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The President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry

Patrick DeLeon, Ph.D., J.D.


One of the most significant developments during the past year for professional psychology was the decision by President Clinton to establish the Advisory Commission on Consumer Protection and Quality in the Health Care Industry. The Commission is expressly charged with the responsibility of addressing "quality of care" issues raised by managed care. A psychologist, Beverly Malone [President of the American Nurses Association (ANA)] is one of the Commissioners. Another Commissioner is Mary Wakefield, professor of nursing and a long time friend of psychology, and now Chair of the Center for Health Policy at George Mason University.

Mary's thoughts: "While access and cost of health care historically have been the driving concerns behind state and federal health legislation, recently concerns regarding quality of health care have emerged in the public policy arena. At the federal level, legislation has been introduced including a fairly comprehensive bill by Senator Jeffords, Chairman of the Senate Labor and Human Resources Committee. Secretary Donna Shalala has made quality of health care a priority within the Department of Health and Human Services. In March of this year, President Clinton announced his appointment of the Advisory Commission on Consumer Protection and Quality in the Health Care Industry. The 32 member Commission, selected from approximately 1000 nominations, meets monthly and will provide recommendations to President Clinton in March, 1998."

"Demonstrating the President's personal priority, he tasked two of his cabinet members, Secretary Shalala and Secretary of Labor Alexis Herman, to co-chair the Commission meetings. Seeking a wide range of expertise and views, the Commission includes individuals representing health care providers (e.g., the ANA and the American Medical Association), health care organizations such as managed care and hospital systems representatives, business, labor, state government, consumer groups and quality experts."

"The Commission will recommend policies and activities that should effect continuous improvements in health care quality including: 1) Strengthen consumer rights and protections; 2) Strengthen consumer knowledge of what constitutes good quality health care; 3) Facilitate consumer choice of health insurance products, providers, and treatments; 4) Optimize consumers' access to, and provision of, quality health care through all types of health plans and products; 5) Foster improvements in health care by incorporating advances in health care and quality management sciences; 6) Promote the presence of necessary structures and systems to achieve health care quality improvements; 7) Promote policies and practices by public and private purchasers and regulators to effectively and efficiently pursue these goals; and 8) Foster improvements in health care through support for research and education. Every one of these activities has relevance to psychology and would benefit by psychologists taking the time to share their views, concerns and recommendations."

"To accomplish the work of the Commission, four subcommittees have been established. The first subcommittee, focusing on Developing a Consumer Bill of Rights and Responsibilities, was undertaken at the President's explicit direction. The other three subcommittees are: Performance Measurement and Quality Oversight, Creating a Quality Improvement Environment [which I chair], and Roles and Responsibilities of Public and Private Purchasers and Quality Oversight Organizations. The Commission meets monthly with, for example, three meetings scheduled for Washington, DC (October 21-22, November 18-19, and December 16-17). The meeting on January 27-28, 1998 will be held in Seattle. All meetings are open to the public and time is set aside to consider testimony from witnesses expressing interest. This is an excellent opportunity for individuals and organizational representatives (i.e., State Psychological Associations) to make public comments to both the Co-chairs and the full Commission. Documents produced by the Commission are on the web [http://WWW.HCQUALITYCOMMISSION.GOV] and available at Commission meetings. It behooves psychologists to take the time to review the work of the Commission as it is being developed and shape the recommendations that ultimately will be made. Clearly, quality of health care is a significant concern for consumers, providers and policymakers alike. It takes the best thinking of all interested parties to forge directions that will preserve and enhance the quality of America's health care system. Psychologists should not let this opportunity pass by without actively participating."

INTERESTING EDUCATIONAL INITIATIVES:

I continue to be personally impressed by the potential roles that psychology can play in shaping our nation's educational programs. Today slightly less than 20 percent of our nation's adult population possesses a baccalaureate degree and there are credible reports that of those entering division one colleges, only half actually graduate within six years (56 percent). With psychology historically stressing the doctorate degree, our profession truly is one of the "learned professions". As such, collectively we have a very real societal obligation to affirmatively address society's pressing needs -- most importantly, to provide visual leadership.

Accordingly, I am pleased to report on two new educational initiatives in which psychologists have played an active role. In March of this year, the White House released its: Report To The President On The Use Of Technology To Strengthen K-12 Education In The United States. The report took a global perspective, highlighting the extraordinary importance of quality education to the future of our nation: "While the continuing expansion of international trade has the potential to confer substantial long-term benefits on American companies and workers, it also presents certain challenges. As trade barriers fall and cross-border transaction volume increases, our children will find themselves competing more directly with the citizens of other countries to provide goods and services within the world marketplace.... (There is) the potential for unprecedented (at least within the American experience) disparities in income and wealth among Americans that could threaten the political stability our nation has long enjoyed...."

The panel members felt that while technology will not in itself improve the quality of American education, there were ways in which it could be used as a powerful tool. They emphasized the critical importance of addressing learning with technology, rather than about technology; emphasizing content and pedagogy, and not just hardware; and giving particular attention to the importance of ongoing professional development.

Among teachers who report having computer systems readily available at school, only 62 percent use a computer regularly for instruction. When teachers do make use of these technologies, they are often used for either teaching students about computers or for drill and practice focusing on the acquisition of isolated basic skills.
Approximately $3.3 billion is expended annually in technology-related expenditures, or only 1.3 percent of the $248 billion that is spent on public K-12 education.
Whereas 23 percent of all U.S. expenditures for medications are applied towards pharmaceutical research, less than 0.1 percent of our expenditures for elementary and secondary education are invested to determine which educational techniques actually work and how to improve them.
Targeted federal programs have substantially mitigated some of the disparities in access to educational technology that had earlier been associated with socioeconomic variables. Today, poorer schools have one computer for every 11 students, while each computer in the richest schools is shared by 9.5 students. In 1983, microcomputers were found in four times as many of the wealthiest schools as in the poorest schools.
The most significant disparities in socioeconomic status related access to technology are now found in the homes of students. Computers are present in only 14 percent of all households headed by adults who had completed no more than a high-school education, and in which annual household income was less than $30,000. The comparable figure for households headed by college-educated adults having a combined income of more than $50,000 per year is more than five times greater, at 73 percent. African-Americans are 57 percent less likely to have a computer at home, and Hispanics 59 percent less likely, than non-Hispanic whites. Adjusting for household income, educational attainment, age, gender, and location of residence (urban or rural), home computer ownership is 36 percent and 39 percent less common among African-Americans and Hispanics, respectively, than among non-Hispanic whites. Interestingly, on average, girls and boys differ only slightly in their use of computers at school and within the home environment.

The second initiative is contained in the Senate version of the Amtrak Reform and Accountability Act of 1997 (S. 738, as reported). Section 412 of the bill, entitled "Educational Participation", states: "Amtrak shall participate in educational efforts with elementary and secondary schools to inform students on the advantages of rail travel and the need for rail safety". The accompanying Senate report further references teaching children about the advantages of careers in transportation. Although stated in very broad terms, this legislative effort possesses the potential for providing a substantial number of children with an exciting "hands on" educational experience; one that, if crafted appropriately, might make a real difference in the lives of many who otherwise might find themselves trapped in our nation's inner city ghettos. A recent General Accounting Office (GAO) report indicated that each day, 14 million children attend classes in a school where at least one building is in need of extensive repair or replacement -- our nation's educational programs definitely do need psychology's attention.

THE PRESCRIPTION AGENDA -- A STEADY MATURATION:

In more ways than many of us seem to appreciate, the future of our profession lies with those who are currently in their graduate training. Accordingly, we were very pleased that James Cantor, the APAGS liaison to CAPP, recently authored a formal "resolution of support" for prescription privileges which was formally adopted by APAGS. APAGS represents approximately 61,000 psychology graduate students. The specific wording of the proposal: "That APAGS supports the APA stand on prescription privileges". The motion passed, with 7 voting in favor and one abstention.

CONTINUING INSTITUTIONAL ADVANCES -- Janet Matthews, APA Board of Directors liaison to the Association of State and Provincial Psychology Boards (ASPPS), reported: "(D)uring the September, 1997 meeting, the Executive Committee presented draft language of several changes in the ASPPS Model Act for Licensure of Psychologists. Under the section on 'Scope and Limitation of Practice', they are working on language for prescriptive authority. At this point, final language has not been determined but the draft language included the concept that the practice of psychology shall include the prescription and administration of psychotropic medications within the scope of practice, and that the prescribing psychologist would be required to meet the standards of training established by that licensing board. Such language permits each jurisdiction to set its own criteria, reflecting other sections of the Model Act."

At the annual APA Convention in Chicago, under the leadership of APA President Norm Abeles and Recording Secretary-elect Ron Levant, a special mini-convention was held, entitled: "Towards Prescription Privileges for Psychologists". This featured "first hand" reports from the ten Department of Defense (DoD) psychopharmacology Fellows, as well as very exciting discussions about evolving legislative and training initiatives in states such as Georgia, Missouri, Illinois, and Hawaii. Cal VanderPlate, chair of the GPA Prescribing Committee, provides this update: "We have received numerous inquiries regarding our progress on post-doctoral psychopharmacology training, and wanted to update you. Georgia Psychological Association (GPA) has coordinated a comprehensive post-doctoral psychopharmacology training curriculum for psychologists in Georgia. Our first class began September 6, 1997, with 27 students enrolled. Classes are being offered in a consortium with Georgia State University Center for Brain Sciences and Health and the University of Georgia School of Pharmacy (our two main state universities). The Center is a free-standing entity with joint appointments from Psychology and Biology Departments. Faculty have expertise in neuropsychopharmachology and biobehavioral pharmacology. Both schools remain neutral on the issue of psychologists prescribing. APA has played a very important role, supporting us in this development."

"The curriculum is the product of over two years of planning, assisted by our valued and appreciated consultant, DoD Prescribing Psychologist Morgan Sammons. This university-based training meets the retraining criteria of the Georgia Board of Examiners in Psychology and the APA criteria for retraining. Curriculum is based on the APA model curriculum. Courses have been reconceptualized to meet the unique needs of psychologists (i.e., the 'psychology model')."

"Each of eight courses will be offered every other Saturday (eight weeks of class per course/ 40 hours per course). The first course is in its fifth week. All courses have been developed to be philosophically compatible and fit a seamless, coordinated curriculum. With our second cohort group, we will be utilizing distance learning through GSAMS (the state university telemedicine interactive system with 300 different sites around the state). We plan 40 students in Atlanta and at least 20 students in two or three distance learning sites around the state. Our every other week schedule means the 360 hour curriculum (with 120 credits) will take over two years to complete."

"The response to our curriculum has been very enthusiastic. When announced at our GPA annual meeting in May, the course was fully subscribed in less than a week with a large waiting list. We have our next cohort group filled with a long waiting list." "There is no doubt that the graduates of this program will be very well trained to prescribe, and once authorizing legislation is passed, will be the first psychologists in Georgia to provide comprehensive care to their patients."

"GPA has had an active Task Force on Prescribing (now a committee and working group) since 1991. Our goal over the years has been to educate our members, debate the issues, and formulate a strategy. Our overriding strategy has been to pursue two complementary goals: development of high quality psychopharmacology training, and implementation of authorizing legislation. Our belief was each would strengthen the other. Development of this training program was possible due to the longstanding involvement of our Task Force of academic psychologists representing doctoral training programs around the state."

"We have developed a strong consensus in support of psychologists prescribing in Georgia over the years. Within the last year, our survey of GPA members showed 74% believe psychologists should be authorized to prescribe. A surprising 52% said they would seek training to prescribe if it were available." [Pat Gardner, GPA Executive Director - GPA@MINDSPRING.COM]. (Army physical therapists have possessed limited prescription privileges for two decades; nursing has independent prescriptive authority in 19 states.)


Jeff McKee
Saturday, April 25, 1998