Health Care Reform Blog

By Doug Tynan, PhD

Collaborative care has been defined by the American Psychiatric Association as care for mental health disorders that is provided by a primary care clinician for a patient by having a behavioral health care manager who will screen and monitor the patient, the PCP provide medication treatment, the care manager either providing psychotherapy or case management and having a psychiatrist (or NP or Psych PA) provide consultation for the patient. The model cited is always that of the AIMS center from the University of Washington Medical Center. In this model, “A behavioral health care manager (BHCM) is a behavioral health professional, typically a counselor, clinical social worker, psychologist or psychiatric nurse, who performs all of the care management tasks including offering psychotherapy when that is part of the treatment plan.”  By this definition the BHCM really takes charge of the patient care. So, the essential staff in this model are: the PCP, the consulting psychiatrist, and the BHCM. Their model requires two behavioral health clinicians: the BHCM and a psychiatry consultant. The essential tasks of the team is to provide patient centered, evidence based, population based, accountable care that relies on repeated measurement, described as treatment to target. The elements of collaborative care from the AIMS center are as follows:

• patient-centered team care: Primary care and mental health clinicians collaborate effectively using shared care plans that incorporate patient goals.
• population-based care: This is a misnomer. Care is not for the entire patient panel population. Care is actually for a defined group of patients tracked in a registry. Practices track and reach out to patients. Care is not available for other patients, such as those going through an acute event.
• measurement-based treatment to target: repeated measures with PHQ 9
• evidence-based care: Patients are offered treatments with research evidence to support their effectiveness including both psychotherapy and medication.
• accountable care: Providers are accountable and reimbursed for quality of care and outcome—this is in effect only in clinics operating with alternative payment models that reimburse for quality and outcome.

In presenting this model, the American Psychiatric Association inevitably cites, the 2012 Cochrane Review as the evidence base for this model. (This is one in a series of reviews in 2006, 2012 & 2014 done by Archer, Bower, Gilbody & Coventry.)

Archer et al.’s (2012) paper has a distinctly different definition of collaborative care. They define collaborative care much more simply, with four elements:

• multiprofessional approach with a primary care clinician providing medical care, and one other health professional (nurse, psychologist, psychiatrist, pharmacist) providing mental health care. (1 PCP & 1 MH)
• structured management plan, with access to evidence based psychotherapy and/or pharmacological treatment and patient education
• scheduled patient follow-ups
• enhanced interprofessional communication

Both models thus endorse common elements, including a multiprofessional team that communicates well internally, evidence-based treatment, structured management plan, and patient tracking and follow up. Archer’s (2012) definition does not specify a psychiatrist, it clearly states any mental health provider. They also do not specify treatment to target, repeated measures PHQ 9. 

Thus, using Archer’s et al. (2012) definition, you can simply remove the psychiatrist from the figure above, and you still have collaborative care. The team described by Archer et al. (2012) is in the figure below. This review showed that collaborative care resulted in improvement in depression and anxiety in short and medium term, but not long-term results. It also showed that collaborative care resulted in better medication adherence, but this review did not specifically ask which elements of treatment (patient education, psychotherapy, medication) were related to improvement. That was done in a follow up review by Coventry et al. (2014)

The same group of authors published a follow up paper (Coventry et. al) in 2014, that is never mentioned by the American Psychiatric Association.

This was a meta-analysis that specifically asked the question of what works in collaborative care. Same model definition of collaborative care, a PCP and a mental health provider, enhanced communication, structured management plan and scheduled follow up. Their (Coventry et al. 2014) conclusions were: “Trials of collaborative care that included psychological treatment, with or without antidepressant medication, appeared to improve depression more than those without psychological treatment. Trials that used systematic methods to identify patients with depression and also trials that included patients with a chronic physical condition reported improved use of antidepressant medication.”  They identified psychological treatment as the core essential element for patient improvement. Medication did not have a main effect, it only had an impact as part of a multi-treatment program.

Sawchuk (2016, 2018, 2021) has published a number of papers with large sample sizes showing that psychotherapy is effective for depression, anxiety, insomnia and stress, and indeed the effect sizes are larger than are seen in the IMPACT collaborative care studies.

Additional support for psychotherapy comes from a recent paper on collaborative care widely cited by the American Psychiatric Association on a ‘replication’ of collaborative care. This group demonstrated very good outcome improvement in depression, blood pressure, and diabetes measures in what is described as collaborative care. However, in this study, it appears that the main treatment differences were that the collaborative care group had more in person visits, and more phone calls. All patients were offered counseling through care managers who had some basic training in cognitive interventions. With regards to antidepressants, 17.3% of the collaborative care group were prescribed antidepressants and 5.6% of the control group. Thus, the vast majority of patients did not receive antidepressant medication, and interaction with the psychiatrist was minimal (Ali et al. 2020). This collaborative care study carried out very effectively in India appears to support the Coventry et al. (2014) conclusion that psychotherapy was an essential component.

Policy implications

We have at this time collaborative care billing codes that are all tilted toward prescribing providers and a model that includes a psychiatrist and a second behavioral health provider on the team.  The fundamental underlying research documents that were used to create these codes, the Cochrane Review by Archer et al. (2012), clearly states that collaborative care requires a primary care clinician and a mental health consultant, it does not specify a psychiatrist. Indeed, they specifically say a psychiatrist, or psychologist, or nurse, or pharmacist, or a paraprofessional.

The essential effective elements cited are offering structured management, follow up and enhanced communication between health and mental health clinicians. The follow up studies by that same team of investigators (Archer, Coventry, Gilbody, Bower) specifically cites psychotherapy as the active ingredient that is needed. Based on these studies the NHS in the UK has been on a 10-year program to provide psychotherapy.  However here in the U.S., these studies have been used to support a pharmacologically based model.

At this point in time, we have enough data for a comprehensive review of the existing data on collaborative care, showing where it has worked and where it has failed (Solberg 2015).  Archer et al. (2012) speculated that team communication and enhanced follow up were the active ingredients of success. Coventry et al. (2014) cited the need for well supervised psychotherapy. Sawchuk’s series of studies tend to support psychotherapy as the preferred treatment modality. 

Based on the published data, and the existing reviews, we should really be asking that all of the collaborative care codes that have been developed should be accessible for psychologists as well as psychiatrists, for diagnostic and supervision purposes. If psychotherapy is essential, it makes no sense that a psychiatric physician assistant could be used for all the collaborative care codes, but not a doctoral level psychologist. We have the data in hand to make an informed effort to change the collaborative codes as they exist. 

In addition to these effectiveness data, there are populations for whom there are few if any pharmacological psychiatric treatment that have been shown to have any benefit. That would include all children under the age of 5 and all adults over the age of 80. For those vulnerable populations we should have collaborative care with a psychologist, rather than a psychiatrist, serving as the consultant.

Two reasons to ask for opening those codes for psychologists.

References

Ali, M. K., Chwastiak, L., Poongothai, S., Emmert-Fees, K. M., Patel, S. A., Anjana, R. M., ... & Mohan, V. (2020). Effect of a collaborative care model on depressive symptoms and glycated hemoglobin, blood pressure, and serum cholesterol among patients with depression and diabetes in India: the INDEPENDENT randomized clinical trial. Jama, 324(7), 651-662.

Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., ... & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, (10).

 Bogucki, O. E., Mattson, A. B., Leasure, W. B., Berg, S. L., Mulholland, H. L., & Sawchuk, C. N. (2021). Adaptations of an Integrated Behavioral Health Program During COVID-19. Cognitive and Behavioral Practice.

Coventry, P. A., Hudson, J. L., Kontopantelis, E., Archer, J., Richards, D. A., Gilbody, S., ... & Bower, P. (2014). Characteristics of effective collaborative care for treatment of depression: a systematic review and meta-regression of 74 randomised controlled trials. PloS one, 9(9), e108114.

Craner, J. R., Sawchuk, C. N., & Smyth, K. T. (2016). Outcomes of a 6-week cognitive–behavioral and mindfulness group intervention in primary care. Families, Systems, & Health, 34(3), 250.
Sawchuk, C. N., & Craner, J. R. (2017). Evidence-based psychotherapy in primary care. Focus, 15(3), 264-270.

Sawchuk, C. N., Craner, J. R., Berg, S. L., Smyth, K., Mack, J., Glader, M., ... & Katzelnick, D. J. (2018). Initial outcomes of a real-world multi-site primary care psychotherapy program. General hospital psychiatry, 54, 5-11.

By Stella D. Nelms, PhD

Behavioral health psychologists (BHP) are playing an integral role providing tools that help mitigate the development of serious psychological challenges during this pandemic. The COVID-19 pandemic has placed a demand on the mental health field in unimaginable ways. Comparable health-related threats in the past 20 years include H1N1, SARS, Ebola, MERS, and Swine Flu (LePan, 2020) all reported devastating death tolls, but are low in both death toll and economic toll in comparison to the COVID-19 pandemic.

As a BHP that works with chronically ill patients, the impact on mental and physical health has proved devastating. Lives were and are currently being upended as patients with chronic medical conditions who were forced to disconnect from their routine in-person care had to switch to telemedicine/virtual services as the shutdown of communal spaces rapidly ascended. This includes chronically ill patients who participate in outpatient rehabilitation, received home health services, and those who were or needed to be hospitalized. With some patients there was an indefinite disruption in their care with no guidance or plan of action communicated. Some who had to continue to receive in-person services had to face risk of exposure. In addition, not all patients had the technological means or savviness to engage in virtual services. BHP have witnessed patients that had been working towards physical and mental health goals suffer setbacks. For many this disruption showed signs of significant concern for access to medical care (e.g., medications, procedures/surgery, and rehabilitation), financial uncertainty, and fear that their preexisting condition puts them at a high risk for contracting COVID-19 (Pfefferbaum & North, 2020).

As BHP are called on to address the psychological, social, physical, and systemic concerns that are present in healthcare, they are also navigating the unseen threat this pandemic has on their personal wellbeing and professional practice. Such threat can inadvertently impact the work they do with their patients. The pandemic has had effects on professional practice involving layoffs, office closures, and workplace safety demands. In addition, the delivery of behavioral healthcare services has been impacted by fluctuating guidelines regarding exposure risk, increase in crisis care caseload, a rapid transition to telehealth, and potential delays in reopening clinics, hospital outpatient services, or individual practices. Lastly, a provider’s own concern for theirs and their family’s physical and emotional wellbeing during the pandemic, including worry about infecting love ones, long work hours, and moral distress (Kang et al., 2020; Pfefferbaum & North, 2020).

The call for BHP acknowledges the expertise and unique skills needed to work with chronically ill patients during this devastating pandemic:

• BHP bring knowledge of behavioral and psychological challenges in common medical conditions (Dobmeyer et al., 2016).
• BHP often work either with a medical interdisciplinary team, primary care provider/clinic, or/and maintain communication with the patient’s medical providers. 
• BHP are in a position to help ensure that communication and appropriate consultations are facilitated during a time when chronically ill patients may be disconnected from their care team.
• BHP tend to utilize a biopsychosocial assessment and treatment model, which is crucial in providing telehealth services while patients are homebound and navigating social and environmental challenges that encompass more than just their medical condition. 
• BHP are positioned to treat psychological problems that can develop or exacerbate during a pandemic as such problems can have severe health related impact in the chronically ill (e.g., exacerbation in chronic pain, increase in HBP, disruption in rehabilitation).

As a psychologist working in healthcare, I quickly had to transition from inpatient care and outpatient clinic care to at home telehealth care with no prior experiences in this mode of service delivery. Equipment, office space, technical navigation, ensuring I’m providing legal and ethical telehealth services, and navigating accurate billing procedures, all became the forefront of preparations to manage and support the continuity of care for my patients. For most patients transitions to telehealth was effortless but for some it either was not a preferred option or they did not have the technical know-how or lacked privacy in order to participate. Enlisting support from caregivers for patient that had challenges accessing telehealth services or played a role in support.

The world continues to adjust and prepare for a possible future with COVID-19 as a feature of daily life as we manage an unpredictable health crisis. The impact of COVID-19 on the chronically ill has been devastating and could potentially have long-term or irreversible consequences. This national crisis is a call for behavioral health professionals to address how to care for the chronically ill as they face the challenges of loss or limited access to medical care, social services, finances, and social connections. 

References

Dobmeyer, A.C., Hunter, C.L., Corso, M.L., Nielsen, M.K., Corso, K.A., Polizzi, N.C., & Earles, J.E. (2016). Primary care behavioral health provider training: Systematic development and implementation in a large medical system. Journal of Clinical Psychology in Medical Settings, 23(3), 207-224. doi: 10.1007/s10880-016-9464-9.

Kang, L., Ma, S., Chen, M., Yang, J., Wang, Y., Li, R., Yao, L., Bai, H., Cai, Z., Yang, B.X., Hu, S., Zhang, K., Wang, G., Ma, Ci., & Liu, Z. (2020). Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study. Brain, Behavior, and Immunity, 87, 11-17.  https://doi.org/10.1016/j.bbi.2020.03.028

LePan, N. (2020, March 20). Visualizing the history of pandemics. Virtual Capitalist.  Retrieved from https://www.visualcapitalist.com/history-of-pandemics-deadliest/

Pfefferbaum, B., & North, C.S., (2020). Mental health and the COVID-19 pandemic. New England Journal of Medicine. doi:10.1056/NEJMp2008017

Brief bio

Stella Nelms is a licensed clinical psychologist and assistant professor in the Department of Rehabilitation Medicine at the Emory University School of Medicine in Georgia.

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By W. Douglas Tynan PhD, ABPP

The American Academy of Family Practice (AAFP) developed a position paper last year on the use of the term “provider” and many of the issues they appropriately raised apply to psychologists. The first point made is the term "provider" levels distinctions and implies uniform expertise and knowledge among different health professionals. It reduces important differences such as education level, range of abilities. In particular, AAFP was concerned that it conveyed legitimacy to health services provided by non-physicians that are best performed by or under the supervision of physicians. A similar concern can be raised in the mental health professions when services provided by all of the licensed professions are considered to be equal, and even those services provided by professional psychologists are considered to be equal without paying any regard to specialty training.

The term provider was created by administrators and insurers, not by professional societies or regulatory boards. The effect is to send a message to those seeking help that all providers are equally qualified to provide such care. Within mental health it is quite clear that while many licensed clinicians can receive training and provide effective services, there are clear differences between professions both in training and in the scope of practice services. There are also important differences within psychology between specialty areas. I recall once being questioned extensively on a call by a physician seeking an evaluation for her child. Having gone through two prior evaluation appointments with a psychologist and a licensed counselor who each assured her that they saw children, she asked about my training, was I a child psychologist? To which I could affirm yes, and it was clear after the visit that a particular level of expertise was needed.  The family needed very specific recommendations regarding child care arrangements and school settings, along with some parenting strategies.

People seeking services should be allowed to make decisions concerning their selection of clinicians based on training and specific professions. That right is denied by the use of the term "provider." The same is true for another generic term used in integrated care, that of the "behavioral health consultant (BHC)," which implies uniform skills. If an individual wants to see a psychologist, or a clinical social worker, they should have that right. They should not be confused by having a "BHC" presented to them as the mental health provider, and not knowing the professional qualifications of the BHC. It has been suggested by some working in integrated care that BHC is more acceptable to patients than “psychologist,” but that also denies the patient the right to make their choice.

Licensed psychologists, social workers, counselors, marriage and family therapists all have specific training, examination, and licensure. People seeking care should know the credentials of those providing the care, and clinicians should be prepared to describe their training when asked by people seeking care. Using the appropriate professional title clarifies our own roles on health care teams, and provides essential information to people seeking care. Generic terms such as "provider" or "BHC" provide less information to consumers, and only serve to confuse professional roles.

Brief bio

W. Douglas Tynan, PhD, ABPP, a licensed psychologist, Delaware and Pennsylvania, is board certified in clinical child and adolescent psychology, and clinical health psychology.

By Kathleen Ashton, PhD, ABPP

California: We worked with the other mental health associations in CA early on in the crisis, and secured a mandate from the Department of Managed Health Care to private insurance companies that they had to reimburse telehealth at the same level as in-person sessions. This has now included an Executive Order from the governor and a mandate from the insurance commissioner. It also now states that plans may not dictate the platform that must be used. So at this point, things seem to be going well on this front.

• At the CEO’s request, I have provided information to the California Society of Association Executives about mental health concerns during this crisis, which they have included on their website resources.
• CPA issued a statement regarding the damage of xenophobia during this crisis.
• We issue regular information alerts summarizing all the changes in regulations, including Medicare and other changes at the federal level. Our goal is to streamline the information since we are hearing everyone is inundated with information.
• We issue regular advocacy updates about anything related to changes in regulations, laws, etc. Same idea…simple and to the point.
• We have held five (last one is today) free-to-members virtual conversations as a way to connect with members while also providing information. Topics were “Update to Telehealth, Billing, Insurance”; “Building Resilience During a Difficult Times”; “Updates on Supervision During the Pandemic”; “Self-Care During COVID-19”; and the last one today on “Changes in Practice, Now and in the Future Due to COVID-19”.  All have had good attendance and the feedback has been great.
• We are now developing a series of virtual CE events using speakers who were lined up for our convention.
• Starting in May I will host a CEO Café—just a casual virtual get together for anyone who wants to grab a cup of coffee (maybe I should say a cup of Jo?) and pop in with questions or just to say hello to a smaller group.

Connecticut:The Connecticut Psychological Association has also been active on several fronts. I’ll outline them below. With so many changes to our professional and personal lives, it has been especially comforting and reassuring for me to be in touch with APA colleagues, our neighboring state associations (RI, MA, NY, NJ), and to be with you all on this listserv. Our state associations collectively are doing such important advocacy, education, and professional support work.  

• CPA’s lobbyist and legislative committee are in frequent contact with the CT departments of public health, social services, insurance, mental health, emergency services, and economic development. We worked closely with the CT Office of Health Care Access and state legislators co-chairing the Insurance Committee about a number of our concerns surrounding insurance payment parity for telehealth services and that certain codes for neuropsychology had been overlooked by insurers. These issues have subsequently been remedied. In CT commercial insurers must follow the CT Medicaid guidelines: Telephone and/or video sessions must be reimbursed at the same rates as face to face sessions. 
• CPA has sent out several eblasts to members and non-member psychologists to inform them about our Governor’s Executive Orders (over 25 so far) outlining those affecting our profession (such as allowing psychologists licensed in another state to work in CT without obtaining a CT license for up to 60 days including telepsychology across state lines; Protection from civil liability for actions or omissions in support of the state’s COVID-19 response; economic relief efforts among others). Eblasts also contain information on ways psychologists can volunteer their time and expertise and resources available to psychologists and the people we serve.  
• In addition to eblasts, we post nearly daily updates on our listserv which along with our social media have all been more active than usual.
• CPA held three town hall style Zoom meetings for members to connect. Members discussed and offered their knowledge and experiences with different telehealth platforms, reimbursement, access for new patients, online testing options, suggestions for increasing reach to the public, and provider stress and fatigue.  
• We also offered a webinar on "Psychotherapy over Telehealth: How to Do It and Do It Well." It was free to members and $25 for nonmembers with 24 nonmembers paying and three former members rejoining!  
• Every Wednesday at 5:15 pm, CPA offers a free meditation guided by one of our members.
• CPA has supported our state’s volunteer efforts. However, to date, the state is still focused on the medical response. In the meantime, CPA is working closely with other CT organizations to find ways to support the mental health of those on the frontlines such as healthcare and funeral workers. We created a volunteer registry for psychologists and through our state hospital association this list is being distributed twice per week to hospitals, nursing organizations and funeral directors.  
• CPA has received many more information requests than typical and of course many from nonmembers. As always, we answer them and encourage nonmembers to join CPA. 
• Last, to capitalize on all this activity, we are running a postcard campaign with three prongs (1) a postcard sent to members thanking members for their membership/reminding them we’re here for them; (2) a postcard asking lapsed members to rejoin; and (3) a postcard targeting nonmembers letting them know all that we’re doing for our profession.)  Happy to share these postcards with any state associations.

• Due to the foresight of one of our board members, WSPA had a Disaster Relief Network (DRN) prior to the current pandemic. As a result, very early on in COVID-19's spread, WSPA was identified as a key, state-level partner for the COVID-19 behavioral response. Our DRN Lead participates in weekly meetings with the Department of Health and other agencies, and this involvement has shaped our organization's response. To meet our members' needs during the pandemic, we have done the following:
• Distribute monthly behavioral health forecasts and newly developed resources, including those for individuals, groups, workers, and populations at high risk.
• Quickly disseminated information for our members and healthcare workers on best personal and professional practices by early March 2020, and followed up on this initial information with guidelines to consider when portions of our state moved to reopening.
• Provided training opportunities for our members and the community via workshops, online courses, and links on a wide variety of topics relevant to COVID-19's far-reaching psychological and behavioral effects, including psychological first aid, resiliency training, trauma and PTSD, complicated grief, bias, stigma reduction, and health inequities.
• Provided our members with telepsychology resources, including a 3-hour CE workshop, as well as essential information regarding insurance billing and information regarding business disaster relief.
• Developed viable partnerships with the American Psychological Association's DRN, the Red Cross, the Public Health Reserve Corps (PHRC), and other local and state agencies.
• Provided ongoing consultation to the PHRC and was part of their task force on how to best serve those affected by COVID-19.
• Developed a web-based resource center with articles and publications by our members and other professionals that will be helpful to members and to the general community and public; we made additional practice-oriented resources available to members.
• Engaged our members in sharing their expertise and consulting with other professional agencies, frontline and essential workers, and all those affected by the COVID-19 pandemic via teleconference calls and other venues.
• Hosted a Town Hall for our members on the pandemic and anti-racism, and took action on items raised in this forum.
• Created a support group for members around issues related to COVID-19, their practice, and additional challenges.
• Established a pro bono database of WSPA DRN volunteers for frontline and essential workers, which includes our providers' expertise and geographical location.
• Created a DRN Listserv for our members to share information, and volunteer and training opportunities.
• Offered Health Support Training at our fall virtual convention to train members to train lay people to enhance community resilience through simple, non-clinical techniques.
• Responded to media requests to discuss the mental health implications of the pandemic, and participated in a live call with a state legislator to provide information on mental health issues and answer questions related to the pandemic.

By Paul T. Korte, PhD

We are all in the midst of a changing environment in light of COVID-19 anxiety and precautions. As healthcare professionals, we are especially cognizant of the risks associated with a new virus that has no cure or vaccine. Health services have rapidly moved from in-person care to various modalities of telehealth. With increased telehealth and enforcement of physical distancing, integrated care psychologists are teleworking from home or restricted to offices where they are limiting their regular close-contact interactions with fellow staff and patients.

Keeping integration alive requires increased effort as the usual curb-side consultations are now more effortful. It is vital that psychologists communicate new integration methods to their medical colleagues so that clinics know how to maintain referrals and utilize behavioral expertise for the ongoing care of patients.

High visibility (maintaining presence)

For those psychologists still going into a medical office, clinic, or hospital care setting make time to walk through the clinical environment and make efforts to have face-time contact with staff (while honoring physical distancing). Remind them that you are still accepting referrals and are available for other consultation needs via electronic communication, digital platforms, or via a given patient’s medical record. Just as you may have done when initiating your integrated care practice, every interaction, no matter how brief, is a way to remind staff that you exist and you have a contribution to patient care. 

Integrated team well-being

Don’t forget that your presence provides a brief moment to also check-in with staff about how they are coping with the adjustments and stressors of clinical work within an ever-changing landscape of guidelines and recommendations. Staff interactions are an opportunity to lend our expertise to medical colleagues who are feeling overwhelmed, especially those who may be directly engaged in treating patients diagnosed with COVID-19. If your clinic has slowed down due to patients rescheduling for a later date, use your time for staff support and education in healthy coping and stress management. Some great examples of these efforts are highlighted in the recent APA article on supporting our colleagues. 

Optimizing communication pathways

For those who are now navigating telework from home, find a way to maintain contact with your clinic. Telephone, video meetings, and email are all ways to keep in contact and demonstrate your availability for referrals and consultation. As you interact with patients during telework, make an extra effort to relay information back to the rest of the care team, particularly any needs a patient may have as it relates to other team members. Other staff are not seeing patients in person either, so may be less aware of a patient who needs a medication renewal, consults to other services, or assistance from social work. 

Considerations for at-risk patients

Of special note, telework and telehealth need special consideration for at-risk patients. Be sure to create a plan should a patient express thoughts of suicide, homicide, or report any type of abuse. Be sure to know how to contact help within your healthcare system and local emergency services. When doing telehealth, ask the patient their physical location at the onset of an appointment in case you need to send help or lose contact with the patient. Taking these steps will assure patient safety and your own piece of mind when you have to function outside your normal work environment and protocol. 

COVID-19 has demanded rapid changes in how we have typically envisioned integrated care. However, successful integrated care programs have always been based on flexibility, some atypical practices, and promoting the model to medical staff and patients. COVID-19 does not change that. Rather, it is a responsibility to demonstrate the value of integrating psychological and behavioral expertise at a critical time in health care. By speaking up and educating leadership and policymakers on psychological science, we can advocate for psychology’s role through the current disruption and help remake the healthcare system better for the future. 

By Kathleen Ashton, PhD, ABPP

On Jan. 23 and 24, I had the privilege to attend both a legislative forum and a continuing education workshop co-sponsored by APA and my state psychological association in Ohio. The event was a pilot project aimed at raising awareness of the role psychologists play in pain management for legislators and regulators, as well as providing evidenced-based training in pain management skills for psychologists. The hope was to provide basic skills for psychologists already in the workforce to help provide access to the many patients in need of psychological pain management treatment. Ohio was a thoughtful choice to kick off this project, given it has the second highest per capita deaths from opioid overdose. In fact, both OPA and APA have addressing psychologists’ role in combatting the opioid crisis in their strategic plan.

The event kicked off Jan. 23, with a strong presence of leaders from both APA and OPA including Arthur Evans, APA CEO; Jared Skillings, APA chief of Professional Practice; Sandy Shullman, APA president; and Jennifer Kelley, APA president-elect. The OPA president-elect, Cynthia Van Keuren, a pain management expert, was one of the panelists.

The continuing education workshop Psychological Pain Management was led by Jennifer Kelly, Daniel Bruns and Ravi Prasad. They did a masterful job covering the relationship of chronic pain and the opioid crisis, explaining theories of pain and the biopsychosocial approach to care, and considering the contextual and cultural factors and pain. For example, Bruns shared that 21-29 percent of patients exposed to opioids will misuse them, and 10 percent will develop a substance disorder. The speakers provided practical tools on conducting a pain assessment, and providing evidenced-based treatments, including for pain and insomnia, activity pacing, relaxation training, and cognitive restructuring. In fact, CBT is one of the five recommended evidenced-based treatments for pain management according to Prasad. In addition, ethical considerations and billing/reimbursement were discussed. Kelly addressed knowing the limits of your competence and examining your own reactions to particular aspects of pain treatment. The curriculum of the workshop was developed carefully to provide a broad overview accessible to the non-expert psychologist that could be used across the country. As a health psychologist with background in pain management, I found the program to be informative and a positive refresher on tools and techniques I use in my practice.

I would like to personally thank APA, OPA and the speakers for providing this terrific opportunity for learning and advocacy. I hope that they will take this experience and bring similar trainings to other states. Div. 31 will keep you posted on developments with this initiative.

Sources

Psychology’s Unique Role in Addressing the Opioid Crisis: https://www.apa.org/advocacy/substance-use/opioids/index

Coping with Chronic Pain: https://www.apa.org/topics/chronic-pain

The Role of Psychological Pain Management Care in Addressing the Opioid Epidemic – Policymaker Forum

Did you Know…The State of the Opioid Epidemic in Ohio – March 12, 2018

Roster: APA Guideline Development Panel for Treatment of Chronic Musculoskeletal Pain in Adults: https://www.apa.org/about/offices/directorates/chronic-pain-panel 

By Roseann Fish Getchell

This past spring, I was honored to present at the annual APA Practice Leadership Conference in Washington, D.C., and share my perspective on integrated care training opportunities within Oregon. As we look to the future demand of the psychologist workforce, IHS Markit projections for 2030 estimate that 57 percent of psychologists will be needed to work within healthcare settings and hospitals. Additionally, ongoing results of major workforce analysis from APA highlight the sense of urgency in closing the gap between training and workforce demand (APA Center for Workforce Studies, 2018). O’Donohue and Maragakis discuss the need to take several steps in addressing this integrated care training gap, including designing and implementing training within systems, facilitating the optimal use of technology, acknowledging that education is constant and implementing strategic planning on a national level to meet workforce needs (O’Donohue & Maragakis, 2015).

Leaders within Oregon have taken this information and transformed the landscape of integrated care training within the western state. The three clinical doctoral psychology programs located in the Willamette Valley (University of Oregon, Pacific University and George Fox University) offer unique training experiences related to integrated care. By offering primary care psychology tracks, academic courses, practicum experiences, internships, postdoctoral residencies, continuing training for licensed providers and other experiential learning opportunities, training programs in Oregon are plentiful and diverse. Oftentimes, these integrated care training options are aimed at developing in-the-trenches training for not only lifelong psychology trainees, but also their interprofessional colleagues invested in integrated care.

Furthermore, integrated care training within the state occurs at every level of doctoral training. For example, practicum sites offering quality training experiences for qualified second-year doctoral students and beyond include well-known Oregonian names in health care such as Legacy Good Samaritan, Oregon Health & Science University, Providence Health and Services, Samaritan Family Medicine and the VA Portland Health Care System. For trainees moving towards a more specialized set of experiences, Oregon also offers two APA-accredited integrated care internship programs with the Pacific Psychology & Comprehensive Health Clinic and the George Fox Integrated Care Internship in Partnership with Providence Health Services. Lastly, several postdoctoral residency programs not only offer quality integrated care training experiences within health systems but go above and beyond to offer training that prepares trainees to work with a plethora of specialty team members.

Lastly, Oregon is home to the Patient-Centered Primary Care Institute (PCPCI) that was founded in 2012. The PCPCI accelerates primary care transformation in Oregon, including training. Through the Institute, health care providers, clinic staff, technical experts, patients, quality improvement professionals and others come together to share valuable knowledge and resources. For example, PCPCI has hosted “Behavioral Health Integration Learning Events” in which “more than 140 physicians, behavioral health professionals and administrative staff from more than 40 clinics throughout Oregon participated in a weeklong training series on integrating behavioral health in primary care settings” (PCPCI, 2016).

Our field continues to grow and transform the way that we are providing quality care to the most vulnerable in our communities. I am inspired by the many who have invested their professional lives to the training, mentorship and development of future integrated care psychologists across Oregon and the rest of the country.

Sources

American Psychological Association Center for Workforce Studies. (2018). Psychologist workforce projections: Addressing supply and demand from 2015-30. Washington, DC. Retrieved from https://www.apa.org/workforce/publications/supply-demand.

O’Donohue, W., & Maragakis, A. (2015). Training the behavioral health workforce for the patient-centered medical home. In W. O’Donohue & A. Maragakis (Eds.), Integrated primary and behavioral care: Role in medical homes and chronic disease management. (pp. 61–73). 

Patient Centered Primary Care Institute. (2016). Behavioral health integration learning events. Retrieved from http://www.pcpci.org/BH-learning-events.

Brief Bio

Roseann Fish Getchell is a passionate clinical psychology resident skilled at engagement, collaboration and leading others. She serves as an empathic and emotionally aware trainee with strengths in conceptualization, client advocacy and professional development, directly serving diverse and high-risk populations within the greater Portland, Oregon area. Roseann has experience in multiple settings (integrated primary care, crisis intervention and dynamic leadership), while implementing critical skills in psychotherapy, systems management and treatment planning. She was elected as the American Psychological Association of Graduate Students Chair for 2019 and enjoys engaging on a national platform to advocate for graduate students and future leaders within the psychological community.

Did you know that APASI (formerly the APA Practice Organization) released an integrated care policy earlier this year? It’s a companion policy to the APA policy approved by APA Council in 2016, and expands on pocketbook issues related to psychologists practicing integrated care. For example, the policy addresses reimbursement issues, business models/colocation, workforce development, legislative advocacy, professional identity, legal/regulatory advocacy, and marketplace issues. Please take a look at the policy (PDF, 180KB), which is available online. 

Why are policies like this one important to psychologists practicing in integrated care?

1. They can be used for advocacy work at a state or federal level.
2. They can be used in legal/regulatory advocacy to promote psychology and integrated care.
3. They can provide support within organized psychology to fund or staff projects.
4. Policies can be used within healthcare systems to promote clinical services.
5. They can promote research ideas around integrated care and psychology.

I hope you will check out both policies and think about how you might use these to enhance your professional goals.

Additional links:

• APA Integrated Care Policy 2016 
• Integrated Healthcare Resources and Videos

*This is my last blog as Committee for the Advancement of Professional Practice (CAPP) vice chair as CAPP will sunset June 30, 2019. I am feeling confident the voice and advocacy work of CAPP will continue among groups such as ACC, BPA, CSL and Div. 31. I am pleased to announce I will continue blogging as president-elect of Div. 31, where state and federal advocacy and integrated care will be sure to be ongoing topics.⁠

By Paul T. Korte, PhD

The Department of Veterans Affairs (VA) has had a long-standing practice of integrating mental health services into medical settings including inpatient, rehab settings, and more recently in specialty medical clinics and primary care. Since 2007, the VA has encouraged the Primary Care-Mental Health Integration (PCMHI) program with more and more VA facilities implementing the service over the last decade.

My own experience as an integrated care psychologist began in graduate school and progressed during my internship year at the VA Medical Center in St. Louis, MO where I received specific training in PCMHI. I was fortunate to become part of the team at Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri, to help initiate components of the medical center’s PCMHI program and have been a part of its growth since that inception.

Implementing and growing an integrated care program presents many challenges, even with the support and structure within VA for integrated care. I, along with one other integrated care psychologist, worked diligently to demonstrate to patients and our colleagues that behavioral health is just as vital to primary care as physical health. Our goal was for psychology to not be another ancillary service to primary care, but to become an integral part of primary care.

Psychology is a part of primary care meetings and patient care consultation. Psychologists can be found in the break room and in primary care provider offices. They are present in discussions related to medicine, psychology, and even what each other’s families did over the weekend. Psychology has had a seat at the table and has even been at the head of the table with respect to developing vital principles to the provision of effective health services. We are part of a team whose role is to serve Veterans and our healthcare colleagues.

The VA has provided an abundance of resources and information for integrated care. The network of PCMHI providers, the educational tools, and ongoing research on integrated care helps me feel supported and equipped to help patients. These same resources also demonstrate the benefits of integrated care to other professionals. VA continues to study the benefits of brief, 30-minute PCMHI interventions as well as smartphone apps to supplement office-based interventions and increasing telehealth services to reach patients who may otherwise not be able to receive valuable care.

Recently, the VA rolled out PCMHI competency trainings to all PCMHI staff across the country as a way to encourage adherence to the PCMHI model. The intensive training and skills assessment have assisted those struggling to implement a primary care-behavioral health model. The VA takes integrated care seriously and demonstrates interest by ensuring integration is done correctly for the benefit of patients, as well as clinic functionality.

I’m proud to be part of the VA for its service to Veterans, its health care innovations, and its emphasis on research and training. Although I recognize my bias, I believe the VA is the best at integrated care. The whole system is designed to aid in collaborative work between specialties and departments, which results in better patient outcomes and experiences. I am also proud to contribute to Veteran care by serving as a model of effective integrated care practices for other health care systems so more people may benefit from integrating physical and mental health into a single location.

The above remarks are the author’s personal views and do not necessarily represent official VHA opinion.⁠

by Nataliya Pilipenko, PhD

Psychologists working in primary care settings need to obtain and practice a unique set of skills and competencies. Unfortunately, majority of behavioral health providers lack appropriate experience and/or training that is required from behavioral health consultants (BHCs) (Dobmeyer et al., 2016).

In order to address this gap in training, numerous efforts have taken place. For example, the American Psychological Association (APA, 2013) has published "Competencies for Psychology Practice in Primary Care" (McDaniel et al., 2014), while the Society for Health Psychology launched integrated primary care psychology online training. Several excellent texts are also available, including "Integrated Behavioral Health In Primary Care: Step-by-Step Guidance for Assessment and Intervention" by Hunter, Goodie, Oordt, and Dobmeyer, (2014). The goal of this post is to briefly discuss some of the key areas whereby behavioral health consultation (BHC) may be different from a more traditional psychotherapy approach.

Time/Continuity Considerations

Although a significant portion of patients do not return after the initial psychotherapy session (Simon, Imel, Ludman, & Steinfeld, 2012), most psychotherapeutic approaches function on an assumption of ongoing relationship with the patient, characterized by regular (i.e., weekly) meetings. Patients’ inability or lack of willingness to attend regular appointments is likely to be viewed as preclusive to the formation of the effective therapeutic relationship and treatment progress. In contrast, BHC should expect to see the patient only once, or intermittently. This expectation leads to several challenges including but not limited to: building rapport rapidly; clear formulation of the sessions’ goals and objectives; delivery of brief interventions; and/or ability to address the referral question. Management of these demanding tasks may be potentially challenging for both the psychologists-in-training as well as more experienced psychologists who are unable deliver care within a narrow timeframe. BHC consultants may find it valuable and interesting to familiarize themselves with the biopsychosocially-grounded medical interviewing models that are utilized by physician colleagues in order to deliver patient-centered, problem-driven care. Publication by Smith and colleagues (2013) offers a brief introduction to both the "Four Habits Interviewing Model" and the "Integrated Patient-Centered and Doctor-Centered Interview Model" for psychologist unfamiliar with medical interviewing

Communication of Information and Ethical Considerations

BHCs typically receive referrals from physician colleagues therefore consultation aims to meet the needs of both the patient and the referring provider (i.e., to answer the referral question). Even within large, integrated healthcare systems, negotiation of information exchange specifics demands mindfulness and consideration. This is especially relevant as communication takes place across disciplines and professions which do not necessarily have a shared model of illness conceptualization and management. Unfortunately, current ethics code of the American Psychological Association does not adequately reflect the needs of the BHCs. A review of publications by Christine Runyan, PhD, ABPP, and her colleagues can serve as an excellent starting point in improving one’s understanding of these issues (see Runyan, Carter-Henry, & Ogbeide, 2018; Runyan, Robinson, & Gould, 2018). Frequently, BHCs find themselves as the only psychologist within a diverse care team. Thus BHCs are tasked to thoroughly understand not only the APA’s ethics code but also nuanced discrepancies with other professions’ ethical codes and guidelines. Moreover, BHCs ability to engage in constructive discussions related to ethical considerations can be of paramount importance in maintaining professional relationships.

Medical and Other Knowledge Considerations

BHCs need to have knowledge of behavioral and psychological components of common medical conditions (Dobmeyer et al., 2016), health-related metrics (e.g., A1C in diabetes), common behavioral challenges (e.g., regimen/adherence factors), and interventions which may be specific to a medical condition (e.g., mind-body connection for chronic pain). These competencies are required over and above a more traditional expertise in psychiatric illness diagnostics and management. It is unclear how much training psychologists receive in medical and health-related topics outside of specialty training such as pain clinics and research labs. Like our physician colleagues, BHCs have to engage in lifelong learning, both within and across disciplines with strong focus on evidence-based interventions. Physician training emphasizes utilization of clinical guidelines and evidence-based care, in daily practice with risk calculators and resources such as UpToDate used to make clinical decisions. Unfortunately, similar resources are far less available for BHCs however this may be changing as publications from resources like the APA Clinical Practice Guidelines are increasing. Finally, specialty training and board certification are still relatively uncommon among psychologists.

In summary: Foundational skills for effective BHC include biopsychosocial assessment, brief evidence based interventions, ability to function well within primary care teams, knowledge of behavioral as well as psychological components of common medical conditions (Dobmeyer et al., 2016). Perhaps one of the keys to the successful practice in primary care can be found in improved understanding of the training and practice of our physician colleagues. As BHC service is fairly new to the field of both medicine and psychology, we should continue to discuss the needs of BHC providers and limitations of training.

References

Dobmeyer, A.C., Hunter, C.L., Corso, M.L., Nielsen, M.K., Corso, K.A., Polizzi, N.C., & Earles, J.E. (2016). Primary care behavioral health provider training: Systematic development and implementation in a large medical system. Journal of Clinical Psychology in Medical Settings, 23(3), 207-224. doi: 10.1007/s10880-016-9464-9.

McDaniel, S.H., Grus, C.L., Cubic, B.A., Hunter, C.L., Kearney, L.K., Schuman, C.C. et al., (2014). Competencies for psychology practice in primary care. American Psychologist, 69(4), 409-429. doi 10.1037/a003672

Hunter, C.L., Goodie, J.L., Oordt, M.S., & Dobmeyer, A. (2014). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention. Washington, DC, US: American Psychological Association.

Simon GE, Imel ZE, Ludman EJ, Steinfeld BJ. Is dropout after a first psychotherapy visit always a bad outcome? Psychiatr Serv. 2012 Jul;63(7):705-7. doi: 10.1176/appi.ps.201100309.

Smith, R.C., Fortin, A.H., Dwamena, F., & Frankel, R.M. (2013). An evidence-based patient-centered method makes the biopsychosocial model scientific. Patient Education and Counseling, 91(3), 265-270. doi: 10.1016/j.pec.2012.12.010.

Runyan, C.N., Carter-Henry, S., & Ogbeide, S. (2018). Ethical Challenges Unique to the Primary Care Behavioral Health (PCBH) Model. Journal of Clinical Psychology in Medical Settings, 25(2), 224-236. doi: 10.1007/s10880-017-9502-2.

Runyan, C., Robinson, P., & Gould, D.A. (2013). Ethical issues facing providers in collaborative primary care settings: do current guidelines suffice to guide the future of team based primary care? Family Systems and Health, 31(1), 1-8. doi: 10.1037/a0031895.⁠

Physician burnout is a hot topic, increasingly recognized as affecting the quality of care, mental health of providers and patient safety and satisfaction. As team members, integrated care psychologists have unique expertise in recognizing burnout and providing support for all members of the team. Here are my top ten ways integrated care psychologists can help fight provider burnout.

1. Keep an open door. Be available to listen and support as a member of the team.
2. Know your resources. Have resources ready such as employee assistance program information, referral information, and crisis management.
3. Model good stress management. Take your lunch break, walking break, and vacations. Work reasonable hours and talk about how you manage your stress.
4. Create a positive environment. Give positive feedback to colleagues and recognize their contribution publicly with others. Thank others on your team regularly for their work.
5. Offer psychological expertise. Know the research on provider burnout and be available to discuss at meetings, grand rounds, or other events.
6. Set boundaries. When support turns into the need for a professional relationship, provide referrals and discuss limits of relationships as team members.
7. Recognize burnout and reach out. When you see signs of burnout, check it out and be ready to offer support and resources.
8. Engage and encourage connection. Go to lunch or after work social opportunities with your team members. Know about your team member’s families and interests. Providers who feel connected to each other work better as a team and develop immunity to burnout.
9. Show you care and understand. You may not always have the power to change the organizational culture, but just confirming you see what is happening can help provide relief.
10. Consider intervention skills. Psychologists are the experts in stress management. If your team is open to using your skills, offer to provide training in your area of expertise. You may be able to help the team with relaxation training, sleep hygiene, and communication skills.

Resources

• "Give Me a Break." APA Monitor, January 2019
• "Running Start...to a Great Career: Taking Care of Yourself." December 2018
• "Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Sati⁠sfaction: A Systematic Review and Meta-analysis." October 2018. Maria Panagioti, PhD; Keith Geraghty, PhD; Judith Johnson, PhD; Anli Zhou, MD; Efharis Panagopoulou, PhD; Carolyn Chew-Graham, MD; David Peters, MD; Alexander Hodkinson, PhD; Ruth Riley, PhD; Aneez Esmail, MD, PhD⁠

⁠The Div. 31 Integrated Health Care Task Force has been gathering success stories from states across the country that have helped enable psychologists in their states to practice in integrated care settings. We hope that by sharing their ideas and stories, that your state will be able to find helpful resources to overcome barriers to integrated care.

1. Having psychologists active in government -- Departments of Mental Health but also Human Services, Education, Health, Disability -- and on committee that consults to CMS and insurance oversight -- and consulting to the state Auditor and other offices -- has been very important. Psychologists need to step up and get appointed to state Boards and Commissions, and lobby the legislature actively, in order to make a difference (Minnesota)
2. Get a bill sponsor who is a physician (Missouri)
3. Use argument that insurance companies should not determine scope of practice. (Missouri)
4. Partner with pediatricians (CT)
5. Partner with other behavioral health providers (CT)
6. Provide evidence/date from other states (i.e., list of other states who do reimburse H & B)
7. Build a plan from what services patients need and incorporate payment models for behavioral health services (OR)
8. Approach from the viewpoint of the health of the state versus guild interest (OR)
9. Break down barriers about psychologists owning business with MD. (NJ, CT)
10. Discussing lack of availability/access (number of counties w/o psychiatry). (Doug Tynan, APA)
11. Provide guidelines to billing services about when to bill H & B codes vs. psychotherapy (NY)
12. Form an integrated health coalition (OR)
13. Partner with training programs/provide interprofessional training (OR)
14. Make the case for financial incentives to practice (OH)
15. Offer a model that fits the needs of the practice (i.e., short term, colocation) (OH)
16. Start with a pilot project (OH, DC, APA)
17. Create a state integrated health network (ID)
18. Start with Medicaid and move to other insurers (ID)
19. Hold stakeholder meetings (ID)
20. Partner with Bureau of Workman’s Compensation (BWC) on continuing education needs (OH)
21. Demonstrate value as psychologists (i.e., doctorally trained, health behavior change) (OR)
22. Focus on person/patient centered model (APA/OR)
23. Ask to look at their scorecard and how psychologists could help (APA)
24. Consider urban and rural needs and use a pilot to show Medicaid integration (APA)
25. Work with managed care companies in Medicaid vs. through regulation (APA)

by Peter Oppenheimer, PhD, and Kathleen Ashton, PhD, ABPP

As CAPP has moved to more virtual meetings, we have been working on improving our skills meeting via technology. Peter Oppenheimer and I put together these tips to help with your next virtual meeting.

Virtual meetings can be a positive way to allow people to meet and accomplish goals while reducing expenses, travel, and time commitment necessary to face to face meetings. However, virtual meetings also pose some challenges to organizers and participants to make the meeting time a productive and satisfying experience. We offer these suggestions in support of work together:

1. Participants should be prepared. Get online early and make sure the technology is working on your device. Be ready to start on time. Set aside dedicated time. Make sure just like any other meeting you have time to “get there” and then transition back to another activity. It’s tempting to fit in virtual meetings in tight time slots but it’s difficult to transition back and forth.
2. If you have concerns about your technology working try to test the system and resolve the problems prior to the meeting. Consider a back-up plan should your primary technology fail.
3. Find an appropriate location where you won’t be disturbed so you can focus on the meeting and avoid interruptions and distractions as best you can. Consider turning off phone and computer notifications, and telling your receptionist to hold your calls. If you are home, let your family members know what you will be doing, and ask your children and pets to be quiet and not to interrupt you.
4. Try to be in a location that will not cause distraction for others. If you’re driving, a dog is barking, or children are crying in the background, it’s going to be hard for you and others to concentrate on the meeting.
5. If you have technical difficulties, use the organizer’s requested method to communicate with them (chat option or text/email, SMS) instead of taking time from the meeting to resolve your difficulty.
6. Use the mute option when you are not talking. Mute yourself until you plan to speak to cut down on background noise.
7. Use a headset (headphones with a microphone) or a directional microphone to help reduce background noise
8. Introduce yourself before speaking, every time. It can be difficult for other participants to recognize your voice and this can cause confusion.
9. Consider turning on your camera. Video helps you to connect to other participants’ nonverbal communication and feel more connected. If it is a larger meeting (one where all participants cannot be seen at once) consider turning on your video when you want to speak, and off when others are speaking.
10. If you use your camera be aware of your on screen behavior and how you are dressed. Remember others can see you if you decide to eat your lunch, etc.
11. Consider using screen sharing so that everyone can view the relevant information at the same time Putting documents on the screen helps the whole group to see what you’re referring to as you speak.
12. Use chat options. Chat on virtual meetings is like passing a note or whispering to your neighbor. It helps you to connect with others more informally even when you’re not speaking to the whole group. Some platforms have chat features that allow you to send comments to the group or particular people without interrupting the conversation.
13. Avoid multitasking during the meeting. It’s easy to become distracted with other work or diversionary activities during virtual meetings. Give the meeting your full attention (or as much of your full attention) as you would if you were there in person. Be respectful of other participants. If something outside of the meeting grabs your attention, think long and hard before sharing that in the meeting.
14. It’s difficult in a virtual meeting to realize when other people would like to talk, so make sure you are giving others room to voice their opinions. Some platforms have options to raise your hand virtually when you want to speak which can help with speaking order.
15. If you have to step-out or leave the meeting or attend to something else during the meeting, tell the organizers by the means they have asked to be notified.

Meeting Organizers

1. Meeting organizers should select a software platform that will meet the need of the meeting for attendance capacity, and audio and visual functions.
2. Meeting organizer should send out directions for how to access the meeting, agendas and materials ahead of the meeting time.
3. Meeting organizers should inform participants how to ask to speak (i.e. “raise hands”) and how to contact them if they have difficulty with their connection.
4. Everyone should expect meetings to start and end on time.
5. When using a new meeting platform or adding new members, organizers should offer an opportunity for attendees to try out the platform ahead of the meeting.
6. Organizers should sign on-early (10 minutes?) so that people can connect and fix problems. This could be a time for informal social conversation.
7. Organizers should include reasonable breaks. If the virtual meeting is longer than one hour, people may need to get up and move around, use the restroom, etc. just like any other meeting. Let the group know when breaks will occur.

We hope these tips will make your next virtual meeting run smoothly and efficiently.

by Kathleen Ashton, PhD, ABPP

I’m back in Ohio after another energizing Practice Leadership Conference (PLC). The theme this year was “Advancing Practice Together,” and it was a very apt title given the historic vote at APA Council for a new membership concept that combines our c(3) organization (APA) with a new c(6) organization encompassing practice, science, education and public interest. The proposal guarantees practice advocacy funding at its current level, with no raise in dues for at least three years. From this point, a workgroup will be formed to discuss governance and financial models, and a final vote will take place at APA Council in August.

The Committee for the Advancement of Professional Practice (CAPP) had endorsed the model at their February meeting, stating it “believes it will ensure and expand the advocacy and other resources of importance to practitioners. CAPP perceives the new model will increase the ability of the association to create a stable financial future in order to advocate for and support all members of the association.” The final workgroup has not yet been announced, but CAPP is hoping for strong c(6) experience to be represented including at least one CAPP member.

After watching the important work at PLC, it has never been clearer to me that psychologists and psychology need to have a strong advocacy presence. PLC is one of the best examples of the c(6) work that the APA Practice Organization (APAPO) has funded. It includes essential supports for state psychological associations, such as the training for presidents elect and executive directors and opportunities for states to share ideas. PLC engages students, early career psychologists and diverse psychologists into advocacy providing stronger psychology advocacy for the future. In addition, PLC has often been the inspiration for early career and diverse psychologists to move into leadership. Many state psychological association presidents and APA/APAPO leaders were first introduced to leadership opportunities at PLC. My first PLC experiences as a public education campaign liaison strongly influenced both my involvement in OPA and APA/APAPO.

Importantly, PLC also takes hundreds of psychologists up to Capitol Hill and helps them engage with their legislators on issues affecting psychologists. Our messages for this session included supporting the Medicare Mental Health Access Act, which adds psychologists to the “physician” definition and asking for protection for Medicaid expansion. (The Legislative and Legal Advocacy Action Center provides more information, including how to contact your legislator.) For the first time in my recollection, delegates were encouraged to discuss social justice issues at their Hill visits, signaling a change toward a more integrated advocacy model.

Psychologists at the state and national level will continue to need strong, organized advocacy. Transparency and the opportunity for two-way communication will continue to be important. It will be critical for members to stay engaged and informed during this change process.

by Roseann Fish Getchell
Doctoral Student, Clinical Psychology PsyD Program
George Fox University
Chair Elect, American Psychological Association of Graduate Students (APAGS)

As our profession hurtles into a new era of innovation and creative approaches to population health, I am struck with the question: How do we continue to have a seat at the table? More importantly, how do we increase the impact our psychological community has in making pivotal decisions regarding funding, access, and impact of psychological research and practice? Whether the table represents a neighborhood association, a local board, or even state and federal government, psychologists at every level have the potential to impact the health of our communities for the better.

One pivotal piece in our psychological community that holds boundless potential is our group of graduate students and early career psychologists. As emerging leaders in the field, APAGS members and EPC’s enter into the profession with several strengths that can be harnessed in the field of advocacy--with the direction and mentorship of seasoned psychologists. Whether we are focusing on harnessing knowledge of technology and social media, supporting social justice movements, or energizing conversations with new ideas, our next generation of psychologists are ready to pull up a chair to the table and impact population health in a major way.

This type of dynamic leadership including graduate students and early career psychologists has the potential to reach across many types of legislative structures, impacting integrated care at its core. As a graduate student myself, I have reflected on the impact my own legislative advocacy training has had in my ability to stay informed of relevant hot topics in healthcare, understand how changes in policy impact patient access to care, and engage in contacting legislators in my community whose decisions impact the health of thousands every day. This training started with my mentors, who welcomed me to the table and guided me through the process of legislative advocacy on a fundamental level.

I have hope that when graduate students like myself are introduced to such a dynamic process early on in our careers, we are much more likely to advocate for the guild and for mental health access as we grow into our own professional selves. Furthermore, early career psychologists and graduate students have the potential to engage in this type of leadership across many domains. It is entirely possible for psychologists across the country to not only make an impact as researchers, teachers, clinicians, and administrators, but to also engage as government representatives and experts in our field.

As we continue to think of new ways to impact our community’s health on a population scale, I urge our psychological community to think outside the box when it comes to leadership and advocacy. Who knows, the next early career psychologist you meet may one day have a seat on the Senate.

Here are some helpful links to advocacy resources for psychologists and graduate students nationwide. Feel free to share them!

• APA Services, Inc  Advocacy 
• APA Advocacy Initiatives 
• APAGS Legislative Issues and Advocacy Training Tools⁠ 

by Caroline Bergner, JD

The information below is as of April 2017. Because Medicaid fee schedules are updated daily, weekly, monthly or yearly (depending on the state), it is important to note that this information is only technically accurate as of that date. Though it is likely still accurate, I wanted to state the limitations of the data we have.

1. Alaska (only one code: 96154)
2. Arizona
3. California
4. Colorado
5. Connecticut
6. Delaware
7. DC
8. Hawaii
9. Idaho
10. Indiana
11. Iowa
12. Kansas
13. Kentucky
14. Maine
15. Maryland
16. Michigan
17. Montana
18. Nevada
19. New Hampshire
20. New Jersey
21. New Mexico
22. North Carolina
23. North Dakota
24. Oklahoma
25. Oregon
26. Pennsylvania
27. South Carolina
28. South Dakota
29. Texas
30. Utah
31. Vermont
32. Virginia
33. Minnesota
34. Missouri

There are some other caveats. Some states (like TN) are entirely run by multiple managed care companies whose fee schedules are not necessarily publicly online (and information was not available on their state Medicaid website) so we do not have information. The data for the states listed above was mined from the fee schedules listed on each individual state’s Medicaid website.

⁠by Kathleen Ashton, PhD

What are those unwritten rules that professionals seem to know about how to "play nice with others?" I call it "professional etiquette."  These are social skills for the integrated care workplace that I’ve learned over the years or adapted from mentors and colleagues. They may not apply to every integrated care setting, but I hope they may be useful for many of you practicing in integrated care or elsewhere.

1. Respondez sil vous plait! Respond to emails, phone calls, and texts in a timely fashion. If you’re not able to respond the way you’d like, respond and let them know you’ve seen it and will respond later.
2. Pick up the phone. Sometimes a text or an email just doesn’t cut it. If you need a quick response, connect by phone or in person.
3. Connect in person (gasp!). Nothing is stronger than a personal connection. Make time to see team members and colleagues in person, even for a quick hello.
4. Say thank you. We don’t provide reinforcement nearly enough.
5. Be kind. The best integrated care colleagues are kind to everyone from the cleaning service to the hospital CEO.
6. Dress appropriately. Presenting yourself professionally is important. Your team will value being able to introduce you and know you will be professionally turned out. At my hospital, the men wear ties, the women wear suits or dresses for the most part. White coat optional.
7. Catch others doing a good job and make it public. Reinforcement again. Everyone loves to have their team members recognized.
8. Do what you say you’re going to do. Follow through on commitments.
9. Stop competing with each other. Psychologists in medical settings sometimes feel like they need to compete each other for a piece of the pie or leadership. Celebrate your colleagues and let them shine.
10. Don’t get too big for your britches. Whether you are reviewing a journal article or doing a job interview, remember that the person you are interacting with may come up later in life in a different position. Excellent professionals are respectful and courteous, even when giving critical feedback, and especially with early career professionals.
11. Don’t take it personally. Remain courteous and don’t burn bridges.
12. Keep it brief. Don’t go on forever in meetings; again, some psychologists sometimes feel like they need to make their presence known. Do this, but do it when it is pertinent and keep it pithy.
13. Support your colleagues. Write recommendation letters, nominate them for awards, and be there for consultation and support.
14. Be respectful. Remember that your colleagues come from different professions and different backgrounds. Respect other’s strengths.
15. Be timely. Set deadlines and keep to them. When you can’t, let others know and set a new deadline. And be mindful of other’s time.
16. Be present. Listen to your colleagues and avoid multitasking. Checking your phone, working on your laptop, and avoiding eye contact tell everyone you’re not listening (even if you think you’re being subtle).
17. Wait before sending that email. Or even trash that first draft and start over when you're feeling calmer and thinking more clearly.
18. Be a cheerleader for psychology and psychologists. Have confidence in your background in psychological science, and let your expertise shine while recognizing the value of other guilds.
19. Consider culture, gender. Don't make assumptions, ask inappropriately personal questions, or cross boundaries.

by Kathleen Ashton, PhD

I love integrated care! I’ve been fully integrated into health clinics since the beginning of my career, working with women’s health, sleep clinics, headache clinics, bariatric clinics and now a medical breast clinic. I was fortunate enough to receive excellent training through practicum, a health psychology internship and fellowship. As healthcare reform continues to evolve, many psychologists are considering moving from private practice into integrated care. But they may be thinking, “How do I do this? Do I need more training?” Particularly relevant to the APA Practice Organization (APAPO), there are issues when working in integrated care with billing, reimbursement, advocacy and legal/regulatory bodies.

A word of caution: Just because I am highlighting integrated care issues addressed by the APAPO, it doesn’t mean that the PO is not still interested and addressing the interests of independent practice. There is a healthy representation of independent practitioners in APAPO leadership, and their voices are appreciated. I am proud that the APAPO is able to provide a professional home to both independent practice AND integrated health folks.

APAPO and Integrated Health

Policy: The APAPO is working on a policy addressing c-6 issues in integrated care that is a companion to the APA Council policy. The policy addresses issues such as colocation and collaboration; workforce development; quality and outcome assessment; and reimbursement challenges. The hope is that the policy can be used to guide advocacy efforts and support legal/regulatory activities related to integrated care. So far, the policy has made it through the public comment period (thanks for your feedback!), and the comments are being incorporated back into the document. Its next step is review by the APAPO Board. This is the APAPO’s first official policy and we are excited to be part of the process.

Webinars: Have you taken advantage of the free webinars for APAPO members available recently? Helen Coons, PhD, and Connie Galetti from APAPO staff put on a terrific recent webinar “Transitioning Your Psychology Practice to Primary or Specialty Health Care: Are These Settings Right for You?” Other webinars have included APAPO President Antonio Puente on coding. These are a great resource for those interested in integrated care.

Training Opportunities: One excellent opportunity is through the APA Center for Health. APA worked together with CMS and received a grant to help train psychologists in integrated care models. The Integrated Health Care Alliance was developed by experts in integrated health care, and provides a training and support network leading to new skills for integrated practice care. The idea is to give psychologists the tools to transform their clinical practice. Hopefully, this will increase psychologists’ participation in the healthcare system and with healthcare teams, position psychologists for value based reimbursement in the future, and improve patient outcomes by addressing the behavioral health component of patient care.

The program consists of online CE courses, an assessment of your practice, and access to an ongoing support network. You can earn up to eight CE credits. Psychologists in anything from solo to large group practices are eligible, After you enroll in the IHCA, you will get access to the APA’s six-hour training on integrated primary care. Access to a two-hour training on business and payment models for integrated primary care will be available in a few months. Additionally, throughout the three-year project duration, you will gain access to other relevant training and materials, technical assistance, and more. Those that enroll will also be expected to complete assessments on how well their practice is integrated throughout the program.

by Shirley Ann Higuchi, JD

APA Practice’s Legal & Regulatory Affairs Department (LRA) and the Education Directorate have just overcome a major regulatory barrier and can now move forward on a pilot project to use supervised psychology trainees to bring integrated behavioral health services to underserved Medicaid populations in Washington, D.C. The pilot project will place trainees in primary care physician (PCP) offices; help build a pipeline of highly qualified psychologists to fill the extraordinary need for these services; and develop a model for replication in other states. A special shoutout to Caroline Bergner, JD, in LRA and Education for her hard work on overcoming the regulatory barrier and moving this project forward.

Background and Details

As many of you know, APA’s larger agenda in the Practice and Education Directorates is to remove barriers to psychologists and interns/postdocs fully engaging in the Medicaid system. Through targeted advocacy we have been working with jurisdictions across the country, including D.C., to increase access to psychological services for diverse, low-income Medicaid populations.

The D.C. pilot program grew out of a collaboration between APA, the District of Columbia Psychological Association, the largest Medicaid managed care company in D.C., AmeriHealth Caritas District of Columbia (ACDC), and the APA-accredited Mid-Atlantic Internship Consortium (affiliated with the Argosy School of Professional Psychology).

ACDC identified increased integration of care as one of its top priorities. Because of the limited availability of primary care psychologists in D.C., we looked to a trainee model that would help build that critical component of the psychology workforce in D.C.

The pilot program will involve supervised trainees, both interns and post-docs, providing behavioral health services in three primary care clinics in underserved areas of D.C. Their services will be reimbursed by Medicaid through ACDC, a big win for the sustainability of such an integrated care program.

We added post-docs to the program to dramatically increase the amount of integrated services provided by the program to meet ACDC’s substantial needs. (The multiple demands on interns’ time limited the amount of service that they could provide.) The plan is to train the post-docs to become supervisors for future generations of interns after their postdoc years are complete.

We are now able to move forward with the pilot program, which APA sees as a model to be replicated in other jurisdictions and with other Medicaid managed care companies.

by Kathleen Ashton, PhD

On all of our minds over the past few months has been the repeal and replace effort for the Affordable Care Act. The APA Practice Organization (APAPO) has opposed proposed repeal and replace efforts as negatively affecting mental health, including provisions that remove mental health benefits as essential health benefits, eliminate Medicaid expansion and do not protect pre-existing conditions. The Committee for the Advancement of Professional Practice (CAPP) received a briefing from Doug Walter, associate executive director for government relations, during the process. The bill has been called a “zombie” bill on Capitol Hill as it seems to never die. The process appears to be different than seen in the past. The Senate is currently using a budgetary reconciliation process, and passed a motion to proceed to debate. To pass any changes, they needed a majority 51 votes, and some issues were not eligible for this process. The first vote on repeal/replacement with amendments failed. One key vote was on straight repeal and was delayed. A vote on the replacement bill, “Better Care Reconciliation Act,” failed, in dramatic fashion with Senate Democrats; Sen. Collins, R-Maine; Sen. Murkowski, R-Alaska; and Sen. McCain, R-AZ, voting against. Your psychology PAC money has been at work; the advocacy staff at APAPO has been talking to Senators and getting out grassroots effort to get the message from psychology out to key votes. Psychologists have been amazing with 14,000 plus messages during house debate and 8,000 during Senate debate. Keep it up! Our advocacy office will continue to keep a close watch on health care as it affects psychologists and consumers.

CAPP has developed an integrated care policy to be a companion to an APA Council policy passed in 2016 that addresses the (c) 6 guild issues related to integrated care. The policy includes recommendations on colocation, reimbursement, workforce development, advocacy and values-based reimbursement. It is the first policy from the APAPO and continues to move through the new policy making process, being reviewed by the Office of General Counsel and the Finance Committee. The policy is currently available for public comment for stakeholders.

CAPP also continued discussion on the Master’s Training Summit, which made recommendations about “the master’s-level issue” (i.e., finding a place for those with a master’s within psychology to remain with a psychology identity and a mechanism for the ability to practice, either via certification or licensure). Of note, these recommendations were not an official APA or APAPO policy on the master’s issue. APA Council is currently considering discussing the recommendations, and the APAPO/CAPP has been considering the implications for professional psychologists. The arguments for master’s-level licensure include lack of diverse doctoral level psychologists, lack of licensure opportunities for those with a terminal master’s psychology degree, increasing numbers of master’s-level licensed mental health professionals (MFTs, LISW, LPCC), the workforce that would be needed for the potential behavioral health demand given changing U.S. demographics and considering master’s-level psychology trained extenders for doctoral psychologists. Arguments against master’s licensure include the importance of maintaining the doctoral standard, worry about weakening the market share for the doctoral degree, difficulty of defining training and weakening resources by splitting membership. The importance of maintaining the doctoral degree as the standard for title of “psychologist” and defining the value added of doctoral degree psychology training compared to master’s-level training was discussed.⁠

by Kathleen Ashton, PhD

Tips for using social media successfully as an integrated health psychologist.

• Keep it all professional. I write every tweet and blog as if anyone could see it—my employer, my patients, etc. It may be dry for some (not everyone gets as excited about integrated care as I do!), but your online history is forever.
• Have a focus. I tend to tweet about specific areas: stress management, breast cancer care, integrated care, APAPO. People who follow generally know what to expect from my feed.
• Vet retweets and links that you post. Sometimes the quick blurb sounds good, but the actual article is bad science.
• Post original health psych content. If you read an interesting health psych article (or wrote an interesting one!), think about creating a post with a link, or even linking to a short blogpost on the content. I get more of my research reading in this way than I would like to admit, and appreciate others vetting my articles for me.
• Live tweet from conferences. I use my twitter feed after conferences as notes on what I thought was most important. It's a great way to stay engaged and connect with others at professional conferences.
• Post regularly (but not incessantly). Some people post once a day or have a regular theme. Others just when they have time. I set aside about 10 minutes in the morning for social media and try to do at least one original post daily.
• Use posts to feature your work. Post about upcoming conferences, papers coming out, and community events you're speaking at. This gets the word out to a wider audience, and also helps feature your host/organization.
• Have a social media policy. Keely Kolmes (@drkkolmes) has a great resources on this. Mine is not so intense, but in my informed consent there is a line “I do not interact with patients over email or social media given the insecure nature of these forms of communications.”
• Follow your hospital's or institution’s social media policy. Limit your time at work, and don't post as official statements from your organization, just your unofficial feed.
• Use pictures. No one likes an egg (this is the faceless picture Twitter gives you until you replace it). You need a professional profile picture. Using pictures with your post is also more eye catching.
• Use links. Links help you to get more info in those 140 bites. I send out lots of links from my workplace (@ClevelandClinic) and the Practice Organization (@APAPractice). Both have great information.
• Tag others in your posts (i.e., just mention their handle in your posts (i.e., @DrAmySullivan). This will alert them to your post and they are also likely to retweet you.
• Retweet others. If someone alerts you to their post, it is good etiquette to retweet it if it is relevant to your twitter feed. This sends good vibes to your followers.
• Like posts. This is a nice way to reinforce colleagues. If they are letting people know they gave a talk or completed an accomplishment, liking their post lets them know you are interested and rooting for them.
• Follow your colleagues (psychologists, physicians, nurses, etc.), and check out who has a large following/influence. Tag them in posts so they retweet you (this is how you build a following of your own).
• Follow feeds that give you news on integrated care—for example I follow APAPO (@APAPractice), @APADivision38, @APOSHQ, & @APAHCnews, for health psych news.
• Direct tweets. Remember, it you tag a person in a tweet at the very beginning, you are sending that tweet only directly to them (and anyone who follows you both). Use these for more personal or light hearted messages—but don’t forget it’s still out there.
• You can also send direct messages more privately. This is a good way to follow up with someone that you don’t have their regular contact info but maybe connected with at a conference through social media. But otherwise, put it out into the “twitterverse. “
• Consider other social media outlets: Facebook, Linked In, ResearchGate. I can’t keep up with too many of these. Facebook has a more personal feel to me, so I try to keep my privacy settings there high and rarely post but follow family/friends there. Linked In can be good for professional connections/job hunts. ResearchGate is useful in the academic medicine world. There are literally thousands of other social media venues but these are the most common ones I see integrated care psychologist in.
• Have fun with it.

by Kathleen Ashton, PhD, ABPP

In many ways, as I participated in APA Practice Organization (APAPO) Committee for the Advancement of Professional Practice (CAPP) this weekend, I feel like my career transition is a microcosm of changes facing the profession of psychology.  We are at an important transformational point as a guild, and I feel that   CAPP and APAPO are working to approach our future with strength, teamwork, intentional positive influence over own destiny and emphasis on the value that the profession of psychology brings to the health care field and larger practice world. I am hopeful that this vision will be one that focuses more on demonstrating our value as psychologists with a positive view on teamwork rather than one of competing for scarce resources and devaluing other professions. I am confident that as psychologists if we focus on our strengths and value, we will assure our place in the health care field and practice world.

So how do we do this? APAPO priorities identified in the meeting included focus on Ps: payment, prestige (for psychology), products. Vehicles to deliver these goals included advocacy, focus on science/outcomes and membership services.   I think the single most important accomplishment at this meeting was something you will hopefully start to hear more about: the development of the Qualified Clinical Data Registry (QCDR) by the APAPO. This is an initiative for psychologists to control their own future of outcome measurements, and it has the potential to not only help psychologists get better reimbursement ( payment ), but also be a member service ( product ), as well as a way to build a research basis for our value ( prestige ). I think it will also prove to be a source of non-dues revenue for the APAPO, which will help with sustainability for the organization.  In addition, being able to use outcome data for research on impact of psychological services can only help us with our advocacy efforts with Medicare such as physician definition and positioning ourselves in the new health care system.

What else did CAPP work on this weekend? Increasing the ease and value of the APAPO membership is huge. You should have received your renewal email recently, and you will notice it is easier to complete a one click there to the renewal page.    

Paper renewals will also be streamlined and out by the end of the month.  I have been assured that APAPO membership for those APA members who choose this later will also be streamlined by November, including eliminating the need to call APAPO versus adding your APAPO membership online.

CAPP and the APA/APAPO Board are also examining new membership models to help keep the APAPO financially viable and models that enable members who wish to have primary membership in APAPO vs. APA or join one without the other. There are challenges to this, including (c)(3)/(c)(6) issues, financial and legal implications.  Many members still do not understand the difference between APA and APAPO. It cannot be stated enough: APA cannot advocate on behalf of practicing psychologists or guild issues from a legal/tax status. Many psychologists assume that APA does this and are frustrated, asking, “Why isn't APA doing this or that?”  However, it is the APAPO that supports the guild of professional psychologists. If you're a practicing psychologist and want someone to fight for reimbursement, prestige and provide products for practicing psychologists, you want to be a member of the APAPO.

Other Hot Topics at CAPP

Membership

• Practice guidelines for PTSD, depression and obesity are likely to be out by 2017.
• Look for   new APAPO benefits including five free CE credits, webinars, updated Psychologist Locator.
• Valuable services: legal consultation, guide to Medicare, Innovative Practice Toolkits, Research Round Up.
• Good Practice will have a freshened look and include early career psychologist (ECP) column, State Beat column, legal corner and quick polls.
• Short-term and long-term updates to the APAPO website to make it more user friendly.

Listserv, Take Two

APAPO is working on relaunching its listserv this fall. We believe this is an important two-way communication tool with APAPO members. It will be an opt-in listserv (you will have to sign up). You also will default reply to sender rather than reply to all. We hope this will avoid some of the problems of our last launch (still have PTSD). The great thing about an APAPO listserv is we can discuss advocacy issues in a way that is prohibited on APA listservs. Some topics are likely to include reimbursement, integrated care, insurance issues, regulatory challenges, etc.  You still will have to be careful about anti-trust and business promotion, but it should provide a great way to keep current with practice issues as well as provide feedback to APAPO about what is affecting you as a practitioner.

EPPP2

Feedback from students and ECPs was presented along with feedback from the Association of State and Provincial Psychology Boards (ASPPB). Student/ECP concerns included cost, burden, increased time to licensure and sequence of training issues. ASPPB noted that competency-based assessment is important to help psychology establish itself in health care arena and for future reimbursement. While competency-based assessment is likely to be a more engaging process for students approaching licensure, it could be helpful to encourage sequence of training changes that would move EPPP-1 up to the finish of coursework (graduate school), EPPP-2 to end of internship, etc. CAPP will be discussing the EPPP2 in more detail at upcoming meetings. They encouraged ASPPB  to do outreach to ECPs and students, in particular, to better explain what the licensure climate would be post EPPP-2 and to continue dialogue and engagement with ECPs and students.

Legal/Regulatory Victories

• Successful Summits on Alternative Practice Models were held in Chicago and Washington, D.C.
• Partnered with nine SPTAs for Chicago and seven for D.C.
• Working to develop toolkit for spinoff conferences and one to two regional events for 2017 in new geographic areas
• HIPAA update: Considering business plan regarding updating this important practice tool.
• Good progress on work with New York regarding fighting against exclusions for neuropsychological testing for patients with severe mental illness and autism.
• Medicaid advocacy-working on intern reimbursement in several states.

State Issues

• Organizational development grants to continue. These are vital to keeping the doors open in several small states.
• SLC is now PLC—“Practice Leadership Conference.” Significant financial pressures have led to cost reduction, with institution of a $100 registration fee, hotel reimbursement reduction for FACs, EDs, CAPP; and replacement of the opening session with an evening reception on Saturday. Staff successfully renegotiated the hotel contract, and SPTAs will likely have increased cost sharing for the conference through the changes above.  Kudos to APAPO staff for working to make PLC a continued strong leadership and advocacy opportunity for psychology despite challenges.

Government Relations

• APAPO political action committee did well with fundraising at convention: $27,000—thanks to all, especially improved leadership participation.
• Mental Health Reform bill has bipartisan support, and psychologists have done well advocating (sending emails/letters). Thank you.
• Physician Definition bill needs Congressional Budget Office score. Time is running short.
• Goals to introduce early next Congress.
• Other issues include integrated care codes, testing codes, parity law enforcement.
• Encouraged mechanism to communicate more regularly (e.g., new listserv, social media).

QCDR

• Currently offering PQRS-PRO to our members to help with value-based Medicare payment (i.e., report on measures to avoid penalties/bonuses). PQRS expires on Dec. 31.
• Merit-Based Incentive Payment System (MIPS) will replace PQRS and continue to focus on value versus volume and will take effect for psychologists in 2019.
• QCDR would be our own system we could use for MIPS. Will enable APAPO to pick 30 outcome measurements to follow.
• Could be used to help negotiate with insurance issues, would have access to your own data.
• Data could be de-identified and used for research.
• MIPS reporting could result in -8 percent to +8 percent incentive payments for psychologists. Bottom line: your bottom line as a Medicare provider will be affected.
• Could be marketed to other behavioral health providers.
• CAPP approved funds for start-up costs.

CAPP Elections

• Currently there is low participation rate in voting for your APAPO leaders; it's open until Sept. 30.  
• We discussed ways to make the elections more visible at convention including a Meet the Candidates Forum.
• Discussed a shorter timeline for voting, more reminders to vote.
• Recommended using a matrix system to help look at APAPO priorities, competencies for slating.

Center for Health

• Applying for grant to train 6,000 psychologists in integrated care, value-based models. Free eight-hour continuing education course, would work with SPTAs.
• Working on diabetes training—two-hour CE will link to physicians who work with diabetes.
• Starting newsfeed on psychology and health. SPTAs and divisions—beneficial to hear about state health care reform and then disseminate as well.

Policy

• A motion to allow CAPP to originate policy (reviewed by APAPO Board, Finance and General Counsel) was passed.
• As an example, a workgroup was formed to make a companion policy on integrated care to the one approved by APA Council.

Divisions

APAPO is reaching out to divisions regarding collaboration, particularly for APA convention programming.

Wow! I'm tired after reading all that much less being there.  Seriously, it was a very full meeting, but so important. The members of CAPP, CAPP liaisons, APAPO Board and APAPO staff are a wonderful group to work with, and I am learning so much from each of them. I am sure I missed other important information, so stay tuned for the official minutes.  The last important news is that apparently CAPP will be moving to one in-person meeting per year, with the rest of the work done in virtual meetings because of budgetary restraints.  As of now, this meeting is tentatively scheduled for Oct. 12-15, and CAPP will also meet at PLC on March 6 for a half day.

What are your takeaways?  APAPO CAPP is working hard to promote the profession of psychology and maintain a positive vision where psychology has a strong place in the health care and practice marketplace . They are focused on increasing recognition of your worth as psychologists, promoting policies that will give you better payment for your services and providing services that you need to function as a practitioner. I am grateful to be part of the APAPO; I know as a practitioner how vital it is to have the advocacy, regulatory assistance and services APAPO provides me every day.  I am privileged to be able to use these APAPO benefits to help me in my new position.  As I move forward with new challenges, I am excited about my professional future and the future of all psychologists.

As a reminder, this blog is not an official APAPO or CAPP communication. This is my personal take on APAPO/CAPP activities. My goal is to provide timely and transparent information on APAPO/CAPP to APAPO members.

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.  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/payers 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 payer 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).