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2002 Practice Organization's Town Hall Meeting
These changes have, of course, forced changes onto the practice of psychology. No longer can psychologists in the healthcare system be concerned only with the clinical aspects of our work or with just the welfare of our patients. We must, simultaneously, be concerned with relevant federal and state law, regulations, health policy, market forces, public opinion and, more recently, with new information technologies fast becoming an inevitable component of the healthcare system. The importance of taking into account factors external to psychology seems to us today to be a given. But it has not always been so. In fact, historically, the profession of psychology has been more insular, introspective and internally focused than it has been outward looking (3). I recall one of the very early tasks of the newly created Office of Professional Practice in 1986 which included efforts to refocus the practice community to look outward, rather than just inward, and to realize that what we did in the therapy and consulting rooms was significantly influenced by what went on in the Congress, legislatures, the courts and in the public at large. And we realized, perhaps more than ever before, that we needed to take steps to influence what goes on in these areas in order to continue to practice effectively. This, then, set the stage for the development of the Directorate’s legislative advocacy, judicial advocacy and public education agendas. Similarly, in the mid 1990’s, after the demise of legislated healthcare reform and the rise of market-driven reform, we began to appreciate the influence of market forces on the delivery of psychological services (4). No longer were freedom of choice laws, for example, sufficient to insure that psychologists could provide services in the healthcare market. Rather, the level of purchaser demand for our services, the perceived value of psychological services and the extent of psychologists’ bargaining power in the marketplace became significant variables influencing our practice, often more so than state laws and even some federal laws. This set the stage for the Practice Directorate’s marketplace agenda to work to put business into practice, to educate employers and other payers about the value of psychological services, and to work to influence those market forces affecting us. Now, another major set of external forces is beginning to influence what we do in healthcare and psychology (5). The Internet explosion and the development of new information technologies are poised to have a dramatic impact on healthcare, an industry considered by some to be the most information-intensive sector of the economy. Many, many consumers are receiving health information online. Some are even receiving services via the Internet. But more to the point for this morning’s program, information technologies are beginning to be used in an effort to restructure the healthcare system, a system badly in need of reform. We must now prepare ourselves to deal with these technology forces and their impact on the practice of psychology, just as we have needed to deal with the impact of legislation, market forces, and public opinion (6). With this array of potential influences on the practice of psychology as a backdrop, we will look at some specific trends, influencing today’s, and tomorrow’s practice, as well as some tools and technologies to help the profession and psychologists respond to these trends. Our first focus is on a few key advocacy issues reflective of important trends in healthcare and psychology – patient protection, parity and prescription privileges for psychologists. All three have been evolving for years, and while enactment of the laws necessary to implement each have been slow in coming, each continues to be a major objective that will have a significant impact on our ability to deliver care to our patients and clients. The rise of market driven managed care has led to the need for patient protection. And while many protections have been established at the state level, and even some at the federal level, managed care accountability, the lynchpin of real reform, remains a work in progress (7). While both the House and Senate have passed bills which include the ability to sue negligent managed care companies, the bills differ in the extent to which they enable damages to be obtained by an injured party. The Practice Directorate’s language, and our goal of no caps on damages, is incorporated into the Senate bill but not the House version. Resolving that difference, in order to get a law enacted, seems an uphill battle right now. But as you will hear in this video taped message sent to us by friend and patient protection advocate, Georgia Congressman Charlie Norwood, the fight is far from over. [ROLL VIDEO TAPE] (8) No less difficult to accomplish than managed care accountability, and no less necessary, has been mental health parity. The current federal legislation – the Mental Health Equitable Treatment Act – reflects the next step in a long-standing battle to stop discrimination against people with mental health disorders. And as you will hear from two parity champions, Congresswoman Marge Roukema of New Jersey and Minnesota Senator Paul Wellstone, psychologists and consumers are playing an important role in keeping this agenda moving. [ROLL VIDEO TAPE] (9) Later this morning you will see how with the use of our new information technology -- the Practice Organization’s Internet-based portal -- you can follow Congresswoman Roukema’s direction and actually become much more involved with your Members of Congress on these important issues. It is, of course, not possible to talk about major trends affecting psychology without talking about prescription privileges for psychologists. While we have quite recently congratulated and celebrated New Mexico's historic passage of a prescriptive authority law, the prescription privileges agenda has been an evolutionary one, not a revolutionary one. A number of years of development and preparatory work by our profession preceded enactment of the Guam law, and now the New Mexico law. In fact, steps have been underway since 1984 to get us where we are today (10). We are fortunate this morning to have with us, by video-taped message, an individual who was among the first to encourage psychology to take the necessary steps towards prescribing, Senator Danniel Inouye of Hawaii. Let’s hear what the Senator has to say. [ROLL VIDEO] The ability of appropriately trained prescribing psychologists to help meet a currently unmet mental health service need in this country is a significant evolution within our profession. But so too is the ability of psychologists to be recognized as central contributors to the healthcare delivery system an important trend in healthcare. In fact, psychologists are increasingly being recognized in the mainstream of healthcare, not merely peripheral to it as allied health professionals. Prescription privileges is among a number of developments helping to bring this about just as Senator Inouye predicted(11). After all, how often does psychology find itself on center public stage with a bright media spotlight on our ability to provide healthcare, as has been the case with prescription privileges. Let’s watch. [ROLL VIDEO] While some trends are long in developing, others are sparked in an instant. The terrorist attacks of September 11th have had a profound effect on us all – as individuals, as a profession, as a community and as a nation. In an effort to tap the pulse of the post 9/11 nation, the Practice Directorate conducted focus groups in Los Angeles, Indianapolis and Baltimore during the months of October and November of last year (12). Among the things we learned were that participants identified the presence of a chronic stress level, one which was described to have been present before the terrorist attacks and not just as a result of them. But it was also clear that this was a stress level noticeably increased since 9/11. Participants described a sense that “the other shoe was about to drop.” And they said this was made all the more difficult because they were already living with a chronic high level of daily stress resulting from pressures both at home and at work. But without question, the strongest sentiment expressed by participants in the focus groups was one of confidence and determination that people will “bounce back” from the initial emotional and psychological impact of the attacks. Resilience, the term that has come to be associated with successfully struggling with hardship, adversity, tragedy and even significant ongoing stressors, seemed to take on a new relevance for participants (13). More importantly, people expressed a clear desire to learn how to be resilient. They were not so much interested in just “coping with” or “dealing with” or simply “living with” change, stress and uncertainty as they were interested in being able to be “resilient” in the face of such challenges. Providing the public with information to help build resilience is, of course, quite consistent with the goals of our “Talk to Someone Who Can Help” Public Education Campaign. And we have been very fortunate to come together in partnership with cable television’s Discovery Health Channel for the production of a documentary on resilience entitled “Aftermath: The Road to Resilience” (14). I am delighted to introduce to you Discovery Health Channel Senior Vice President and General Manager, Bob Reid, who is here with us today to tell us more about the documentary and provide us with a glimpse of what will soon be aired on television. Mr. Reid is the chief editorial executive for Discovery Health. He is responsible for the strategic development and executive programming and production strategies, as well as the day-to-day programming and production operations for the Discovery Health Channel. He has served as executive producer for numerous award-winning programs, including the Emmy award-winning Discovery News; Discovery and BBC America’s worldwide telecast Behind the Terror: Understanding the Enemy that provided a comprehensive examination of the issues behind the events of September 11; and Vietnam POWs: Stories of Survival, which won Discovery’s first Primetime Emmy Award (15). Please welcome Mr. Bob Reid. [Bob Reid Speaks] [Clips of Aftermath] Thanks, Bob. We’re really glad to be working with you on this one. The airing of the documentary on August 29 and September 11 will mark the kickoff of a grassroots outreach effort by the Directorate working in coordination with all of you and your state and provincial psychological associations, much as we have with the “Warning Signs” outreach (16). Later this morning, we will also see how the practitioner portal will help facilitate this grassroots public education effort and put the necessary information and materials into the hands of an army of psychologist spokespersons around the country. While it has always been important to educate the public about good psychological health and psychological services, some would argue that the emergence of the Internet and new information technologies will so empower consumers that public education will be even more important than it has been. As I mentioned at the beginning of this morning’s program, the development of new information technologies is expected to have a dramatic impact on healthcare, since it is among the most information – intensive sectors of our economy. Some policy experts believe that greater empowerment of patients alone will help reform the healthcare system (17). Beyond its impact on consumerism, however, the Internet and information technologies do have implications for the structure and reform of the healthcare system. The impact of information technology on cost and efficiency in healthcare – a key to successful reform – is a relevant but complicated issue. A special issue of the Journal of Health Affairs, published last year, framed this issue quite well. According to the editor: “The Internet explosion has inspired an outpouring of predictions that the health sector’s long-awaited breakthrough in information is finally at hand. But will network computing really help create order amid the befuddling maze of insurance claims, clinical records, and quality data in which the key to a more efficient system now lies hidden?(18) Or will the ultimately localized idiosyncratic and fragmented enterprise of care continue to prove resistant to rationalization?” We’ve witnessed efforts in the last 10 years to decrease the cost of healthcare by decreasing utilization through increased administrative activity and, I would add, increased administrative cost. Decreasing utilization through increased administrative activity is, after all, the “MO” of managed care. The grand result has been that we are still spending more than 14% of our total economy on health (compared with about 8-10 percent in other countries), with no recognizable improvement in outcome. Our administrative costs are two and half times larger than in any other national system. Few problems have been solved and many others created (19). Virtually everyone willing to be objective has concluded that market-driven, managed healthcare has failed. One medical economist, J.D. Kleinke, in his recent book, “Oxymorons: The Myth of a U.S. Health Care System”, paints the picture well. He writes: “Five hard years after the Aetna-US Healthcare merger, conventional wisdom has it that managed care has failed to live up to all but its most brutal promises. Left in the rubble are bewildered consumers, disappointed employers, enraged patients embittered physicians and a raft of lawsuits – along with a handful of failed or enfeebled healthcare vendors. What once looked like a permanent reduction in health insurance premiums – thanks to a onetime round of severe price competition among managed care organizations – turned out to be an anomaly, a momentary pause in their inevitable rise (20). And the overwhelming majority of clinical studies have shown that for all their rhetoric about population health, illness prevention and disease management, managed care systems do not improve the overall health status of their members. In the final analysis, most managed care was “managed cost” all along – but it failed to accomplish even that goal, and the US healthcare system is worse off for the experiment”. Shifting the focus of reform away from efforts to decrease utilization and service costs towards attempts to decrease administrative activity and transaction costs seems to provide an alternative solution for reform. It is also fertile ground for the use of information technology since the ability to facilitate transactional activities is one of the Internet’s greatest strengths (21). Jim Clark certainly believed this when he founded Healtheon with the expectation that he could take $400 billion of waste out of the healthcare system using Internet technology to streamline the transactional aspects of the healthcare system. But what Clark didn’t realize, and perhaps Newt Gingrich said best, was that “…..each of those ($400 billion) dollars was loved by somebody who didn’t want to give it up.” According to Kleinke, “In the language of the insurance business, the ‘float’ rules…. If the process of claims adjudication is haunted by a computing, contract and analytic nightmare, this nightmare is good business for health plans that make money sitting on money." Proponents of the use of information technologies to remedy the ills of the healthcare system acknowledge that benefits have been slow in coming (22). The full benefit of these developments, they believe, hinge partly on supporting public policy not yet completely developed. The absence of shared standards for electronic data communication has long limited the ability to utilize technology to realize savings in transaction costs. Enter HIPAA -- the Health Insurance Portability and Accountability act -- as the possible missing piece. While HIPAA is perhaps fast becoming a “household word” in the health arena for its inclusion of health information privacy rules – something I will say more about in a minute – this was not the primary intent of HIPAA. Through the Administrative Simplification provisions, specifically the Transaction Rule, HIPAA was primarily intended to establish a standardized and uniform electronic claims process (23). When implemented, all third party payors will be required to accept an electronic claim if it is submitted according to the standard format. And the format of the claim remains the same irrespective of which third party payor is involved. The law and its rules do not compel a healthcare professional to submit claims electronically but, if you do, the claim must be in the standardized format. And, as we are all learning, certain privacy practices will need to be established and followed as well – something the congressional drafters of HIPAA believed critical to public acceptance of a standardized electronic claims process. But the real hope of HIPAA was to provide a central mechanism for reducing the administrative complexity and increasing the efficiency of the healthcare system (24). Perhaps this legal requirement that insurance companies establish a standardized, more efficient electronic transaction process will free up some of those $400 billion dollars Jim Clark was looking to uncover. Only time will tell whether a technology-driven standardized electronic claims process will trigger a healthcare reform effort with markedly different results than what we’ve seen from the last decade of “reform”. In the meantime, here are some important HIPAA compliance dates to put on your calendar: First, the Transaction Rule Compliance Extension Form is due to the Center for Medicare and Medicaid Services (CMS) by October 15, 2002. Completing this relatively simple form buys you until October 16, 2003 to do anything else that might be required of you by the Transaction Rule (25). The Practice Organization, in conjunction with the Insurance Trust, have just sent every licensed health service psychologist member of APA a mailing which will tell you exactly how to complete and file the CMS form online. The mailing should be waiting for you when you return home from Convention. But in the event that you just can’t wait, we’ve provided Town Hall attendees with an advanced copy, which you’ll find at your place. This information is also available at www.APApractice.org, the Practice Organization’s portal, which you will hear more about in just a minute. Second, other Transaction Rule requirements come due, as I mentioned, October 16, 2003. As a practical matter, this will mean being ready and able to put electronic claims data into the HIPAA standardized format, should you chose to use electronic claims (26). The Practice Organization is presently exploring various technology and/or vendor solutions to recommend for those of you who expect to be doing electronic claims. Third, the Privacy Rule Compliance date is April 14, 2003. I hope everyone here has already read the HIPAA primer for psychologists we produced with the Insurance Trust, and that each of you has already begun the compliance process. Additional information and materials will be ready mid fall, including model policies, procedures and forms, all of which will be customized for each state to include the requirements of relevant state law. We will also be including the amendments to the privacy rule just issued by the Administration (27). The Security Rule – which includes compliance requirements for ensuring that your electronic systems are physically secure – has not yet been issued in final form. The compliance date will be two years from the point at which the final rule is promulgated. When the Practice Organization’s portal is launched next month, it will provide, among other things, an on-going resource for getting the latest information about HIPAA compliance. Speaking of the portal, over the last year the Practice Organization has been working to enhance our information technology capability in order to increase our efficiency and help us better accomplish our advocacy mission on behalf of practitioners (28). A central component of this process has been the development of our Internet-based practitioner portal – APApractice.org. If you are like most members we’ve talked to, you are probably now asking yourself ‘what’s a portal?” Some equate it to a Web site, but we believe it is much more. If a Web site is pictured as a two dimensional presentation of information, a portal should be viewed as three-dimensional. Some describe it as a gateway to wide array of strategically organized information and services, a place to go online that enables easy access to those materials and services that are most relevant to practitioners. There is also an interactive quality to a portal, something often missing from web sites (29). With overwhelming amounts of information available on the Internet, the portal will enable you to readily find the information and services most relevant to you and to customize, to a large extent, the information you receive. Two members of the Practice Organization’s portal development team – Norbert Scully, formerly of KPMG Consulting, and Elizabeth Bailey of 2B Communications – are with us this morning to introduce you to the portal and provide a glimpse at what it will be able to do for you. While the uses and benefits of the Internet have probably been over-estimated and over-hyped in recent years, the Internet definitely does have attributes we believe will be helpful to our work on your behalf and helpful to your work as well (30). Increased “connectivity” is one potential consequence of the Internet that we believe the portal will make use of. We look forward to being better able to connect the Practice Organization to the practice community. Getting information out to you and hearing from you at “Internet Speed’ will contribute to our efforts. And we anticipate the portal will help you connect to each other. |
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