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Keynote speech to 2004 State Leadership Conference
Given that stay-the-course approach, however, it may now seem confusing to begin to entertain a strategy that proposes we meet change with change. It may appear paradoxical that I now ask you to consider a strategy that argues for “getting different”, not just being the best at what we already do. It may be surprising that I now suggest we move beyond building traditional resilience, despite its ability to help us “bounce back” in the face of change, set backs, crises and adversity. And it may even be somewhat anxiety provoking to now contemplate “developing the ability to change before the case for change becomes desperately obvious.” What I am beginning to describe is an approach that strives to get a jump on change, not just react to change while it is happening, or worse yet after it has already happened (3). What I am describing is strategic resilience, in contrast to the resilience we have previously discussed. Strategic resilience is a process of building an ingrained agility and flexibility that will allow us to change in evolutionary and incremental ways while avoiding the necessity of having to undergo major upheaval or cataclysmic shifts. And in that context, an important goal of strategic resilience is to deal with change that occurs around us, no matter how large, with “zero trauma”; that is, dealing with change without incapacitating stress and distress. Despite the apparent departure from last year’s focus on staying the course, in the end, we may just find that getting a jump on change can co-exist quite well with our stay-the-course strategy. More about that later. Since last year’s State Leadership Conference much has happened. On the legal front, a very favorable settlement was obtained in the case of Virginia Academy of Clinical Psychologists versus Blue Cross/Blue Shield of the National Capital Area, now called CareFirst (4). [Slide 2] The 2003 mid-March settlement of breach of contract claims awarded both psychologist and consumer plaintiffs everything they could have received had they prevailed in the trial court. A key component of the settlement -- and a highly unusual one as far as settlements go -- was that it also preserved the plaintiffs’ rights to appeal the fraud claims which the trial court had previously dismissed. Included in this appeal is the allegation that CareFirst misrepresented to consumers the existence of a large, stable, panel of health professionals, all the while intending to pare back the panel by foisting a “take it or leave it” rate reduction on panel participants. Also on appeal is the issue of whether the company’s fraudulent behavior warrants punitive damages. Among the potential benefits of this appeal is the chance to have the appellate court expressly outlaw the managed care practice of constructing “phantom panels” -- those panels which appear on the surface to provide considerable choice and access to care but in reality do not (5). Oral arguments before the D.C. Court of Appeals could occur as early as May. Once again, I want to thank the plaintiffs for their willingness to stay the course, and all of you who have contributed financially to the Legal Action Fund. We would not be able to pursue this type of litigation without your help. Also, along the managed care battlefront, the Practice Directorate recently teamed up with the New York State Psychological Association to challenge Oxford Health Plan’s practice of retrospective audits of mental health patient records. As many of you know, under the guise of fraud prevention audits, Oxford was demanding large refunds, primarily from New York psychologists, for what the company described as “insufficient” record keeping. We believed that both the audit and recoupment practice was in conflict with Oxford’s contractual agreement with its psychologists, and potentially in violation of New York law regulating managed care companies. In response to a pointed letter from the Directorate and NYSPA, [Slide 3] Oxford discontinued its audit and repayment demands related to claims of inadequate record keeping and returned money that some psychologists had previously repaid (6). Oxford also established a mechanism to get input from the mental health professional community concerning its record keeping policies. All of which just goes to show, some days the good guys do win. Sometimes it takes a long time for the good guys to win, however. Such appears to be the case in California where more than a decade ago the California Supreme Court opined, in the case of CAPP v. Rank, that psychologists were well able to take primary responsibility for the admission, diagnosis, treatment and discharge of their hospitalized patients. [Slide 4] Despite this opinion, and two subsequent legislative amendments to facilitate implementation of the state’s hospital practice statute for psychologists, state-employed psychologists are still fighting to be recognized as attending clinicians in their hospitals. In fact, just last year the Department of Mental Health issued a special order allowing only psychiatrists to serve as attending clinicians (7). The order also required psychologists to practice under the supervision of psychiatrists. In response, state-employed psychologists, lead by Bill Safarjan, a past president of the California Psychological Association and a current member of our own Committee for the Advancement of Professional Practice, have raised over $100,000, hired a litigator and incorporated an organization called “Psychology Shield” for the purpose of taking the fight back into the courtroom. For those who can’t quite fathom why the California Department of Mental Health is so resistant to psychologists practicing to the full extent of our license, consider this. Psychiatrists, who heavily influence the decision making of the Department, provide “on call” services for their respective hospitals in their capacity as attending clinicians. Psychologists are unable to provide on call services because they are proscribed from being attending clinicians. Attending clinicians get paid for on-call services above and beyond their annual salary (8). A San Francisco Chronicle article this summer revealed that of the top 10 highest paid state employees, five were psychiatrists, earning as much as 300% above their annual salaries through recruitment and retention bonuses and on call pay. One particular psychiatrist reportedly earned well over $100,000 beyond his salary, largely due to on-call pay. It seems rather clear that psychiatrists have a financial incentive to keep psychologists from serving as attending clinicians in state hospitals. In fact, this was something I discussed with the Federal Trade Commission and Department of Justice Antitrust Division in June when we had the opportunity to testify at the Joint Hearing on Health Care and Competition Law and Policy. [Slide 5] In addition to detailing a number of instances of what we believe are organized psychiatry’s efforts to restrain trade in hospitals, we also alerted the FTC to what we expect will happen as more states come on line with prescriptive authority statutes (9). After all, who better than psychologists to explain to the FTC that the best predictor of future behavior is past behavior. Attempts to undermine regulatory implementation of prescriptive authority laws and potential boycott activity by psychiatrists against pharmaceutical companies who support psychologists are a couple of the future behaviors we thought the FTC could expect from organized psychiatry based its past behavior. Speaking of prescription privileges for psychologists, the past year witnessed considerable continuing activity on this front. Nine states introduced RxP legislation in 2003 – Florida, Georgia, Hawaii, Illinois, New Hampshire, Oregon, Tennessee, Texas and Wyoming. [Slide 6] Six of these states had committee hearings on their bills, the largest number ever in one year. And Wyoming had its first-time bill not only pass out of a senate committee but also go to a floor vote (10). Bills in 2004 so far include Georgia, Hawaii, Illinois, Louisiana, Maine, New Hampshire, Oklahoma and Tennessee. And Guam continues to work to implement its law. Importantly, the New Mexico Psychological Association remains hard at work implementing their prescriptive authority law. Although the process has been slow going for sure, recent developments have provided reason to smile. At the end of February, the state’s Board of Medicine voted unanimously to accept the draft regulations. The Board of Psychology recently approved the regulations as well. You’ll recall that the statute required the regulations to be developed jointly by the boards of psychology and medicine, and getting the Board of Medicine sign-off has been no easy task. The regulations face their next major hurdle during a 30-day public comment period followed by a public hearing where organized psychiatry will undoubtedly try, once again, to derail the process. Thank you, New Mexico psychologists, for staying the course (11). Clearly, there is much state action in the RxP area and momentum continues to build. I recently saw a membership recruitment letter from the New Hampshire Psychiatric Society, [Slide 7] which, not surprisingly, listed keeping psychologists from prescribing medication as one of the “big issues” of the day. The letter also said, “The struggle against psychologist prescribing privileges will be an ongoing one in New Hampshire, [Slide 8] as our state has been targeted by the American Psychological Association as vulnerable regarding this matter.” For the record, we consider every state where prescription privileges are being pursued to be ‘vulnerable regarding this matter.’ Other activity of note on the state level saw no fewer than six states battling to preserve psychological services in Medicaid. [Slide 9] In Missouri, new regulations promulgated in June required that psychological services for adults are to be covered by Medicaid when furnished by independently enrolled psychologists. [Slide 9 – Cue 1] Previously, the state’s Department of Medical Services would only allow psychiatrists to be reimbursed for adult services (12). The new regulations were the result of a lawsuit previously brought by the Missouri Psychological Association against the department. The suit was based on a unique clause in the Missouri psychology licensing law which prohibits the state or its agents from denying payment to psychologists for services within its licensed scope of practice for which psychiatrists are paid. Also as a result of recently promulgated regulations, [Slide 9 – Cue 2] the state of Wyoming gained coverage for adult outpatient psychological services in Medicaid. In New York, the New York State Psychological Association won increased funding for patients who are jointly eligible for Medicaid and Medicare. [Slide 9 – Cue 3] Significantly, this victory comes at a time when health care funding cuts have been the rule, and increases the rare exception. Indeed, despite valiant efforts by organized psychology in Ohio, Connecticut and Texas, Medicaid coverage for adult outpatient psychotherapy was eliminated (13). [Slide 9 – Cue 4, 5 & 6] The Ohio Psychological Association, however, has recently been able to get the ear and support of some powerful state legislators and is definitely not yet ready to throw in the towel on this one. In Georgia, the Georgia Psychological Association [Slide 9 – Cue 7] was able to reverse elimination of Medicaid psychological services in the Governor’s proposed budget. Also of note, the Montana Psychological Association [Slide 9 – Cue 8] secured a 25% increase in fees for psychological evaluations from the state’s Disability Determination Service. Other successful state legislative efforts include [Slide 10] a continuity of care law in Pennsylvania requiring attending physicians to take reasonable steps to involve a hospitalized patient’s psychologist in the treatment. [Slide 10 – Cue 1] Any of us who have at some point in our practices been refused access to our hospitalized patients because “only family members are allowed to visit” can truly appreciate the Pennsylvania Psychological Associations efforts (14). The law also makes clear that psychologists can have voting membership on the medical staff and are eligible for clinical privileges. Also in the hospital arena, the California Psychological Association achieved a law that gives psychologists, [Slide 10 – Cue 2] in consultation with psychiatrists, the ability to discharge patients who have been involuntarily committed to a hospital. And the Massachusetts Psychological Association [Slide 10 – Cue 3] got the state to finally implement a law that prohibited unlicensed individuals working in state institutions from using the title psychologist. Due to the efforts of the Maryland Psychological Association, the state [Slide 10 – Cue 4] passed a new managed care accountability law requiring managed behavioral healthcare companies to publicly disclose financial information to make it clear what is and is not being spent on direct care. The Maine Psychological Association worked [Slide 10 – Cue 5] to successfully expand its limited parity law to a comprehensive one, as well as to include parity coverage for substance abuse treatment (15). And, in a first of its kind statute, the Florida Psychological Association was instrumental in getting protection from spurious complaints against court appointed psychologists doing custody evaluations. [Slide 10 – Cue 6] The law offers protection for psychologists conducting evaluations performed consistent with the recommendations in APA’s Guidelines for Child Custody Evaluations. On the Federal level, with the exception of some so-called Medicare reform activity, the healthcare reform agenda remained slow moving and more the focus of discussion than action. [Slide 11]. The Paul Wellstone Mental Health Equitable Treatment Act stalled in 2003 despite an ever growing number of bipartisan co-sponsors in the House and Senate and the solid grassroots support of over 200 organizations. Congress’ focus on major foreign and domestic issues, such as Iraq and our country’s energy grid problems last summer, made it all but impossible to move parity to the GOP leadership’s agenda (16). The good news, though, is that New Mexico Senator Pete Domenici -- long time champion of parity [Slide 12] -- did secure a commitment from the Senate leadership to bring the bill to the floor early in 2004. You will hear much more about this issue through the course of the conference. I am optimistic that, this year, given the chance, we will finally achieve broad based parity for all people in need of mental health services. Managed care accountability legislation has been similarly stalled in the Congress. And in a Congress where the majority is looking to limit damages in medical malpractice, overhaul the civil liability system to limit the damage awards against business, curb class action lawsuits and protect gun manufacturers and dealers from lawsuits brought by victims of gun violence, increasing liability for managed care companies has little prospect for success at present. Fortunately, the federal courts continue to make progress in limiting the size of the ERISA loophole available to managed care company defendants looking to avoid accountability in state courts (17). Perhaps the biggest disappointment of the federal legislative year was getting so close to victory in gaining Medicare funding for hospital based psychology internship programs, only to watch it slip away in the final hours of conference committee negotiations. Despite the efforts of our champion Louisiana Senator John Breaux, despite bipartisan support in the conference committee from Iowa Senator Charles Grassley, Utah Senator Orrin Hatch and Montana Senator Max Baucus, and despite support from influential House Republicans -- Representatives McCrery, Shaw and Price -- the psychology provision was one of the very last provisions stripped from the bill. I do believe, however, we have furthered the awareness of our cause and gained those who will help us in our next attempt to get this passed (18). On the “win” side of the Medicare box score for psychology was a provision in the recently enacted Omnibus Appropriations Act which directs the Center for Medicare and Medicaid Services to do a demonstration project to study the impact of integrating psychological services into the treatment of heart disease. This study, proposed to Congress by the Practice Organization, is an extension of the research which suggests that incorporating stress management and other psychological interventions in the treatment of cardiovascular disease improves health outcomes and reduces health costs. This integration of the psychological and the physical is an increasingly important step in improving the health of our nation and in highlighting the value of psychological services. Also on the “win” side, with the help of the Division of Public Sector Psychologists, a new federal law removed a number of barriers to advancement in the Veterans Administration health system for 1200 VA Psychologists. The past year also saw implementation of the HIPAA Privacy and Transaction rules around the country. [Slide 13] And from the reaction to psychology’s implementation plan when presented at the American Public Health Association’s annual convention, organized psychology was way ahead of most other health professions in its efforts to get a jump on this particular change (19). The Practice Organization’s information technology infrastructure [Slide 14] was an instrumental part of the implementation plan. In related developments, APApractice.org has been redesigned to make the portal more user friendly, and we have launched a biweekly electronic newsletter as well. The public education campaign, with your help, launched “Resilience in a Time of War,” “Homecoming: Resilience After Wartime,” and Resilience for Kids and Teens which kicked off in collaboration with Time for Kids Magazine. [Slide 15] A special issue of the magazine on resilience went to over 2 million 4th through 6th graders and their parents, and close to 100,000 teachers. Thirty-Four state and provincial psychological associations are continuing their public education efforts with the business community by bestowing Psychologically Healthy Workplace Awards on deserving companies. [Slide 16] Since SLC last year, Arizona, British Columbia, Ohio, Oregon and Wisconsin have come on line with new programs (20). And in October at the Institute of Health and Productivity Management’s annual awards ceremony, the Practice Directorate recognized 15 companies, as part of a new Psychologically Healthy Workplace program, for specific “Best Practices” contributing to psychologically healthy workplaces. Our Disaster Response Network responded to the devastating wildfires that raged across Southern California and to Hurricane Isabel in the Mid-Atlantic. In addition, individual DRN members participated in a host of local initiatives ranging from flooding in West Virginia to tornadoes in Oklahoma to a school shooting in Pennsylvania. Last, but certainly not least, in a continuing effort to increase our profession’s political giving capabilities, the APA Practice Organization executed a formal affiliation agreement with the Association for the Advancement of Psychology. [Slide 17] As one result of the agreement, we have now increased the number of psychologists legally eligible to make political contributions to AAP’s PAC from roughly 3,000 individual members of AAP to the almost 40,000 psychologists who pay the special assessment. Much has gone on over the last year (21). And we in the Directorate owe a debt of gratitude to all of you for helping psychology stay the course through difficult times. But now I want to turn our attention ahead to the future and away from the past. [Slide 18] It is no great prediction that practicing psychologists will continue to confront a healthcare, system that is simply not working. Health professionals will continue to be devalued by corporatized health care, and health services will continue to be commoditized. Reform may be in the offing, although what form that will take is anyone’s guess. It is unclear whether it will be government based reform or market reform, single-payer-reform or consumer-driven reform, grassroots-enabled reform or technology-driven reform. Probably it will be all of these. And, of course, we must also consider whether it will be George W. Bush initiated reform or John Kerry stimulated reform. It will definitely not be both of these (22). With so much uncertainty facing us, it was quite timely when I came across an article in the September 2003 Harvard Business Review entitled “The Quest for Resilience.” [Slide 19] I was drawn to this piece because of the public education work we have been doing on resilience. The article offered a framework for businesses, corporations, and organizations to build their resilience in the wake of turbulent times and in the face of an uncertain future. But unlike the traditional concept of resilience which offers ways of bouncing back from crises, adversity or cataclysmic change, this brand of resilience -- termed “strategic resilience” -- is more about proactively anticipating change. It’s about building ever evolving change and flexibility into the very fabric of an organization before the organization is required to change by forces beyond its control. Strategic resilience is about the pursuit of “zero trauma”-- the goal of forever morphing to take advantage of opportunities and incipient trends without the need for gut-wrenching overhauls, chaotic reorganizations or dramatic turnarounds. Strategic resilience is about constantly making the future rather than just defending the past (23). With this concept in mind, I began to wonder if perhaps a profession was not so different from a business or an organization that it, too, could achieve zero trauma as it moved forward and grappled with an uncertain future. Perhaps a profession -- the profession of psychology to be exact -- could build strategic resilience, effectively anticipate change and make its future in the process. But building strategic resilience doesn’t just happen and is not without its challenges. In fact, the authors of the article, Hamel and Välikangas, describe four specific challenges that make the task difficult: the cognitive challenge, the strategic challenge, the political challenge and the ideological challenge (24). [Slide 20] Each must be met head on and overcome if strategic resilience is to be a useful tool. The cognitive challenge to building strategic resilience is, simply put, denial, nostalgia or arrogance that prevents awareness of what is changing in the surrounding world and prevents recognition of the likely impact of those changes. The result is utter surprise with the discovery one day that the business, the organization or perhaps even the profession, can no longer function effectively in the changed world. This surprise is less the product of a world which is changing in ways that cannot be anticipated and more a function of inattention to that which is, in fact, changing. According to Hamel, for many organizations which fail to anticipate the future, “the future was less unknowable than it was unthinkable, less inscrutable than unpalatable.” [Slide 21] Meeting the cognitive challenge effectively means, first and foremost, “confronting the brutal facts of reality” as Jim Collins described in his book Good to Great (25). [Slide 22 ] Collins found that all companies he studied which were able to transform from just good companies to great companies began the process by confronting the brutal facts of their current reality. According to Hamel, it is simply not possible to make good decisions without “infusing the entire process with an honest confrontation of the brutal facts.” Conquering the cognitive challenge also means looking outside of ourselves, and outside of our profession, to see what trends may be developing. For example, how are society’s demographics changing to form more diverse communities which we will need to serve? How is the concept of family changing? What will the Baby Boom Generation demand five years from now? What do we know about the preferences, the needs or the idiosyncrasies of Generation X, or Generation Y? Overcoming the cognitive challenge means going where change and new ideas are occurring, where the status quo is the exception rather than the rule (26). Among other things for us psychologists, it may mean spending as much time reading Modern Healthcare, Medical Economics, Fast Company, or Wired Magazine as we now spend reading the American Psychologist or Professional Psychology: Research and Practice. Only when we expose ourselves to what is new and different will we be in a position to understand the implications of those developments for our profession’s future. Assuming the cognitive challenge is effectively managed, the core of strategic resilience is finding alternatives to the traditional ways of doing business or to the traditional ways of practicing. The strategic challenge, as this challenge is called, is all about fostering innovation to create variety. Variety is the key to evolving, to changing, and to staying a step ahead of the forced need to change. Innovation, according to Hamel, comes not from brilliance, but from looking at the world through a slightly different lens; it comes from having a different perspective. And in his experience with innovators, four different lenses seem to dominate (27). Innovators tend to challenge the dogmas and orthodoxies of the status quo, even when the status quo is successful. Innovators spot the new trends that are already developing but which have gone unnoticed by most people. Innovators are able to see beyond articulated needs and gain insight into unarticulated needs. In other words, innovators are able to empathize with human frustration and look for solutions before others are even aware solutions are needed. And innovators understand and know how to build on an organization’s recognized assets; it is, not a blow-it-up-and-start-over-again process. But, when it comes right down to it, successful innovation is a numbers game. It takes thousands of ideas to produce dozens of promising strategies to yield a few successes. The remaining two challenges, the political and ideological challenges to strategic resilience work against this. The political challenge is all about the process of reallocating resources in order to support a broad array of strategy experiments (28). It means liberating resources used to support the status quo in order to support something different or something new and unproven. It is an intensely political process whereby legacy strategies have powerful constituencies while embryonic strategies have none. For psychology to meet the political challenge, reallocating dollars and people from old strategies to new ones is certainly one part of the task. But so too is the need to liberate psychic energy from the traditional in order to invest it in the new and untested. In fact, this may be the most difficult part in the face of a health care system that has been transforming for decades; there are no banks or venture capitalists from which to secure a large influx of new psychic energy to continue this process. Also working at cross purposes with innovation is the ideological challenge. In our culture, optimization is the ideal against which progress and success are measured (29). Have we made something bigger or provided more of it? Have we done it better? Have we done it faster? Have we done it cheaper? Strategic resilience, by contrast, depends on being able to strive to “get different” just as strenuously as we strive to get bigger, better, faster, cheaper, or to provide more of the same. If we are able to overcome the cognitive, strategic, political and ideological barriers to building strategic resilience, we can hope to have many innovative ideas from which to choose. Yet, we are left with one critical task which Hamel so eloquently describes as follows: “It takes a lot of acorns to grow an oak tree. Whether you’re trying to innovate in the music business, the pharmaceutical business, or the fashion business, you’re going to be confronted with an inescapable math problem: You need 1,000 crazy ideas to find 100 plans that are worth funding experimentally so that we can then identify 10 projects that are worth pursing seriously in hopes of coming up with one or two strategies that have true transformative power. Every CEO would love to be able to walk through the forest and know which acorn will germinate. But it can’t be done. There’s simply no way to know in advance -- not when there are so many variables and there is so little actual control. We can’t know where the rains are going to fall, which acorn will get washed into better soil, and which one will end up in a rocky stream bed. But that doesn’t make (you) powerless and subject to whim. When you walk through the forest, you can tell the difference between an acorn and a rabbit turd. And when it comes to innovation, the rule is simple: Don’t waste time on rabbit turds (30).” [Slide 23]I’m willing to bet you never had a graduate course covering the identification of rabbit turds! In case you might be concerned about your own ability to spot one you’ll be happy to know that the breakout groups following this afternoon’s plenary may help with that important task. More to the point, the breakouts are intended to further explore how your organizations can enhance their ability to effectively innovate in the service of strategic resilience. But for now, lets return to an earlier question. Can strategic resilience co-exist with our prior strategy of staying the course? The answer is, of course it can. These are not mutually exclusive processes. Staying the course on important goals and objectives does not prevent us from being innovative in finding new strategies to achieve these goals and objectives (31). Perhaps you recall our last year’s discussion of staying the course led us to conclude that our central focus, from which we should not veer, is to identify and magnify for all to see the utility and effectiveness of psychological services. Building strategic resilience and our capacity to be innovative should not interfere with this focus. In fact, I believe it will help us better achieve it. By being innovative, we can find more aggressive ways to promote psychology and psychological services to consumers and third party payers. By being innovative, we can find additional creative ways to utilize the Congress, the legislatures and the courts to assure access to quality psychological services. By being innovative, we can take advantage of the developing trend in this country to recognize the importance of lifestyle for physical health and physical illness. By being innovative, psychology can capitalize on the next iteration of incremental reform which will likely target chronic disease management in an effort to provide more efficient and effective care. By being innovative, we may even be able to change the paradigm so that good physical health is subsumed under the larger umbrella of good psychological health (32). And by being innovative, we can find new ways to incorporate technology to make practicing psychology easier and to better serve our patients. Although I won’t try to predict the future -- I’ll leave that to our next speaker – I do have a picture of a strategically resilient psychology of the future. If we successfully build our strategic resilience, I see a profession whose activities are diversified well beyond traditional mental health. I see a profession that is clearly recognized as a comprehensive health profession. I see a profession that is valued for its unique problem solving capacity wherever behavioral problems are found. I see a profession with a critical role to play regardless of whatever health reform occurs. I see a profession that effectively sorts the acorns from the rabbit turds. I see a profession that achieves zero trauma. I see a profession that consistently gets a jump on change. But perhaps most importantly, if we are able to build our strategic resilience, I see a strong and vibrant psychology that is constantly making its future rather than just defending its past. [Slide 24] |
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