Feature article

A vision softly creeping

Is psychology ready to accept the clinical responsibility of prescriptive authority?

By Patrick H. DeLeon, PhD
Congressional Engagement

These are interesting times for our nation's non-physician health care providers, and particularly for those in the mental health/behavioral health field. In deliberating on the fiscal year 2015 appropriations bill for the Department of Defense (DOD), the U.S. Senate noted:

Mental Health Professionals. – The Committee recognizes that service members and their families face unique stresses beyond those of everyday life. After over a decade of war, the need for mental health professionals in the Department is at an all-time high, and the Committee believes that every beneficiary of the Military Health System should have timely access to mental health services. However, the Committee is concerned with the Department's inability to recruit and retain enough psychiatrists, psychologists, social workers, nurse practitioners, and registered nurses to provide adequate mental healthcare. The Committee has asked the Government Accountability Office to review this issue including the Department's current inventory of mental health providers, current and future needs for providers, challenges the Department faces in recruitment and retention, actions taken to mitigate these challenges, and recommendations going forward to ensure an adequate inventory of mental health professionals within the Military Health System. The Committee looks forward to receiving the results of this review and working with the Department to provide the tools necessary to implement any recommendations.

We would suggest that this is an excellent time for psychology to showcase its innovative treatment initiatives, communicate the ways in which the integration of behavioral and mental health services into primary care improves health outcomes, as well as its success in appropriately expanding its clinical scope of practice in obtaining prescriptive authority (RxP).

The Patient Protection and Affordable Care Act (ACA)

President Obama's landmark Patient Protection and Affordable Care Act (P.L. 111-148) provides an exciting opportunity to make a real difference for those colleagues with vision and the willingness to demonstrate leadership. Combined with the enacted mental health parity legislation, this represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation. Mental health and substance-use treatments are deemed “essential health benefits” under the ACA. Priority will be given to prevention, wellness care, and services which are high quality and cost-effective, as our nation moves our health care system towards population health-based care, rather than stressing individual acute care episodes. The ACA calls for the development of integrated, interdisciplinary systems of patient-centered care which will be transformational. Chief among these is the integration of behavioral health and medical health care, where the public sector has consistently demonstrated proactive leadership.

The foundation is steadily being put in place for bringing the advances occurring within the communications and health information technology (HIT) fields into the health care environment. As a nation, we are moving from reimbursement for specific clinical procedures towards encouraging value-based care – including the critical psychosocial-economic-cultural gradient of quality care. This fundamental shift in emphasis is expected to result in the U.S. no longer being ranked by the Commonwealth Fund as last among developed nations on overall measures of health system quality, efficiency, access to care, equity, and healthy lives, as compared with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the United Kingdom. This is in spite of the fact that we presently spend more on health care than anywhere in the world.

The Need for Greater Public Awareness

At the Uniformed Services University of the Health Sciences, we are fortunate to have a number of APA elected officials and senior staff address our interdisciplinary health policy seminar. Rhea Farberman recently described APA's efforts to ensure that the value of psychological expertise is appreciated by health policy experts, other disciplines, and the public. There is a surprisingly significant knowledge gap with only 4 percent of Americans being aware of the Mental Health Parity and Addiction Equity Act (MHPAEA) and what it means for their access to mental health and addictions care. Consumers report that psychology can help people lead healthier lifestyles (51 percent somewhat agree and 42 percent strongly agree) and that health care can be improved through better understanding of human behavior (49 percent somewhat agree and 26 percent strongly agree). Consumers believe that psychological research has a role to play in finding ways to address health issues such as obesity and smoking (49 percent somewhat significant and 23 percent very significant). Yet, the public often doesn't pursue psychological services for themselves or loved ones when it could make all the difference in their treatment outcome. This action gap could be the result of stigma; it could be due to access issues. Regardless, it presents both an opportunity and responsibility for psychology. As highly educated professionals, we may understand how psychology can contribute to improving the overall quality of health care in our nation if appropriately recognized. However, we have a significant way to go before the rest of society does. And, this is particularly true with our physician colleagues. When physicians were asked: Does psychological research have a role in finding ways to address health issues such as obesity and smoking – 45 percent responded somewhat significant and 40 percent very significant. Even more telling: How helpful do you think a psychologist would be when it comes to assisting your patients in making lifestyle and behavior change? Fifty-eight percent indicated somewhat helpful and 24 percent very helpful.

Prescriptive Authority

In her recent mailing to the membership, APA's Katherine Nordal praised the Illinois Psychological Association for their success in obtaining RxP. “It's good news for our profession and very good news for the residents of Illinois… Right now in our country, nearly 80 percent of psychotropic medications are being prescribed by primary care physicians who have very little training in mental health. I'm sure you agree that mental health patients are well served by having qualified mental health professionals available to prescribe. That's why the victory in Illinois is so important.” The World Health Organization (WHO) defines an adverse drug reaction as “harmful, unintended reactions to medicines that occur at doses normally used for treatment” and points out that these are among the leading causes of death in many countries.

Reflecting upon their success in Illinois, Beth Rom-Rymer reminds us that: “The Illinois Medical Society and the Illinois Psychiatric Society vigorously and vociferously lobbied against our RxP bill until they realized that we wouldn't stop fighting and until they had already spent $1 million to keep us out of the prescribing community!” Persistence and community involvement are the key to long-term change, which Beth and her colleagues vividly demonstrated. Why is it that more colleagues within the VA have not sought prescriptive authority? The experiences of their DOD colleagues clearly demonstrate that they can obtain these clinical skills and that the quality of care they would provide would be excellent. The need is there. There are a significant number of psychologists who are veterans and who belong to veterans' organizations – the true beneficiaries. Under President G.W. Bush, VA Secretary Tony Principi was quite open to initiating a pilot project, similar to the way that the DOD program initially began. At that time psychology's leadership was not willing to demonstrate proactive leadership; notwithstanding that a number of individual VA psychologists had informed me that they were, in fact, prescribing. Have we matured sufficiently as a bona fide health care profession to affirmatively accept this clinical responsibility? The sounds of silence.