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| Washington Update 7-01 | Practitioner Report 5-01 |

WASHINGTON UPDATE (July 2001)

Ronald F. Levant, Ed.D., ABPP
APA Recording Secretary

Psychology at the Table

Psychology is definitely on the move. I have reported in recent columns that I have observed signs of a new spirit of optimism, perhaps even of a renaissance in psychology. A weekend in June was no exception. I had the honor and pleasure of attending the meeting of the Association of Veteran's Administration Leaders in Psychology (AVAPL) held in Las Vegas, Nevada. Also in attendance were: Russ Newman, Randy Phelps, and Anthony Chuukwu from the APA Practice Organization; APA President Norine Johnson, APA Past President Pat DeLeon; APA Presidential Candidates Stanley Moldawsky and Kathy McNamara; and Susan Zlotlow, Susan Phillips, and Tom Jackson from the
APA Office of Accreditation and Committee on Accreditation.

One of the most important lessons that I have learned over the years is how vital it is for psychologists to participate in the public policy process - to be at the table where important policy decisions are made and to speak to policy makers at every available opportunity. This lesson was perhaps most strongly reinforced by my participation in the White House Summit Meeting on Children's Mental Health hosted by former First Lady Hilary Rodham Clinton and in the resulting Surgeon General's conference on Children's Mental Health, public policy events in which psychology's voice was clearly heard. Leaders of AVAPL -- Peggy Cantrell, Judith Patterson, Christine LaGana, Bob Gresen, Russell Lemle, and others -- are to be strongly commended for their contributions in elevating psychology's role in the public policy process. For (with the help of the APA Practice Organization), they were successful in bringing Anthony Principi, Secretary of the Veterans Administration, to the meeting as a keynote speaker. Over the years we have not had many opportunities to interact with Cabinet-level officials; however, these opportunities seem to be increasing, For example, during Pat Deleon's Presidency we were honored with the presence of both HHS Secretary Donna Shalala and Education Secretary Richard Riley at APA meetings during the year.

The importance of such events lies not only in the fact that psychology becomes more visible to the high level public official, but also in the opportunities to build a relationship in which we are increasingly called upon for information and expertise deemed helpful to that official. At the AVAPL meeting an important dialogue occurred that illustrates this processes. Secretary Principi is known to be a no-nonsense public official who is dedicated to providing the best services for veterans and their families and is open to new ideas and data. During the Q & A session, Kathy McNamara asked the Secretary if he was aware of the important role that psychologists could play in the VA healthcare system beyond the narrow confines of mental health (in which we are still under the thumb of
psychiatry in many cases), and into health care more broadly conceived, including such areas as primary care, oncology, cardiology and the like. The
Secretary confessed that he was not aware of this but he stated that he definitely wanted to know more about it. Thus a door was opened for the AVAPL with the assistance of the APA Practice Organization to follow up with data on the important role that psychologists play in general health care.

Furthermore, since this is one of Norine Johnson's Presidential themes and thus a high profile initiative of APA, additional follow-up is also likely. Russ Newman also gave one of the keynote speeches, continuing a theme that that he addressed at that the State Leadership Conference earlier this year - namely the emerging role of technology in shaping the health care industry http://www.apa.org/practice/slc2001/speech.html). With Russ's permission, and with reader's understanding that any mistakes herein are my own, I would like to summarize his comments (adding some of my own along the way). Russ began by reminding us that cost containment became a national issue about a decade ago as health care costs consumed an ever-larger share of GDP, reaching a peak at 14%. Managed care came on the scene and proposed to contain costs by reducing utilization which would necessitate increased administrative costs in the form of utilization review. It turns out that increasing administrative costs was not a wise strategy. In fact, it has sounded the death knell for managed care. We now spend about 21/2 times as much as any other country on health care administration, which is clearly out of line. Hence the managed care approach has not worked, and in fact has created other problems, which requires legislation (such as the patient protection bill) and litigation (such as the New Jersey) suit against MCC to address.

Information technology offers an alternative approach to addressing the cost problem: Control health care costs by reducing administrative and transaction costs. Jim Clarke, the CEO of Healtheon.com estimates that there are about $400 billion dollars in excess transactions costs alone. This approach receives some support, heretofore generally unrecognized, from the Health Insurance Portability and Accountability Act of 1996 (HIPAA), also known as the Kennedy-Kassenbaum bill after its two principle co-sponsors. HIPAA was primarily aimed at eliminating preexisting conditions provisions in health plans in order to allow employees to have uninterrupted coverage if they changed jobs or health plans. Imbedded in this Act, as a "statute within a statute", was the Administrative Simplification Provision, which is aimed at creating an electronic standardized claims submission system. This dovetails nicely with Jim Clarke's point by identifying fragmentation in the claims submission process as a major reason for excess transaction costs. There are obviously a lot of issues to work out in terms of confidentiality of mental health records (which the APA Practice Organization is working on), but this may well be the crest of the wave of the future for health care.

Following along closely behind are efforts to address other "imperfections" in the health care marketplace. Employers have been wishing to shed their role as third party payors for quite some time, but have been unable to do, especially in the last few years as the labor market grew ever tighter. But now that the labor market is getting slack as the economy slows, employees are looking more closely at their options. One approach which has special appeal right now is the "defined contribution plan," which works like 401k plans and medical savings accounts (MSA's), and would have the desired effects of both constraining employers' health care costs and forcing employees to become more cost-conscious. Certain trends in the InfoTech industry fit in very nicely here. For example, Vivius.com is working with employers to create an electronic health care exchange network, which Russ, with tongue in cheek, referred to as the "e-bay of health care".

These specific trends may or may not come to fruition. However, information technology seems to hold the keys to reducing a major impediment to controlling health care costs -- namely the considerable "imperfections" in the marketplace which have historically muffled the effect of competition on costs.

As a final point, I want to challenge the notion that health care costs are too high. As Russ asked: "who is to say how much we should spend on health care?" Although I understand that employers want to limit their mounting health care costs, that should not drive the public policy debate. In a recent column (summarizing an analysis published in the Atlantic Monthly), I made the distinction between price and utilization as elements of health care costs and pointed out that price in health care has actually gone down as medical technology has improved our procedures. I gave the example of operations (such as gall bladder surgery) which previously required quite invasive surgery and long recovery periods and now use arthroscopic procedures, which have dramatically reduced the recovery procedure. But although the price of such procedures has gone down, utilization has gone up both because of the reduced price and the increased safety. Hence from this point of view increased costs (or at least some portion thereof) are actually a good thing, and reflect greater utilization of improved health care procedures.

As always, I welcome your thoughts on this column. You can most easily
contact me via email: Rlevant@aol.com

PRACTITIONER REPORT (May, 2001)

Ronald F. Levant
APA Recording Secretary

Priorities

Something new is stirring in psychology. For so long now we have been afflicted by the ills of managed care. Discouragement and depression have been rampant among our colleagues. I wrote in a recent column that, since the beginning of this year, I have noticed a perceptible change in spirit at several psychology meetings. While acknowledging that a few good meetings do not necessarily indicate a sea change, I wondered if we are not in the beginning stages of a renaissance in psychology.

I have also noticed another trend over the last few months. We seem to be looking with new vigor at our identity and priorities as a discipline and as a profession. This trend seems to be related to the new signs of a positive spirit. For, when would be a better time to examine our identity and priorities than when the clouds are lifting and the future seems brighter? Priority-setting was a major focus of the February Council meeting, where Council engaged in an exercise using nominal group process (which begins with a brainstorming process followed by an allocation of "dollars" to the list of priorities in order to determine their relative ranking). Priority-setting was picked up at the Board of Directors Retreat in April, where the focus expanded to also include our identity as psychologists in the new health and educational environments. I have also seen this in other venues, such as winter meetings of APA divisions.

The Board made a commitment to engage all of the constituencies of the Association in this priority-setting exercise. In anticipation of that, I thought it might stimulate thinking to look at some of the priorities that have been generated, focusing on the top seven priorities generated by Council.

The top priority was to "Enhance membership recruitment, retention and services in APA". This item is a priority of both President Norine Johnson and President-elect Phillip Zimbardo. It is a top priority for good reason. Analysis of membership data over the past 10 years reveals some concerning trends. For decades we had been able to count on continued growth in paid membership, but for the past five years growth has been stagnant. Meanwhile, the number of unpaid members and dues exempt member has been increasing. Hence it is indeed important that we make it a top priority to reverse these trends.

The second priority was to "Enhance the public awareness of psychology, and generate a more realistic public image of the field". This is an area in which we have made significant progress, thanks to visionaries such as Stan Moldawsky, Dorothy Cantor, and Ron Fox, as well as APA staffers Russ Newman and Rhea Farberman, with the Public Education Campaign, and the MTV collaboration on the warning signs of youth violence. However, there is
clearly room for improvement, given the stigma that still remains in our society regarding mental health.

The third priority was to "Promote efforts to utilize psychological knowledge to inform and develop public policy". As APA Past-President Pat DeLeon has repeatedly said, we are a learned profession and have much to offer in the public policy development process. Psychological science and practice can inform virtually every aspect of our society from education and health care to corrections and public safety. However, for whatever reasons, many of us are reluctant to enter the realm of public policy. We need to change this and make informing public policy a priority. We should follow the examples of colleagues who have made great strides in this area, such as those who serve on public policy boards and commissions and in state legislatures and, of course, the sterling examples of our two colleagues who serve in the U.S. Congress, Ted Strickland and Brian Baird.

The fourth priority was to "Enhance diversity in all aspects of the psychological profession, including membership, students in the pipeline, APA governance, and course content". In March, the press announced that for the first time in history, the state of California no longer had a white majority in its population. This is clearly a harbinger of the future. For psychology to remain relevant in an increasingly multicultural society, we must do more to increase the diversity of our profession. Further we need to think of diversity not only terms of race and ethnicity, but also in terms of gender, sexual orientation, age, and disability status. Colleagues such Derald Wing Sue, Lisa Porche-Burke, Steven James, Melba Vasquez, and Rosie Phillips Bingham are to be acknowledged for their major contributions in this area, in coordinating the highly successful second National Multicultural Conference and Summit (NMCS 2) held in Santa Barbara, California in January, 2001, which was attended by over 800 psychologists.

The fifth priority was to "Increase advocacy for psychological science and
for the academic discipline of psychology, including the promotion of
psychology as a science". Our scientific heritage is one of our greatest assets, and it is clearly in our best interests to not only support it but also to strongly promote it. Whether we are "scientist-practitioners" or "practitioners informed by science", we stand above other professions that do not have such a strong science base. I recently saw new evidence of this as I was attempting to negotiate a new practicum experience in psychopharmacology for my postdoctoral master's degree students in clinical psychopharmacology, when the chief psychiatrist of a major teaching hospital indicated his willingness to consider my proposal because he thought it would upgrade the science in his department.
The sixth priority was to "Advocate prescription privileges for appropriately trained psychologists". The prescription privilege agenda has the capacity to dramatically accelerate the evolution of professional psychology, and to move us closer to fulfilling our potential of being a premier primary health care profession. The Department of Defense Psychopharmacology Demonstration Project graduates who are now prescribing have recently demonstrated through the USGAO report of 1999 that not only will properly trained prescribing psychologists NOT be a public health hazard as psychiatry has so ignominiously claimed, but also that such psychologists will do an outstanding job at psychodiagnosis and at expertly combining psychological and pharmacological treatment. Our colleagues in Guam and New Mexico are making this a reality.
The seventh priority was to "Expand activities in health psychology, and
promote the further use of psychology in health care practices". One of the
most important issues for the future of professional psychology is the
redefinition of psychology from specialty mental health care to primary
health care. As a specialty profession of mental health care, we deal primarily with the people who self-identify as having psychological problems and who have access to a mental health specialist, which is just a fraction of those who need psychological services. As a primary health care profession we would be able to serve the much larger group of people who do not have access to mental health care or who do not identify their problem as psychological. Remember that seven out of the nine leading causes of death have significant behavioral components, that as much as 75% of all visits to primary care medical personnel are for problems with a psychological origin or psychological component (including those with unhealthy lifestyle habits such as smoking, those with chronic illnesses, and those with medical compliance issues), and that the vast majority of people receiving mental health treatment are cared for by medical professionals with minimal specific training in mental health. The Cartesian worldview, which separates mental health from physical health, is breaking down and, as a result, psychology has a tremendous opportunity to evolve into a premier primary health care profession.

I hope this column helps you consider what your priorities are for psychology and for the Association as we begin this process of reflection. As always, I welcome your thoughts on this column. You can most easily contact me via email: Rlevant@aol.com