State Leadership Conference

Implementing health-care reform is still a work in progress, Katherine C. Nordal, PhD, said in the opening session of the 2014 State Leadership Conference.

"It's no news flash that the rollout of the Affordable Care Act has been chaotic," said Nordal, executive director for professional practice in APA's Practice Directorate and the APA Practice Organization (APAPO). "But there are hopeful signs, especially related to the goal of increasing the ranks of Americans with health coverage."

Sponsored by the Practice Directorate and APAPO in Washington, D.C., March 8–11, the 31st annual conference brought together more than 400 representatives from state, provincial and territorial psychological associations (SPTAs); APA divisions and governance; and the American Psychological Association of Graduate Students, as well as early career and diversity delegates, who are funded by APA or their SPTAs.

In addition to participating in educational briefings and networking opportunities, participants also made almost 350 visits to members of Congress and their staffs.

While on Capitol Hill, they shared APAPO's three legislative priorities: halting the plummeting of Medicare payment rates for psychologists, making psychologists eligible for Health Information Technology for Economic and Clinical Health (HITECH) incentives and including psychologists in Medicare's definition of "physician."

At the opening session, Nordal emphasized that the changes brought about by the Affordable Care Act will transform the way many professional psychologists practice. In particular, the law's push for integrated care will spur the creation of more collaborative, multidisciplinary practice models.

The law has also changed psychology's advocacy strategies, Nordal said. "The way the Affordable Care Act is unfolding reminds us that no single advocacy strategy for psychology can address the diverse legislative, regulatory and marketplace environments we see from one state to another," she said.

At the national level, Nordal said, APAPO scored a major win this year by reversing the downward Medicare payment trajectory for psychological services. At the regional level, neuropsychologists have come together in a group that uses what it calls "360-degree advocacy" to monitor and intervene when the nation's nine Medicare Administrative Contractors (MACs) take action that could harm psychologists. The neuropsychologists' latest advocacy win, which affects practitioners in 10 states, resulted in changes to a coverage determination issued by the National Governmental Services MAC. The changes include clarifying that when medically necessary, providers may assess depression in patients entering nursing homes and permitting providers to bill for integrating emotional measures into neuropsychological testing.

Advocates at the state level are also seeing success. The Alabama Psychological Association successfully fought efforts to remove "diagnose and treat" from the psychology licensing law, for example. The Kentucky Psychological Association persuaded the state to include psychologists as eligible providers in its Medicaid program. And the Minnesota Psychological Association helped get a law passed that provides Medicaid reimbursement for psychologists who provide consultation to primary care providers.

"We need lean, mean advocacy machines to protect our seat at the table and move psychology forward as the health-care marketplace evolves," said Nordal.

APA President Dr. Nadine Kaslow presents a presidential citation to Dr. David Barlow, founder and director emeritus of the Center for Anxiety and Related Disorders at Boston University.Advocacy is crucial for improving patients' welfare, agreed keynote speaker David H. Barlow, PhD, founder and director emeritus of the Center for Anxiety and Related Disorders at Boston University.

Study after study shows that psychological interventions are at least as good as and often better than medications for treating psychological problems, said Barlow. Plus, he said, the overwhelming majority of patients prefer psychological treatment. Nonetheless, he said, use of psychotherapy is going down while medication use is soaring, even as first-line treatment for such conditions as panic disorder and insomnia, which can be treated safely and effectively with psychological interventions.

What's behind this discrepancy? "It's no secret: heavy marketing and the readily available nature of medications," said Barlow. It's also hard to put knowledge into action, he added, citing a study showing that an intervention designed to increase hand-washing among hospital staff wasn't successful enough to reduce infection rates. "If you can't disseminate hand-washing easily, what are we faced with?" Barlow asked.

There are two broad approaches to disseminating psychological interventions more broadly, said Barlow. One is an intensive community training model, an expensive, labor-intensive approach often used in closed systems like the VA or the United Kingdom's National Health Service. The other is a public health model that seeks to influence the greatest number of people the least expensively. Examples include Internet- and telephone-based treatment and community workers with rudimentary instruction from mental health professionals working in developing nations. "Who devises these programs? Psychologists," said Barlow. "Who oversees implementation? Psychologists."

Barlow's clinic is even exploring the idea of the same kind of direct-to-consumer advertising that the pharmaceutical industry uses. In a study in Canada, clinic staff found that ads about the benefits of psychological treatment increased people's likelihood of seeking treatment. "We'll never match the ability of Big Pharma, which can buy 10 Super Bowl ads and never miss the money," he said. "But we need to increase awareness of the services we have to offer."

The facts are on psychology's side, said Barlow. What's needed, he emphasized, is advocacy. In the United Kingdom, he pointed out, a chance encounter between a psychologist and a member of Parliament led to a conversation about psychological treatment's cost-effectiveness and then a multi-year initiative to increase access to psychological therapies within the National Health Service. Because there weren't enough psychologists to deliver those treatments, the government boosted funding for training programs.

"Did this just happen?" asked Barlow. "Of course not. … Nothing will happen unless we do it."

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