will not go below the lowest of these figure...why should I when I can stay in my office and make that amount rather than the inconvenience of travel time to and from the hospital (for which you will probably not get paid). 

A second approach is to get figures on the reimbursement rates from the various providers for which you may have fee schedules and charge what would be the highest on those fee schedules. Why the highest? Because, very often the reimbursement rate is lower than your hourly fee and there is inconvenience in traveling to and from the hospital and inconvenience of lugging testing supplies and equipment to and from the hospital, etc. Also, keep in mind that you may not be able to provide the reimbursement schedule given to you by insurance companies (proprietary info), but it is quite likely that the hospital has access to this info since they tend to be providers for many insurers. So, I will indicate to the hospital which insurers I provide services for and without attaching a provider to a fee, I will indicate the range of fees that are paid by these insurers. 

I ALWAYS negotiate to get paid for the time whether or not the patient shows up. They have scheduled your time, time for which you could have been reimbursed had you stayed in your office to see patients. Finally, I also negotiate to get paid whether or not the hospital gets reimbursed for the service. I have been able to convince the hospital that they can avoid scrutiny by regulatory agencies by them providing needed services to those who can pay and not providing needed service to those who cannot pay. So by having the hospital pay me as a contractor, I will see all patients, regardless of ability to pay, because I will be paid by the hospital and they can avoid scrutiny regarding discrimination against those who may not be able to pay. The hospital may indeed be able to find some way to avoid providing some services if a patient cannot pay, but very often then would simply rather pay me to see everyone rather than draw the attention of any regulatory agency. 

Thank you, Glenn Ally, for sharing your experiences in negotiation with Div. 31 members. 

Leslie Riley, PsyD, HCRTF Chair

As we begin to focus upon our forthcoming annual APA Convention, to be held in Hawai’i, we should reflect upon the challenge issued by Practice Directorate Executive Director Katherine Nordal at this year’s exciting State Leadership Conference (SLC) to get personally involved in our state association’s legislative efforts. 

Nordal has a wonderful gift of vividly capturing the most critical agendas:  This year, “Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  No one else is fighting the battles for psychology… and don’t expect them to.”  Last year, “If we’re not at the table, it’s because we’re on the menu.  And I quite frankly don’t want to be on anybody’s plate to be eaten.”

Phelps’ vision:

APA launched its new Center for Psychology and Health under the direction of CEO Norman Anderson in January. One component of that center is a new Office of Health Care Financing (OHCF), which we are currently setting up and will be directed by me.  First, some background. As Anderson has indicated in a number of venues, the purpose of the new APA Center for Psychology and Health is to vigorously pursue Goal Two of APA’s Strategic Plan: Expand psychology’s role in advancing health. The center pulls together top leadership, staff, and major initiatives across all of APA to focus the association’s efforts on four inter-related challenges outlined by Anderson towards achieving this goal. They are:  1) Workforce, education and training challenges; 2) Influencing how we are viewed by policy makers, the scientific community, other disciplines and the public; 3) Addressing how we view and define ourselves; and, 4) What Anderson calls the ‘getting included, getting paid’ challenge. There is, and has been, a tremendous amount of work by APA on each of these challenges, and we will keep the membership informed.

Health Resources and Services Administration (HRSA):

Having finally completed deliberations on its very contentious Fiscal Year 2013 budget, the administration recently submitted its request for Fiscal Year 2014.  Administrator Mary Wakefield, who has participated in Cynthia Belar’s Education Directorate Advocacy Breakfast: 

As a result of the continuing diligent efforts by Belar and Nina Levitt, the HRSA budget request includes $2,892,000 for the Graduate Psychology Education (GPE) program, which was the level provided in FY 2012 (with a slight increase in FY 2013).  This APA sponsored program funds accredited health profession schools, universities, and other public or private nonprofit entities to plan, develop, operate, or maintain doctoral psychology schools and programs and programs in mental and behavioral health practice to train psychologists to work with underserved populations.  The program is designed to foster an integrated and interprofessional approach to addressing access to behavioral health care for vulnerable and underserved populations.  Fifty-five percent of graduates were underrepresented minorities and/or from disadvantaged backgrounds and 29 percent report practicing in a medically underserved area.  In support of the program, HRSA noted that mental disorders rank in the top five chronic illnesses in the U.S. and that the National Alliance on Mental Illness reported approximately six percent, or one in 17 Americans suffers from a serious mental illness.  Serious mental illnesses cost society approximately $193.2 billion in lost earnings per year.  Individuals suffering from a serious mental illness earned at least 40 percent less than people in good mental health, confirming that mental disorders contribute to significant losses of human productivity.  Over the years, we have come to appreciate that the federal government is much more sympathetic to paying for clinical services rendered by practitioners when it has supported their training.

The Office for the Advancement of Telehealth (OAT) would receive $11.5 million, which was also its level in FY 2012.  Funds would be provided for two grants under the Licensure Portability Grant Program, as well as associated technical assistance and evaluation activities.  OAT anticipates that 204 communities will have access to adult mental health services and 239 communities will have access to pediatric and adolescent mental services by FY 2014.  The OAT programs are viewed as an integral component of the overall DHHS Improve Rural Health Care Initiative to expand the use of telecommunications technologies that increase access to and improve the quality of health care provided to rural and underserved populations.  Telehealth programs strengthen partnerships among rural health care providers, recruit and retain rural health care professionals, and modernize the health care infrastructure in rural areas.

Very Timely Steps  - Division 31:

Intriguing Incremental Steps:

Those involved in shaping APA’s Guidelines for the Practice of Telepsychology, which is a collaborative effort by APA governance entities, the Insurance Trust, and the Association of State and Provincial Psychology Boards (ASPPB), have taken notice of the parallel evolution of the notion of an “E. Passport” by ASPPB.  This would address a number of issues surrounding interjurisdictional telepsychology practice and ASPPB is currently seeking public comment on their preliminary proposal.

The ASPPB Telepsychology Task Force is considering the E. Passport proposal as such a mechanism to monitor and regulate interjurisdictional telepsychology practice.  This goes directly to the underlying issue of licensure mobility which, with the advent of technology and integrated health systems, must be effectively addressed in a timely manner if psychology is to remain competitive within the global health care environment.

Clinical Pharmacy:

Pharmacy’s visionary approach proactively addresses the complex issues surrounding providing telehealth services by their profession. 

Aloha,
Pat DeLeon
former APA President

Multidisciplinary, interdisciplinary, trans-disciplinary, multispecialty, integrated, interrelated, interprofessional, and collaborative. These terms suggest the concept of teams of health care providers working together offering comprehensive, quality, affordable health care. The idea is not new. "The concept of medicine as a single discipline concerned with only the restoration of individual health from the diseased state should be replaced by the concept of ‘health professions’ working in concert to maintain and increase the health of society as well as the individual” (Coggeshall, 1965; Mills, 1966).

APA's recently published "Core Competencies for Interprofessional Collaborative Practice" (APA, 2009) defines ”interprofessional” or “Interprofessionality” as “the process by which professionals reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client/family/population… [I]t involves continuous interaction and knowledge sharing between professionals, organized to solve or explore a variety of education and care issues all while seeking to optimize the patient’s participation. Interprofessionality requires a paradigm shift, since interprofessional practice has unique characteristics in terms of values, codes of conduct, and ways of working.”

What Are Barriers to Interprofessionalism?

Although the need for collaborative approaches to health care delivery is clear, barriers exist which hinder implementation. One of the biggest barriers to accessing behavioral health services is the critical shortage of treatment capacity. Currently, 55 percent of U.S. counties have no practicing psychologists, psychiatrists or social workers (NAMI, 2011). Another barrier can be legislative. A remnant of the 19th century, the Corporate Practice of Medicine Doctrine holds that physicians should make medical decisions autonomously. The logic was that if businesses owned by non-physicians controlled the delivery of health care, health care could be decided based on a profit motive, rather than the best interests of the patient. The Doctrine prohibited "lesser licensed" providers from controlling or directing health care. This limitation is particularly onerous in an era of technological advances including electronic health records, computerization and the need for capital to grow a business.  Because states vary in the application, requirements and limitations of the doctrine, it is costly for providers wanting to practice interprofessionally to navigate this legal minefield. Violating the doctrine can put providers at risk of running afoul of licensing laws. Twenty-two states currently allow differently licensed health care providers to form corporate entities, while five jurisdictions have some flexibility to do so. The remainder of the states do not allow these entities (Nessman, 2011).

Other barriers to interprofessional practice include: hierarchical attitudes, differential and declining reimbursement rates for similar services, lack of understanding of the advantages of interprofessional care, fear of change, risk aversion and the challenge of developing an entrepreneurial spirit. These challenges, coupled with psychologists having little formal business training, hinder the transition to interprofessional mental health care delivery.

While innovation and interprofessional groups are the cutting edge of mental health care delivery, according to an APA Practice Survey of Practitioners (2011) with over 2,500 respondents, fewer than 12 percent reported working in a group practice, while 49 percent indicated they were solo practitioners. Those solo practitioners with established practices, or with niche practices, will likely continue to thrive as health care reform unfolds due to supply and demand and having an established referral base, while many other psychologists will move into groups with interprofessional practice opportunities. Early career psychologists will be challenged as they compete in a crowded and confusing marketplace.

The Group Practice Turnkey Model: Rainier Behavioral Health, PLLC — A Thriving Model of Interprofessional Practice

Rainier Behavioral Health in Tacoma, Wash. was established in 1985 as an interprofessional mental health clinic. We currently see approximately 18,000 patient visits yearly, with almost 2,000 new cases each year. Initially configured as a partnership due to existing Corporate Practice of Medicine Doctrine laws preventing a psychologist and psychiatrist from incorporating, the partnership had extensive liability exposure. In 1995, the Washington State Psychological Association, in partnership allied health providers, lobbied successfully to repeal the Corporate Practice of Medicine Doctrine.  Over the years, as the value of interprofessional care became acknowledged as an effective approach to mental health provision, the clinic evolved into its current complement of 17 therapists, including four physicians, a pediatric advanced registered nurse practioner, eight psychologists and four social workers. The practice is incorporated as a Professional Limited Liability Company (PLLC).

Organizational Structure of Rainier Behavioral Health

There are eight full-time and two part-time support staff. Two full-time support staff handle triage, insurance verification and authorization and initial appointment scheduling. Front desk staff are responsible for patient check in, rescheduling, co-payment collection, phone calls, faxing and file management. Billing support staff handle billing issues and insurance submission, while the part-time bookkeeper manages accounts payable, payroll, tax filing and benefits management. Therapist and support staff benefits include health insurance, a flex benefit plan, retirement plan access, life, disability and accidental death and dismemberment insurance, optional dental and vision coverage and vacation and sick leave.  Prescription refills, supplies, equipment maintenance contracts, repairs and support staff management are handled by the office manager.

Employees are W-2 employees. The practice pays malpractice, a yearly continuing education allowance, Social Security, Medicare, unemployment and other mandated taxes, furniture, office supplies, Internet and telephone access, utilities and maintenance. Our philosophy is that Rainier Associates hires well trained, quality therapists who can work as a team in providing excellent mental health care in an interprofessional environment. Our motto is: "Quality is Economy." Each therapist who joins the group automatically qualifies as a member of the insurance panels we contract with, as we have clinic status. Early career psychologists have an advantage in this regard as panels that might exclude them because of inexperience, or panel closure, include them as part of our group.

Therapists are paid a percentage of what they collect, with more revenue yielding a higher percentage. There are no set working hours, no set vacation periods, no micromanaging of time on site. While we hope that productivity will be high and that therapists will work full time (defined as 20-25 weekly billable patient hours), we understand that life happens and that productivity varies over the course of a therapist’s career. Because we are a large group, when a therapist is out, we cover for each other, maintain referral, scheduling, billing and continuity of care. Insurance companies only have to deal with one tax ID number, one point person for credentialing and one payment to the group. Insurance companies are businesses, too, and efficiencies of scale matter.
       
Group practices can provide a valuable and viable model for interprofessional practice. This article briefly describes Rainier Behavioral Health's turnkey model as an example. Rainier Behavioral Health does not have rigid controls on productivity, a competitive work environment or the lowest overhead costs. What Rainier Behavioral Health offers, however, is a collegial interprofessional mental health clinic model that maximizes the therapists’ skills and training, while benefitting from its larger scale in both insurance collections and the value of support staff. 

References

American Psychological Association. (2011). APA practice practitioner survey. Washington, DC: Author.

Coggeshall, L. T. (1965). Planning for medical progress through education. Washington, DC: American Association of Medical Colleges.

D’Amour, D., & Oandasan, I (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care, Supplement 1, 8-20.

Interprofessional Education Collaborative. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: Author.

Mills, J. S. (1966). The graduate education of physicians: Report of the citizens commission on graduate medical education. Chicago: American Medical Association.

National Alliance on Mental Illness. (2011, January). Workforce development: Policy brief. http://www.nami.org/template.cfm?Section=About_the_issue&Template=/ContentManagement/ContentDisplay.cfm&ContentD=114129.

Nessman, A. (2011). APA Practice Organization legal research. Unpublished raw data.

Barry Anton is in independent group practice in Tacoma, Washington. He is board certified in clinical child and adolescent psychology. He served three terms on the APA Board of Directors, and is candidate for APA president-elect.  For information about his candidacy, see his campaign website.

Contact information:

Barry S. Anton, PhD, ABPP

Rainier Behavioral Health

5909 Orchard West

Tacoma, WA 98467

Telephone: (253) 475-6021

A group of psychologists in Massachusetts worked with Representative Ruth Balser (a licensed psychologist) to file an act to promote efficient access to mental health services. This bill aims to provide important protections for behavioral health providers and the vulnerable citizens that we serve.  The bill recognizes the importance of the therapeutic relationship in psychotherapy and aims close loop holes in our insurance laws that allow health plans to use aggressive tactics to terminate contracts with behavioral health providers as punishment for advocacy efforts or as a negotiating strategy. This bill would require a longer period of notice for health plans to non-renew provider contracts. It would also require health plans to show cause for not renewing provider contracts, and demonstrate that any lawful communication concerning regulations and statutes that effect service delivery is not a factor in said nonrenewal. Further, should a behavioral health plan not renew a behavioral health provider contract, said plan would be required to cover payment for an existing patient receiving services prior to the termination date of the contract, until such treatment is no longer medically necessary consistent with terms of contract in place at the time of nonrenewal and usual and customary utilization management processes. Further, behavioral health providers would not be prohibited from collecting any portion of a deductible for services rendered at the time of service. 

This bill received a favorable vote in the Mental Health Committee but stalled in the Insurance Committee in the 2012 legislative session. It was revised and refilled for 2013. The grass roots legislative action was welcomed and supported by the Massachusetts Neuropsychological Society. Given the new revisions that clarify some language that was unclear, we are hoping for unequivocal support of Massachusetts psychologists in passing this bill in the current legislative session.
 
Michael A. Goldberg, PhD
Director
Child & Family Psychological Services, Inc., d/b/a Integrated Behavioral Associates
Pioneering the Integration of Behavioral Health in Massachusetts Since 1994
169 Libbey Parkway, Second Floor
East Weymouth, MA 02189

For many years, the U.S. government and the APA have been discussing health care reform. Psychologists have been working in health-related settings [http://drerlangerturner.blogspot.com/2013/04/psychologist-healthcare.html] for a number of years addressing mental and physical health conditions. Given priorities in health care reform and policies related to the Affordable Care Act (ACA), APA has been positioning itself to make sure that psychologists have a seat at the table. For a complete description of APA’s goals and priorities visit their website.

ACA and Health Care Reform

The ACA was passed by Congress in 2010 and they are in process of clarifying ACA’s implementation. There are several benefits of ACA such as eligibility for prevention services at no additional cost (e.g., wellness visits and cancer screening), coverage of pre-existing conditions for children, and improved services for older adults. There are also implications important for behavioral health practitioners. The APA Practice Directorate recently published an article discussing integrating behavioral and physical health.

Implications for ECPs

Whereas there is potential great benefits of health care reform, there are some serious implications for early career practitioners (ECP). For many ECP’s, we graduate with concerns about paying off debt and succeeding in practice. One potential limitation of ACA is implementation by insurance companies. If you're not working fee for service then you may suffer considerable financial difficulties as a result of billing for your services. Many ECPs are unaware of billing issues prior to obtaining their license to practice. This is primarily due to little information being provided as a graduate student about business of practice issues. Many insurance companies have requirements for becoming a provider (e.g., length of licensure). I personally had to deal with this issue a few months ago where I practice in Virginia. I could not provide services to this child and their family because I was not a provider for their insurance (due to not having my license more than 3 years). That being said, this limitation not only impacts ECP’s ability to bill for services but it also lowers the number of qualified practitioners available to meet the needs of individuals suffering from mental health difficulties.

Several months ago, I had the opportunity to write a piece in The New York Times on President Obama’s policy related to gun violence and mental health. The president called for increase gun control legislation and mental health services. APA also published a statement in support of initiatives to address gun violence of which includes calling for mental health coverage at parity in private and public health insurance plans. There are many opportunities available to increase access to mental health services through health care reform. However, early career practitioners may not benefit from these changes for years. It is important for us to pull together as a field to work towards advocating for more appropriate regulations for psychologists who work in a number of setting including integrated health care systems. Our future as practitioners is at stake let’s be involved in the conversation.

Dr. Erlanger Turner
Assistant Professor of Psychiatry
Virginia Commonwealth University

Check out Sue Franz's, Division 31's technology specialist, simple steps for using free videoconferencing services.

The Coalition for Patients' Rights (CPR) issued the press release, "State Health Insurance Exchanges, Legislation Keep Scope of Practice Issues Front and Center," in which APAPO staff provided input and APA Executive Director for Professional Practice Katherine Nordal, PhD, is quoted in the release on behalf of CPR. APAPO is a founding member of the CPR.

With 42 million more people due to have insurance by 2014, there will be a great need for psychologists and other professionals to practice to the full extent of their licenses. This has caused a backlash by those in the medical profession wanting to protect their scope of practice and deny expansion to other groups. Such a backlash will deny access to care for many Americans.

Emergency Department Diversion (PDF, 506KB) is a pilot project that was executed in Central Oregon, as part of the larger Health Integration Project. It aimed to demonstrate how integrated care can reduce emergency room visits. Below is an excerpt from the report that summarizes the project and the importance of collaborative care: 
 

The Central Oregon region created the 'Central Oregon Health Council,' (COHC) a public/private partnership that includes Crook, Deschutes and Jefferson Counties, the region's health system, the region's Medicaid payer, the region's safety net clinics and the Oregon Health Authority. Over the past 18 months, COHC has overseen the Health Integration Projects, focusing specific attention on high utilizing/high need patients who are disconnected from the regular healthcare system and suffering from the social disparities that impact an individual's overall healthcare. This approach began with the Primary Medical Home pilot at Mosaic Medical, next extended to the Emergency Department (ED) Diversion project, and has now expanded into the Integrated Primary Care project, the Program for the Evaluation of Development and Learning (PEDAL Clinic), and the Affordable Medication project. This report highlights only the Emergency Department (ED) Diversion project....The Central Oregon Health Council has determined that the ED diversion project has been successful in achieving the goals of the Triple Aim: better health, better care, and lower cost, and as such has become an important intervention in the Central Oregon community. Learnings from this project continue to inform the development of integration projects locally and across the state, using the collaborative care models developed in this initial project.

Sue Frantz discusses upgrades to desktop sharing software in a post, "Join.me: New Functionality," on her Technology for Academics blog [SueFrantz.com]. Sue will continue to publish articles about how technology can increase leadership and advocacy efficacy.

Sue Frantz
APA Division 2: Society for the Teaching of Psychology; Vice President for Resources
Editor, APA's Online Psychology Lab
APA Membership Board

Dr. Jerry Grodin, the recently hired Director of Professional Affairs and past president of the New York State Psychological Association, discusses the future of reimbursement for services in his article, "Capitation vs. Fee for Service: Guess What's Coming?" (PDF, 58KB).

Preparing the Interprofessional Workforce to Address Health Behavior Change (PDF, 1.3MB) provides resources about how to engage in integrated behavioral health care. Among other critical findings, the report found that Electronic Healthcare Records (EHRs) enable collaborating professionals within the integrated health care settings to understand the behavioral risk factors that exist in each case and to be kept informed about the health behavior changes that occur with psychological service interventions. The APA Board of Educational Affairs provided technical support to Dr. Ron Rozensky, a distinguished psychologist, who chaired this report for the Secretary of the Department of Health and Human Services.

Coming soon from Division 31 and 42, a digest of the law of each State regarding record keeping and accompanying State specific EHR templates to assist psychologists to move into integrated health care communities in a competent and efficacious manner.

Dr. Donald McAleer, PsyD, ABPP, from the Pennsylvania Psychological Association, engages in a video discussion with state Rep. John Evans (R-Erie/Crawford) about how to communicate concerns effectively with elected officials.

Early career psychologist and Division 31 member Dr. Samantha Slaughter advocated on behalf of psychologists in Washington state during the Washington State Senate Health and Long-term Care Committee work session. She was part of a panel of providers testifying about mental health parity, reimbursement, integrated healthcare and healthcare reform. Read and view a video of Dr. Slaughter's excellent testimony about the problems of reimbursement rates for psychologists below:

Watch Dr. Slaughter's Testimony

Insurance Reimbursement Issues

Good afternoon Madame Chair and members of the Committee. My name is Samantha Slaughter. I am a licensed psychologist in private practice in Seattle. I am also the assistant director of the Fremont Community Therapy Project, a low-cost mental health services clinic. Today, I am representing the members of the Washington State Psychological Association.

Two years ago, when the Uniform Medical Plan changed its third party administrator contract to Regence BlueShield and adopted Regence's reimbursement system, income for psychologists providing mental health services to public employees dropped, in some cases by up to 30 percent. This year, Premera Blue Cross reduced reimbursements to psychologists over 11 percent. In the best cases, our reimbursement rates have remained stagnant for a number of years.

Of course, psychologists know that neither the Legislature nor the Office of the Insurance Commissioner (OIC) regulate reimbursement rates in commercial insurance. We know that the lowering of reimbursement rates is a trend unlikely to change in the near future and that we must take command of our careers and how we individually respond to this reality. We are doing just that.

Psychology is a leader, both through research and practice, in supporting the notion that good health care supports both the mind and the body. In 1998, we drafted the state's wonderful mental health parity mandate in order that patients could afford to use both medical/surgical and mental health care. We have actively supported state legislation creating health care homes and integrated systems of care. In 1996, WSPA sponsored and passed legislation amending this state's professional services corporation laws allowing differently licensed health care providers to form corporations in order to integrate care and to address new payment systems.

But we also know that issues involving reimbursement have broad and significant implications for the Legislature as you consider federal health reform implementation and the impact of this situation on access to mental health services.

The irony was not lost on WSPA when one of our members made this observation subsequent to the Premera fee reductions this past spring:

"Since I became licensed as a psychologist, all the major insurance panels in Washington State have been closed to new behavioral health providers. After years of effort, I have finally become credentialed, only to discover that I now earn less as a paneled psychologist than my newly licensed colleagues who are on no panels."

Our colleagues strive to become credentialed on insurance panels because they know what we knew when WSPA drafted the state mental health parity legislation: that access to mental health services increases when copays are reasonable, when there is one family deductible, and residents can actually afford to use their insurance coverage. But, we are now left to wonder if we can still afford to remain in insurance systems that attempt to effect health care savings on the backs of providers.

We urge this committee, the legislature, and the OIC to pay close attention to network adequacy and the implications of fee reductions on network adequacy right now, and most importantly, going forward as rules governing the new Exchanges are developed. Even as reimbursements go down, health costs still rise. As networks are affected, the delivery of health services becomes more fragmented. This is not the way to successful integration of health services.

This committee knows from testimony by both the Boeing Company and Group Health Cooperative integrated care pilot programs that health care costs are reduced when we reduce hospitalization and inappropriate use of Emergency departments. Nationally, approximately 12 million ER visits result from a mental health or substance abuse disorder — that is one in eight ER visits. Of these, approximately 40 percent result in hospitalization. In testimony before this committee in 2012, both Boeing and Group Health reported significant reductions in ER use and hospitalizations when mental health treatment was included in integrated care.

Psychologists want to continue to provide appropriate and effective mental health services to all residents in Washington state, whether in commercial insurance, the Exchanges, or expanded Medicaid services. We have actively supported implementation of the federal health reform law and legislation to implement integrated care programs. We urge you to consider the issues we have raised here today as reform implementation continues. Thank you.

Dr. Slaughter's testimony truly is advocacy for all psychologists in action. Now that's how it's done.

California has been a leader in the implementation of health care reform. In spite of not knowing if the Supreme Court was going to approve the mandate, a consortium of various mental health organizations including the California Psychological Association (CPA) has been actively working to define the essential health benefits for health care exchanges. Shortly after the Practice Directorate’s State Leadership Conference in March 2012, CPA had the opportunity to give input into the policies of California's Health Exchange. It was helpful to contact staff at the Practice Directorate to gain additional input into the role of psychology in essential health benefits (PDF, 540KB).

CPA has been active in communicating to its members how to stay current with changes in the delivery of care necessitated by the passage of the Accountable Care Act. Dr. Charles Faltz disseminated to CPA members in a special edition of PROGRESS NOTES (an e-publication for CPA members), an article by Dr. Charles Cooper, the Director of Professional Affairs for the North Carolina Psychological Association. The article first appeared in the NC Psychologist newsletter (January February 2012 Issue). Citation: Charles Cooper, PhD; NC Psychologist, January/February 2012 and described what psychologists will need to do to adapt to the changes in practice based on passage of the Affordable Care Act. Dr. Faltz noted, “In it Dr. Cooper cited the Collins study which is an especially valuable resource with some very detailed material regarding implementation” (Collins et al., Evolving Models of Behavioral Health Integration in Primary Care, Milbank Memorial Fund, May 2010 (PDF, 907KB)).

In addition to disseminating information to our members, CPA and Division I of Independent Practice have been active in coordinating a health care think tank entitled the Integrated Health Care Summit.  In some ways this is fashioned on the think tanks that have occurred in other states; however, the CPA one-day conference in late September will be multidisciplinary. As CPA was in the beginning stages of planning, we were contacted by consultants from the Integrated Behavioral Health Project (IBHP), which is a group funded by the California Mental Health Services Act whose monies come from Proposition 63. Their goal is “to reduce stigma and improve mental health outcomes,” according to their website. They have also developed a Tool Kit (PDF, 3.2MB), which has a great deal of interesting information in it for those wanting to create integrated behavioral systems.

The featured speakers at the Integrated Health Care Summit will include Drs. Ben Miller, Elena Eisman and Katherine Nordal. The president of the California Medical Association will also be in attendance along with leaders in the Exchange movement, CPA leaders in practice and education, and leaders from other health care specialties. Participation is by invitation only and according to the Dr. Michael Ritz, the chair of the conference planning, “The spotlight for the program would be to focus on directions in which health care/behavioral health care appears to be emerging for the State. Health care reform appears to be state-centric and thus our primary focus will be on potentialities within California. In addition, we will be creating mutually productive and rewarding relationships to craft effective models of integrated health delivery systems for primary care — respecting the interplay between the body and the mind. Clinical research has documented that integrated health care systems can augment healthy outcomes; may reduce system cost based upon medical cost-offsets; and are consistently well received within a patient centered delivery system. You should consider this summit as the beginning of a process — the next steps for action will be carefully defined.” Once the next steps are defined, information will be disseminated to CPA chapters and divisions and planning for a follow-up summit will begin.

Sallie Hildebrandt, PhD

Division 31 member George Harris just published a column in the The Kansas City Star, "Time for Romney to Get Specific About Health Care," about the striking differences between the Affordable Care Act coverage and the coverage most likely to be provided if President Obama loses the election and Congressman Ryan's thrall continues to influence the Republicans. An excerpt follows:
 
...under the Ryan plan Medicare recipients would receive a voucher to help pay for insurance premiums and that the value of the voucher would be adjusted annually to partially offset increases in costs...
Now let's look at the cost of insurance for people age 65 and older. There aren't a lot of data on this because most people 65 and over have the existing Medicare plan...

Missouri's High Risk Insurance Pool plans can be found on the internet. There are five plans. Let's examine the high and the low cost plan. On Plan 1 a 65 year old male can buy insurance for $1925 per month with a $3000 out of pocket maximum. On Plan 4, a 65 year old male can buy insurance for $812 per month with a $10,000 out of pocket maximum. An 85 year old male would be charged $3615 monthly on Plan 1 and $1527 on Plan 4.
As you can see, a voucher for $1,000 wouldn't go very far in covering premiums and deductibles even on the plan with the least expensive premiums. People with uncovered preexisting conditions would for their first year have to pay those costs, which would be in addition to the deductible and premiums...

Well, you may say, those are the high risk pool premiums. People in good health could get cheaper coverage. But I suspect that most 65 year olds have a preexisting condition that would put them in a high risk category, and almost all 85 year olds would have a health condition that would exclude them. Just do a Google search on "uninsurable medical problems" and you'll see that insurance companies exclude almost everyone who takes any medication, such as statins to control cholesterol, or anyone who has any chronic condition, such as diabetes, or anyone who has had cancer, even if successfully treated.

Thank you George for your dedication to social justice and efficacious health care. Please contribute other postings about Health Care Reform to our Task Force Chair, Leslie Riley.

As the nation awaits the Supreme Court's decision regarding the constitutionality of the Patient Protection and Affordable Care Act (PPACA) (or if the Court can even make a decision about the constitutionality of the PPACA given the Anti-Injunction Act's provision that a lawsuit cannot be filed to challenge a tax until a tax is assessed), important questions remain unanswered regarding the exact boundaries of the PPACA's provisions and how ambiguous language in the PPACA will be interpreted for years to come. Read the entire bill (PDF, 2.2MB) or a summary.

Mental health care providers have a particularly large stake in the Supreme Court's upcoming ruling as the passage of the PPACA brought with it, finally, mental health parity. However, as with other provisions, it remains to be seen exactly what mental health parity will mean should the Supreme Court hold that the PPACA does not violate the Constitution. Rather than simply await the Supreme Court's decision, psychologists have a unique opportunity to proactively engage stakeholders on the demand side of the mental health parity equation—the patients, clients, or consumers of mental health services—in an effort to empower them to advocate for themselves in shaping how the PPACA will be enacted. Several national advocacy groups, with chapters in almost every state, represent important forums in which psychologists can engage recipient stakeholders to advocate for themselves.

• National Alliance on Mental Illness (NAMI): NAMI "advocates for access to services, treatment, supports and research" and local meetings are an excellent forum in which psychologists can describe the areas of the PPACA that require further definition and learn from recipient stakeholders what services are most valuable and essential.

• Mental Health America: Mental Health America "works to inform, advocate and enable access to quality behavioral health services for all Americans," and like NAMI, local meeting represent an ideal opportunity for psychologists to engage with recipient stakeholders, their families, and loved ones regarding the most important aspects of mental health care.

• National Federation of Families for Children's Mental Health: Federation of Families is somewhat different than NAMI and Mental Health America in that it focuses specifically on children's mental health, which provides the perfect opportunity for child psychologists to engage parents who are already involved in advocacy for their children

Of course, there are many other organizations the engage in advocacy at the local, state, and federal levels. If there is an organization you have worked with and you think others might benefit from similar collaboration, email me, and a future installment of this blog will be dedicated to reader contributions and activities in their home states that could translate into action for others in other parts of the country.

Psychologists, highly educated, highly motivated, and often highly independent, have a chance to put their training and expertise to use in exciting and collaborative ways as the nation is more focused than ever on healthcare and health insurance. Professional psychology, for all its contributions and attempts, cannot affect the necessary changes alone, and even the entirety of the nation's mental health care providers probably could not affect these changes in collaboration. It is essential to acknowledge the recipients of mental health care as key stakeholders and engage them in their own advocacy to successfully define the provisions of the PPACA to make mental health parity a reality.

Troy Ertelt, PhD
Division 31 Health Care Reform Task Force

In a recent issue of Progress Notes, an online newsletter for California Psychological Association (CPA) members, Dr. Chuck Faltz, CPA Director of Professional Affairs and Division 31 Board Member noted, "ACA (Affordable Care Act) expressly identifies mental health and addictions treatment services as essential benefits, along with rehabilitative and 'habilitative' services.

However, the extent to which specific behavioral health services are covered will depend in large part on which existing insurance plan each state selects as its 'benchmark' plan — that is, the plan on which the EHB (Essential Health Benefits) package in that state will be based. If the state selects a plan with slim coverage of behavioral health services or a strict interpretation of what is considered 'rehabilitative' services, it could affect individuals' ability to access these services."

In addition, Dr. Faltz wrote, "The HHS guidance confirms that the 2008 Mental Health Parity and Addictions Equity Act applies to individual plans as well as small group plans — a provision that was inserted into the law as amendment by Senator Debbie Stabenow (D-Mich.) during the health reform debate. If the plan that a state selects as the benchmark plan does not currently comply with the parity law, modifications must be made to the benefits package to bring it into compliance with parity."

Recommendations for Future Consideration

1. It is recommended that further investigation of the practices of Blue Cross Blue Shield (BCBS) and United Healthcare (UHC) be conducted. A further survey focusing on these insurers' records with reimbursement would be a start. If the data are compelling, a referral to APAPO for possible legal action and/or meetings with BCBS and UHC officials may be indicated.

2. Reporting insurance companies which appear not to be following parity to APAPO and/or appropriate regulatory and enforcement agencies may also be useful.

Thank you to Dr. Faltz for this article and for the important reminder to monitor reimbursement practices for violations of mental health parity.

Leslie Riley, PsyD
Chair, Division 31 Health Care Reform Task Force

The Division 31 Health Care Reform Task Force blog is pleased to note the achievements of the Arkansas Psychological Association, under the leadership of Dr. Leslie Riley, in ensuring that the implementation of the Affordable Care Act in Arkansas included critical aspects of integrated behavioral care for childhood ADHD.

The ArPA initiative was successful through strategies of alliance building and asserting psychological evaluation and treatment interests throughout the regulatory process. While initially psychology was not invited to the table, Dr. Riley describes the step-by-step process (PDF, 138KB) involved in accomplishing the results. ArPA members are continuing to work on the clinical content of the ADHD treatment package and recognize that additional psychological services must be included in the summary (PDF, 323KB) that describes to date the design and implementation of this new payment system.

In the spring of 2011, Arkansas' Gov. Beebe launched the Arkansas Payment Improvement Initiative (PDF, 513KB) to reform AR Medicaid payment across nine initial clinical areas, including behavioral health. This initiative, known as APII, aimed to reduce inefficiencies in Arkansas' health care system and to promote "important" (i.e., medically necessary), coordinated and patient-centered care. The Arkansas Department of Human Services, the Arkansas Centers for Medicaid Services, the U.S. Dept of Health and Human Services, and Arkansas Blue Cross and Blue Shield are all funding this effort to reform the existing fee for service payment system to a system of bundled packages of treatment, called episodic care packages (ECPs) to provide care to patients across a multitude of clinical areas see the official APII website. Not only is the goal to maximize quality care and minimize wasteful and inefficient care, Gov. Beebe intends for APII to serve as a national model for payment reform.

Last fall, ArPA's executive director attended stakeholder meetings and informed ArPA of the formation of workgroups to develop ECPs. ArPA leadership organized a psychologist team before the first workgroup for ADHD payment reform. In preparation for the workgroup, ArPA consulted with Russell Barkeley, PhD, on the best psychological practices of assessment and treatment of ADHD.

ADHD was selected as the initial behavioral health diagnosis, because ADHD constitutes the largest amount of Medicaid spend on children in AR ($100 million). Current Medicaid data indicates that $48 million is spent on paraprofessionals in agencies. Thus, the ADHD workgroup's task was to develop an ECP for children with ADHD that ensured accurate diagnosis and "[treatment] guideline concordant care." The workgroup meetings consisted of large workgroup meetings for public comment, and then a small, "core" workgroup, which has decision-making power.

Through effective advocacy, ArPA successfully secured a psychologist on the core workgroup. Additionally, ArPA successfully achieved the inclusion of psychologists as "Principal Accountable Providers (PAPs)." Only psychologists, pediatricians, and child psychiatrists can serve as PAPs, enabling psychologists to diagnose and "certify" ADHD and to manage clinical care and the distribution of treatment funds. The payment model will be "retrospective reimbursement," where PAPs will share in profit gains and losses, depending on the use of treatment funds at the end of a one-year period from the initiation of the ECP.

ArPa's current challenge is advocating for the inclusion of best psychological practices in the clinical content of the ADHD care package. At present, the head of the workgroup, a psychiatrist, favors psychiatric guidelines, which are biologically based and not biopsychosocial in nature. ArPA is advocating for research-based guidelines (e.g., CADDRA) that include, in addition to medication, recommendations for diagnostic instruments for ADHD, parent and teacher training, and psychotherapy when indicated. Questions and suggestions can be directed to Leslie Riley, PsyD (ArPA President).