Cover Story

The passage of health-care reform last year was a great victory for psychologists and their patients. But the work is far from done.

Now the U.S. Department of Health and Human Services (HHS), state governments and others are working to flesh out the details of just how the law's many provisions will work in practice. Some parts of the Patient Protection and Affordable Care Act have already taken effect, including some expanded access to insurance coverage, protections against insurance company abuses, new resources for prevention and efforts to improve data collection to reduce health disparities. But if all goes according to plan and the law survives the legal battles it has provoked, the health-care system will look very different by the time the Affordable Care Act is fully implemented in 2019.

For instance, 32 million Americans who currently lack health insurance will have coverage. An expansion of Medicaid eligibility will extend coverage to 16 million new beneficiaries. New "exchanges" in each state will offer health insurance plans to individuals and small businesses and will include coverage for mental and substance use treatment services on par with medical and surgical services. The law also requires that all individuals buy insurance and that employers either offer coverage or face fines.

The nature of health-care delivery will change, too. Health-care reform emphasizes the integration of mental and physical health-care services, so psychologists who are prepared to collaborate with primary-care and other medical professionals will thrive. New structures — including patient-centered health homes and accountable care organizations (ACOs) — will spring up, with the potential for psychologists to become part of interdisciplinary teams. Payment mechanisms will change, too, with a shift from fee-for-service to models that reward good outcomes, bundle payments or pay for episodes of care.

The Affordable Care Act will bring new opportunities for psychologists, including a larger patient population, new funding for training and increased support for research. But psychologists must participate in the process of hammering out regulations or risk being left out, warn APA officials.

To help psychologists avoid that fate, the new State Implementation of Health Care Reform Initiative of the APA Practice Organization (APAPO) will guide them through the process of getting involved as their states begin redesigning their Medicaid programs, creating their state exchanges and more.

APA and APAPO are already working hard to ensure that psychology's voice is heard.

"We're looking to promote the various roles of psychologists and clarify how the whole health-care system will benefit as a result of those roles," says APA Senior Policy Advisor Ellen G. Garrison, PhD.

Here's a wrap-up of the key issues confronting psychology as the Affordable Care Act is implemented and how APA, APAPO and the state, provincial and territorial psychological associations (SPTAs) are working to address them.

Integrating care

One of APA's top priorities in seeking health-care reform was the belief in the mind-body connection and the need for integrating patients' physical, mental and behavioral health care. The Affordable Care Act reflects that vision by emphasizing primary care and interdisciplinary health-care teams.

But now it's time to make sure those redesigning health-care delivery think of integrated care the same way APA does, says Katherine C. Nordal, PhD, executive director of APA's Practice Directorate. Many health-care professionals don't understand the benefits of including psychologists as part of interdisciplinary teams of physicians, nurses and other medical providers, she warns. That's troubling given health-care reform's emphasis on new models of care, such as patient-centered health homes and ACOs. In the patient-centered health home, interdisciplinary teams work together to provide integrated care to patients. In ACOs, individual health-care providers, group providers and hospital systems come together to provide services to a defined population.

APA and APAPO are tracking such developments and working to ensure that psychologists are eligible to participate in such models of care. For example, APA serves on the executive committee of the Patient-Centered Primary Care Collaborative, a huge coalition whose members include large employers, primary-care physician associations, professional groups, health benefits companies, academic centers and others. And, as part of APA's new strategic plan, APA will be hiring a primary-care fellow to help identify integrated health-care models, determine their effectiveness and work to promote the adoption of successful models.

APA and APAPO are also working to eliminate barriers that could keep psychologists from participating in these new models of care. One such hindrance is the high cost of electronic medical record systems, which Nordal calls "the infrastructure that supports integrated care." The Health Information Technology for Economic and Clinical Health Act (HITECH) — passed in 2009 as part of the stimulus package — offered financial incentives to providers who adopted electronic records, but doesn't include psychologists and other mental health professionals and facilities. APAPO is pushing legislation that would include them.

Another of APAPO's legislative priorities is to get psychologists included in Medicare's definition of "physician" — a definition that includes such providers as podiatrists and chiropractors. Doing so would not only remove requirements that psychologists be supervised by physicians in some settings, but might facilitate psychologists' eligibility for future financial incentives for adopting electronic records systems.

Another barrier is state corporate practice of medicine statutes. These statutes prohibit psychologists from forming integrated practice corporations with physicians and other types of health-care professionals in about half the states, including such large states as Florida, Illinois and New York. "This in turn makes it harder for psychologists to form entities that would have the size and diversity necessary for getting involved with ACOs," says Alan Nessman, JD, senior special counsel for legal and regulatory affairs in APA's Practice Organization. APAPO has researched the statutes to find out which states permit integrated professional corporations and will work with SPTAs to change laws in those that do not or to find alternative integrated practice structures.

Health-care reform will also reform payment systems, with a shift away from fee-for-service models. "The government believes the fee-for-service model encourages providers to bill for procedures because the only way you get more money is to bill more procedures," explains Nordal.

To lower those unnecessary costs, the government is now exploring the idea of reimbursing providers based on their outcomes. For instance, the government might contract with ACOs to provide health care for a population of Medicare beneficiaries for a set fee per patient per calendar year. If the ACO can provide the care less expensively, the ACO would share in the money saved. However, if the care costs more than contracted for, the ACO would have to absorb those costs.

"We're concerned about how those reimbursement systems are going to impact psychologists, so we're certainly watching that," says Nordal.

Investing in prevention

The Affordable Care Act also signals a new willingness to invest in prevention.

"The law says, ‘We're not just going to wait around until people get sick,'" says Diane Elmore, PhD, associate executive director of the Government Relations Office in APA's Public Interest Directorate. "We're going to invest money on the front end — on the prevention and wellness side." The law broadens coverage for preventive screenings and some preventive care, for example.

It also created a Prevention and Public Health Fund to support proven preventive and public health programs to tackle such problems as obesity and smoking. Protecting that fund has been an ongoing struggle, says Elmore, as some in Congress have attempted to raid or even repeal the fund. As part of a group of public health associations, other health-related societies and other groups, APA helped fend off those attacks.

Preparing psychology's workforce

Not all practitioners want to work in integrated health-care settings, of course. And that's OK, says Cynthia D. Belar, PhD, executive director of APA's Education Directorate. Having multiple models of care not only accommodates practitioners' desires, but also best serves a public that needs access to a wide variety of services.

But given the direction the health-care system is moving, says Belar, it's critical that APA and the rest of the psychology community work to prepare psychologists who can thrive in integrated, prevention-focused health-care settings.

"Health-care reform is based on expanding and strengthening the primary-care system," says Belar. "We need to train psychologists for broader roles in health care than just the traditional mental health services."

To help achieve that goal, APA has established a Primary Care Training Task Force. The task force's first priority is to determine what psychology training programs are already doing when it comes to preparing students for work in primary care. The group is now analyzing data from a survey of doctoral programs, internship sites and postdoctoral programs. That information will help the group craft recommendations about what APA can do to help ensure future psychologists are prepared to work in a transformed health-care system.

APA's strategic plan already includes continuing-education programs to familiarize psychologists with service in primary-care settings.

The Education Directorate is also working with the Patient-Centered Primary Care Collaborative. "We have to ensure that the broad range of psychological services are available in the health-care system, that psychologists are seen as an integral part of primary care teams and that people understand that we provide the education and training psychologists need to be able to fulfill those roles," says Belar. Along with a family physician, Belar co-chairs the collaborative's Task Force on Education and Training, which is examining the educational needs of both the current and future work force and faculty across multiple disciplines.

APA also participated in a Health Education Summit convened by the Carter Center last year. The discussions resulted in a report outlining five "prescriptions" for overhauling the primary-care education system — including more rigorous training in diagnosing and treating mental illness — as a way of fulfilling health-care reform's potential.

APA also continues to advocate for the Graduate Psychology Education program, which prepares psychologists to work with other health-care disciplines. Psychologists visited Capitol Hill to advocate for the program during APA's Annual Convention and the Education Leadership Conference in September.

The Affordable Care Act also expanded training opportunities for psychologists specializing in geriatrics. Before health reform, the federal Health Resources and Services Administration (HRSA) had three programs for training providers for the aging field, with psychologists eligible for only one. APA and other members of the Eldercare Workforce Alliance pushed to expand eligibility and create new opportunities. As a result, there are now four programs, and psychologists are eligible for three of them.

But winning legislatively is only half the battle, says Elmore, explaining that the next step is to make sure psychologists take advantage of the new opportunities. Take the Geriatric Academic Career Awards, which used to be open only to physicians. At HRSA's request, APA helped draft the request for proposals that went out to psychologists. "We then did a massive outreach to our geropsychology community, saying, ‘We fought to get you all in there and said how relevant you were and how important it was to include you; now you need to apply,'" says Elmore. The result? Psychologist Kristen Sorocco, PhD, of the University of Oklahoma Health Sciences Center became the first psychologist to win the award.

Supporting research

APA is also helping to shape the priorities of the Patient-Centered Outcomes Research Institute established by the Affordable Care Act. The institute is an independent, nonprofit research organization with a mission of helping patients and caregivers make more informed health decisions. The institute will support research on how to effectively prevent, treat and manage health conditions.

So far, the institute has issued two calls for comments to help shape its research agenda. The first asked for comments on the institute's working definition of "patient-centered outcomes research." APA encouraged psychological scientists to share their input and submitted comments of its own.

"We urged the institute to incorporate the behavioral and social aspects of health into the working definition," says Christine Jamieson, science policy associate in APA's Science Directorate. APA also urged the institute to support research on such topics as decision-making, behavior change, treatment adherence, patient/provider interactions and cultural differences in health-related beliefs and behaviors.

The second call for comments asked for input on the institute's proposed list of topics for initial support.

Psychologists will be eligible to compete for the $13 million worth of funding, which will be used to help the institute establish national priorities and a research agenda.

"The Science Directorate will continue to keep the psychological science community apprised of opportunities for input on the institute's priorities as well as research funding opportunities," says Jamieson. "We'll also continue to keep an eye out for opportunities for psychologists to be engaged in any governing capacity for the institute."

Preparing state associations

Things aren't just happening at the national level. In fact, much of the work of health-care reform will take place in the states over the next several years. But the SPTAs vary widely in their capacity to take on the complex challenges of helping to design and implement the innovations reform will bring, says Dan Abrahamson, PhD, assistant executive director for state advocacy in APA's Practice Organization.

Helping the SPTAs meet those challenges is the purpose of APAPO's new State Implementation of Health Care Reform Initiative.

"States are going to have the primary responsibility for implementing health-care reform based on certain parameters dictated by the law but with a lot of flexibility for the states based on their unique needs and public policy structures," says Abrahamson. In some states, he said, seven or eight different agencies will be involved in developing public policy. "We didn't want this to sneak up on the SPTAs."

The initiative will connect SPTAs with the resources they need to educate their members and position psychologists for maximum participation as states redesign their Medicaid programs, create their exchanges and take on the other tasks of implementing health-care reform. The goal is to help SPTAs become knowledgeable about who the key players are in their states, how to be included and how to influence the regulators, legislators and others involved in this complex process.

"It doesn't make sense to reinvent the wheel," says Abrahamson, so the initiative will direct SPTAs to existing resources from such groups as the HHS Office of Health Reform, National Academy for State Health Policy and Kaiser Family Foundation. The initiative plans to create a website to bring such resources together in one place.

APAPO is pulling together an advisory group of SPTA leaders and others to serve as what Abrahamson calls "our own mini-think tank." The group will offer advice on how to get information to the states in a way that spurs action rather than overwhelms them.

"We don't want to flood people with too much," says Abrahamson, emphasizing that implementation will take place over several years. "If this is a nine-inning baseball game, we're at the top of the first inning."

The 2012 State Leadership Conference in March will focus on many of the issues that are defining implementation of the Affordable Care Act for psychologists, he adds.

SPTAs, APA divisions and individual psychologists are already taking action.

"We're trying to give input wherever we can," says Elena J. Eisman, EdD, executive director of the Massachusetts Psychological Association. "We're trying to work on all fronts at once, working with a lot of different task forces and commissions and coalitions to try to address how to include behavioral health in the health-care delivery system."

The association is also working with other members of the longstanding Massachusetts Mental Health Coalition on such projects as developing a list of factors to keep in mind when designing ACOs that recognize behavioral health needs.

"The stakes are high if we don't have a seat at the table," emphasizes Donna Rasin-Waters, PhD, president of the New York State Psychological Association (NYSPA) and a psychologist at the VA New York Harbor Health Care System in Brooklyn.

When she attended a meeting on the ACO model, for example, she was one of only two mental and behavioral health practitioners represented. It soon became clear, she reports, that many physician practices in New York not only don't have mental and behavioral health services integrated into their practices but also don't know what psychologists have to offer.

To help get psychologists "on the train" of health-care reform, Rasin-Waters convened a Think Tank on Psychology's Future in June to brainstorm and develop priorities for action. As a result of those discussions, NYSPA decided to focus on building partnerships with other statewide organizations and making sure psychology is represented as the state develops ACOs and its exchange program.

Other groups are helping psychologists see the opportunities as well as the challenges that health-care reform represents.

"We're hearing from a lot of people in the trenches that they're scared because they don't know how this is going to shape up," says Nancy S. Molitor, PhD, president of APA's Div. 42 (Psychologists in Independent Practice) and a private practitioner in Wilmette, Ill. "On the other hand, this could be exciting, and there could be some opportunities for psychologists we don't yet know." Integrated care could mean new opportunities for both employment and referrals, she points out.

To help position practitioners to take advantage of such opportunities, the division is offering continuing education and other training on integrated care. An upcoming conference on practice innovation will feature sessions on integrated care, for instance.

Of course, ongoing attacks on the Affordable Care Act could change everything if they prove successful. Most states are charging ahead, even as more than half of them are challenging the constitutionality of the law in the federal courts — especially the mandate that everyone buy coverage.

"That's going to be heard by the Supreme Court," says Nordal. "If the individual mandate is struck down, who knows what the implications will be. That's going to send people back to the drawing board."

Rebecca A. Clay is a writer in Washington, D.C.

For more information about health-care reform implementation activities at APA and APAPO, visit Psychology and health-care reform and  and Practice Central's Health Care Reform.