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Rural Health Bulletin - Summer 1998
Table of Contents
Greetings from the APA Committee on Rural Health by Katherine Nordal, Ph.D., APA's former Task Force on Rural Health now has official committee status and it is known as the Committee on Rural Health (CRH). The CRH reports to the Board of Directors and the Council of Representatives through the Committee for the Advancement of Professional Practice (CAPP). The committee is charged with addressing the special behavioral needs of residents in rural and frontier areas. The committee is now fully constituted and eager to meet the challenges lying ahead. Our committee met in Washington, D.C., March 19-22, as part of the APA consolidated board and committee meetings. We, unlike other APA committees, include a day of Hill visits in our schedule and members met with their House members and their Senators on legislative issues. During our regular schedule we met with William Monaco, O.D., Ph.D., Director of Optometry, Department of Veteran's Affairs about the logistics of pursuing prescriptive authority for non-physician providers. The discussion was an interesting one, highlighting many of the common frustrations and difficulties facing non-physician providers in this arena. We also met with Mr. Darin Johnson, Government Affairs Director for the National Rural Health Association, for an update on legislative issues affecting rural Americans. Dr. Harriett McCombs from the Center for Mental Health Services provided us with a presentation on the integration of behavioral health and primary care. Our committee has several areas in which we will be focusing our efforts over the next few years. We will develop a handbook entitled "Behavioral Healthcare in Rural and Frontier Areas", with committee member, Dr. Beth Stamm, serving as editor. Another area receiving a lot of attention from the CRH is telehealth and we have two members, Drs. Stamm and Anker, with particular interest and expertise in this area. Telehealth technology provides much promise for providing treatment services to underserved and isolated populations and will help reduce the isolation felt by providers in these areas. Legislative advocacy is another focus of the CRH. In this arena we will cooperate with other agencies such as the National Rural Health Association, the NIMH Office of Mental Health Research, and the DHHS Office of Rural Health Policy to educate the Congress about behavioral health issues of importance to rural Americans. We are also looking forward to developing a relationship with the House Rural Health Care Coalition, a bipartisan organization of Members of Congress who have a strong interest in improving the affordability, accessibility and availability of high quality health care services in rural areas. Another issue of great importance to the CRH is that of prescriptive authority for psychologists in rural areas to increase treatment options for rural residents. The rural arena, I believe, offers a rich opportunity for pursuing prescriptive authority for psychologists. In much the same way, the rural argument was persuasive in obtaining the inclusion of psychologists as providers under Medicare. Finally, we are looking forward to the final report of the Rural Women's Workgroup, addressing the specific behavioral health care needs of women in rural areas. We anticipate that the fruits of that report will provide much valuable information which we will be able to share with policy makers, including the Women's Caucus of the U.S. Congress, who have an intense interest in women's health issues. The Case for Managed Care Patient Protections in Rural America by Doug Walter, J.D. Traditional wisdom has held that managed care organizations (MCO's) would never penetrate rural areas because rural areas lack a sufficient population base to permit managed care systems to make a profit. However, a 1995 survey of Health Maintenance Organization (HMO) penetration in rural counties reveals that nearly 60 percent of HMO's inventoried in the study include both metropolitan and non-metropolitan counties in their service areas. Evidently HMO's tend to establish themselves in metropolitan areas and, over time, expand their service areas to include adjacent rural counties. Currently MCO's compete based on price and not the quality of care provided. During the 1990's, Congress has considered several bills which seek to ensure that HMO's and other MCO's provide high quality care to patients through the imposition of basic patient protections and standards. Rural advocates will serve their constituents well by seeking passage of managed care reforms to correct the problems that MCO enrollees are experiencing before MCO's spread more widely in rural areas. In one important respect, managed care patient protections already have reached rural America. Through the Balanced Budget Act of 1997, Congress reformed the Medicare and Medicaid programs, major payers of care for persons in rural and frontier areas, to encourage beneficiary enrollments in managed care alternatives to traditional fee-for-service health care. As part of Medicare and Medicaid reform, Congress attached several patient protections to the new managed care alternatives offered in these federal programs such as: a prohibition of "gag" clauses; patient grievance and due process protection; and increased consumer information to permit them to compare plans. With the passage of the Balanced Budget Act, many members of Congress had hoped to pass legislation to apply similar and additional substantial patient protections to MCO's in the private health care market. The "Patient Access to Responsible Care Act" (PARCA) sponsored by Representative Charlie Norwood (R-GA), who serves a mostly rural district, was introduced in the Spring of 1997 and gained wide bipartisan support. Senator Alfonse D'Amato (R-NY) introduced a companion bill in the Senate. This past March, Congressional Democrats answered President Clinton's call for passing patient protections by introducing the "Patients Bill of Rights Act of 1998" (PBOR Act) in both the House and Senate. Both PARCA and the PBOR contain three provisions which the American Psychological Association has advocated and are crucial among the managed care standards to ensure quality patient care. The first would amend the Employee Retirement Income Security Act (ERISA) to permit enrollees in ERISA-regulated MCO's the ability to hold these plans legally accountable for negligent actions. ERISA was enacted in 1974 to regulate employee benefit plans (including health) of large multi state employers. Because ERISA is a federal law. It preempts state laws. So, when an enrollee in an ERISA-regulated MCO is injured due to negligent cost-containment or treatment decisions on the part of the MCO, his or her suit is thrown out of court due to preemption. PARCA and the PBOR Act both seek to close the ERISA "loophole" to permit persons to seek redress for their injuries against their ERISA-regulated MCO's. PARCA and the PBOR Act also propose patient standards that relate particularly to the care that MCO's provide rural consumers. These standards center around two intertwined problems facing rural health care consumers: long distances to health care providers and access to specialized health care services. Perhaps the most powerful standard proposed by both PARCA and the PBOR Act to deal with the problems associated with distance and access to specialists would require insurance companies to permit consumers to join "point of service (POS) plans in their region. POS plans allow patient access to providers out of a closed network of providers for a higher, but reasonable, co-payment. An additional provision that would address rural-specific problems associated with distance and access to specialist providers is one that prohibits MCO's from discriminating against providers based solely on their licensure certification. More prevalent than medical specialists in rural areas, non-physician providers are qualified under state law to provide many of the same services. The provider non-discrimination provision helps to lessen the dilemma rural patients face when needing specialized services by preventing their MCO's from completely excluding non-physician providers from the network. Tied to the provider non-discrimination provision is the additional requirement that MCO's have a sufficient number, mix, and distribution of health providers to ensure the availability and accessibility of the benefits provided by the plan. Public opinion in support of managed care reform, combined with wide bipartisan support for PARCA and the rallying cry for reform from Democrats under the PBOR banner, has pressured Congressional Leadership to act. On July 24th the House enacted a modest managed care reform bill, which unfortunately did not include the ERISA accountability provision or the provider nondiscrimination provision but did include a modified POS requirement. The Senate is likely to consider a modest managed care reform bill sometime in September, but with the legislative clock ticking and several appropriations bills yet to be considered, prospects for reform this year are growing dim. Nevertheless, the APA with several other consumer and provider groups continue to work for legislation that contains substantial patient protections, knowing that as long as patients continue to experience problems with their MCOs, the call for patient standards will remain loud and strong. Telehealth: Rural Medicare Reimbursement, Reduced Telecom Rates and Grant Funding Opportunities by David Nickelson, Psy.D., J.D. Recently, Congress created a number of programs to help psychologists and other rural healthcare providers use telecommunications technology to overcome longstanding problems of patient access to care, including behavioral healthcare services. In 1997, Congress included a provision in the Balanced Budget Act directing the Health Care Financing Administration (HCFA) to begin reimbursing healthcare providers for services provided to Medicare beneficiaries via telecommunications to Health Professional Shortage Areas (HPSAs). On June 22, 1998, HCFA posted a "proposed rule" outlining how it might implement reimbursement for such telehealth consultations. The rule also includes a methodology for determining the amount of reimbursement. HCFA will be accepting comments from interested organizations and individuals. Interested rural psychologists are encourage to comment on the proposal, as the definitions, assumptions and methodology that will be adopted with the final rule will likely be incorporated in any future telehealth regulations. The proposed and final rules may also be used by private insurers to set limits on the services and amount of reimbursement they will provide for telehealth services. The full text of the proposed rule can be found on-line. As part of the Telecommunications Act of 1996, Congress directed the Federal Communications Commission (FCC) to create a program to provide discounted telecommunication rates and Internet connections for rural healthcare providers. In response, the FCC created the Rural Healthcare Corporation (RHCC), which recently began taking applications from eligible rural healthcare organizations and providers. Information on applying for the discount program, including the forms required, can be found at the RHCC (http://www.rhccfund.org/) website, and the entire process can be managed, and the forms submitted, via the Internet. This site is cross-linked to RuralPSYCH. by Tammy Lucas, M.A. RuralPSYCH is a world wide web resource center for rural behavioral health that is available to psychologists, other behavioral health care providers, and their patients. It can be accessed at www.apa.org/rural/homepage.html. The web site contains documents and research in rural practice as well as interdisciplinary information and internship and training opportunities. Over the past several months, numerous changes and additions have been made to RuralPSYCH. Many cross-links have been established with rural and community resources. RuralPSYCH is now linked with the National Rural Health Association (NRHA), a national membership organization whose mission is to improve the health and health care of rural Americans and to provide leadership on rural issues through advocacy, communications, education and research. Another new link is with the Rural Information Center Health Service (RICHS), which collects and disseminates information on rural health issues. RICHS serves a wide range of decision-makers who are working to maintain and improve rural health care, fundamental to the economic and social viability of rural communities. The Substance Abuse and Mental Health Services Administration (SAMHSA) is also now linked to RuralPSYCH. SAMHSA's mission is to assure that quality substance abuse and mental health services are available to the people who need them and to ensure that prevention and treatment knowledge is used more effectively in the general health care system. Finally, we have linked with "Fedstats." This site provides easy access to the full range of statistics and information produced by government agencies for public use and is maintained by the Federal Interagency Council on Statistical Policy. We recently also added a cross-link to "Practicing Psychology in Rural Settings: Hospital Privileges and Collaborative Care." This volume will help rural psychologists and hospital administrators educate hospital board members, medical staff, and rural citizens about the value of psychologists contributing to patient care. RuralPSYCH has also been successful in providing announcement services for employers seeking to fill employment opportunities for rural psychologists and practitioners. We continue to receive many responses to join the initiative and have received positive feedback from members who have visited the site. Our goal is to continue to advance and promote the use of the RuralPSYCH web site to provide a means for psychologists practicing in rural and frontier areas to communicate with each other and access expert resources in tertiary care centers and academic institutions. We hope you will visit our site soon and welcome any suggestions for improvement. Suggestions can be sent by clicking on the button "email to RuralPSYCH". Violence and Victimization Among American Indians by Pamela Jumper Thurman, Ph.D., Ruth W. Edwards, M.A., and Barbara Plested, M.A. While we know that the problem of violence cuts across all cultures, the availability of resources to address the problem are far more limited in rural communities than in urban areas (Edelson & Frank, 1991; Navin Stockum & Campbell-Ruggaard, 1993; Paquin, 1994; Petersen & Weissert, 1981). For women in communities with significant Native populations, including reservations and Alaska Native villages, there are little to no such resources. The few resources that do sometimes exist may be culturally inappropriate, could lead to loss of child custody, are difficult to access, and thus are severely underutilized. It has been well established that American Indian and Alaska Native tribes and bands are diverse groups of people. Although it is imperative to recognize and respect those differences, there are also common threads that bind tribal members together. These threads reflect strong and sometimes tragic histories that weave an intricate and complex story that spans many centuries of change. These changes have included forced removals from ancestral homes, loss of status, confinement to reservations and many efforts toward "acculturation." This history is significant in that there has been an immense struggle with many losses for the Native people. This has resulted in a strong intergenerational pattern of grief, loss, helplessness, and anger that likely have contributed to today's higher rates of violence and substance use (personal communication, Cookie Rose, July 1996). Where previous generations of grandparents experienced grief and loss, the next generation responded with helplessness and hopelessness, and the later generations with anger and violent behaviors. Many of the effects of the historical injuries mentioned are, unfortunately, not so far in the past as to have no significance today. Unemployment is high in Indian communities, with 31.6% of Indian people living below the poverty level compared to 13.1% for the USA population (Indian Health Service, 1994). Opportunities for Native people are still very limited. Healthy People 2000 (1991) states that 2.2 million people are victims of violent injury each year. It also notes a lack of adequate data on violence and victimization among minority and impoverished youth. In spite of the recent interest in studies on violence in the U.S., there is very little information related to research on the services for the prevention of violence in American Indian and Native Alaskan communities. The literature on the nature and extent of violence among American Indians is very limited. Recent data collected by the Tri-Ethnic Center for Prevention Research suggest that the highest percentages of victimization were in the categories of being beaten up by siblings, and rape or sexual assault. 7th-8th and 9th-10th grade non-metropolitan American Indian females report somewhat higher rates of sexual assault than their metropolitan counterparts, though for 11th-12th grade metropolitan females, the sexual assault rate is 42.6%. With the exception of only two groups (beaten up by siblings, 7-8th graders, and hurt with a club, knife or gun) American Indian youth, in general, are reporting higher levels in all categories of violence and victimization than their Anglo counterparts. There are also barriers to utilization of services that must be considered when working with American Indians or Alaska Natives. Often there is a reluctance to seek assistance with tribal programs because of fear of losing custody of one's children if Child Protective Services are called in. Even requesting assistance from an outsider may be difficult for Native women because of distrust of the non-native systems and lack of confidence in the longevity of the program. More often, cultural barriers that result in poor communication and lack of trust in the helping professional are common. Reliance on law enforcement officials is a challenge as well since response times in rural or reservation areas may be measured in days or hours rather than minutes. Transportation and child care for help-seeking behavior is often non-existent, limiting access to the resources that do exist. Finally, considerations for intervention or research for violence and victimization must be introduced as a partnership with that community. It must be an empowering experience that will build on the strengths that are inherent in the area and it must leave something of value for the people living there. It must have cultural integrity. The community must be given the opportunity to assist in identifying and owning the problem, acknowledging potential barriers, and collaborating in the development of interventions that are culturally consistent with the area. A Typical Day in the Life of ... by Dan Egli, Ph.D. RP=Rural Psychologist RFP=Rural Family Practitioner Ring…Ring. RFP: Hello Dan. I wondered what you thought of the patient I referred…you know, Mrs. Smith…the lady who I think is depressed? RP: Yes, I saw her this morning and I'd agree with you…I think she is depressed…I did a clinical interview and a simple self- rating scale for depression to confirm my hunches. RFP: Well, as usual…what's the bottom line here Dan?…What do I do on this end? You know, the usual question, do you think she needs an antidepressant and, if so, which one? There are so many out there now! RP: I definitely think she could benefit from an antidepressant, but I am assuming she's not hypothyroid. She didn't know if the blood work you did included testing for that. RFP: Good point…I'll check here in the chart…no actually I didn't so I'll do a thyroid profile and get the antidepressant started if that comes back negative. Now, which one? RP: Actually, I'd be more inclined to say which class?…probably any of the SSRI's would work well because of their broad spectrum of efficacy and the nature of the symptoms I've observed. In addition to her depression, she's having panic attacks and, as you know, several of the SSRI's are approved for both major depression and panic disorder. RFP: Well…which one and what dosage? RP: In terms of those that are formally approved for panic disorder as well as major depression, there are two that you might consider, PaxilR and ZoloftR. When you decide on the dose, I believe that you should take into account the fact that she seems to worry quite a bit about possible side effects, plus she reports being sensitive to medication. You might want to consider a pediatric dose to start. RFP: Sure…no problem. I've used them both. We'll give her a call, do the additional blood work, and get her started on one of them if it is negative. Will you be seeing her anymore? RP: She really didn't seem interested in that at this time. She said she was only seeing me because you needed some ideas about medication and I was comfortable looking at this one visit consult. On the other hand, if you or her believe some psychotherapeutic support is needed, I'd be pleased to provide it. Feel free to "holler" if you have questions, if she develops any major side-effects, or if she isn't better in a month. RFP: OK…thanks Dan…gotta run. There is a waiting room full of patients and I'm running late. Thanks for your input. In my service area, I would estimate conservatively that 98% of the psychotropics are prescribed by non-psychiatric physicians. In general, they are very willing to acknowledge their discomfort and lack of adequate training in prescribing psychotropics. Some acknowledge that their prescribing patterns are too often based on "recency effect" (based on who the most recent "drug rep" to visit them was or what they have samples of). After 18 years of collaborating with them and building a relationship of trust and rapport, they unanimously acknowledge the crucial role they feel the rural psychologist, appropriately trained in psychopharmacology, can play in helping them feel more comfortable with prescribing psychotropics. The clinical vignette above illustrates one current role of the rural psychologist as a consultant-liaison (C-L) to primary care physicians. In that role the RP who is appropriately trained in psychopharmacology can collaborate with the RFP in treating rural patients and also can function as an educator (of both patient and prescriber), serve as a consultant, and function as a "case manager" coordinating the integration of psychotherapeutic and pharmacologic care. This is a practice pattern that is particularly helpful for patient care in underserved rural areas. In addition to this consultant-liaison role, APA is pursuing new opportunities for psychologists, through its model psychopharmacology curriculum and model prescriptive authority legislation, to be more directly involved in prescribing in the future. Indeed, as I have the opportunity to present psychopharmacology workshops around the country to various state psychological association meetings and to various medical practitioners (typically family practice residents, physician assistants, and nurse practitioners), I hear the same concern echoed: they are uncomfortable prescribing psychotropics and ask me when I (and other appropriately trained psychologists) will get prescription privileges. They don't feel comfortable prescribing psychotropics and they understand that a psychologist can acquire, with appropriate training, supervision, and continuing education, the knowledge and skill base in psychopharmacology. Prescriptive authority for psychologists will be a significant benefit to patients, particularly those in rural and frontier areas. Psychologists could utilize the authority to benefit patients who are currently being undertreated, misdiagnosed, and (as a consequence) spending more health care dollars (for in-patient care and traveling long distances to see psychiatrists who practice in large cities). One of the most common forms of misdiagnosis is the patient who goes to the family doctor knowing "they don't feel right" (safer than admitting they are depressed) and only discussing such socially acceptable somatic and anxious complaints as "I have an upset stomach.", but rarely acknowledging their feeling of sadness and crying spells. As such, the RFP will often put them on benzodiazepine, which may calm their "nerves", but will not help their underlying Axis I mood disorder. With good rapport and the history of having collaborated on many cases together, the RP is free to call the RFP to discuss switching over to alternative medications (e.g., an antidepressant) without being seen as a threat to the RFP's ego-in fact it is welcomed and invited! Rural Hospital book Published by APA by Gil Hill A new book, edited by Jerry Morris, Psy.D.-a former member of the APA Committee on Rural Health has been published by APA Books. This volume, titled "Practicing Psychology in Rural Settings: Hospital Privileges and Collaborative Care" is designed to aid the rural psychologist in educating hospital board members, medical staff members, chiefs of medical services, and rural citizens about the contributions rural psychologists make in hospital settings. In addition, the book is an overview and set of readings for the training of psychologists and the facilitation of their collaborative practice in hospital settings. Psychologists in rural areas, if authorized by state law to practice in a hospital setting, can obtain hospital privileges and practice collaboratively in primary care settings (17 states have passed such laws to date). This book is designed to facilitate both of these efforts. It is organized in 3 parts: I. Foundations of Establishing a Hospital Practice; II. Collaboration and Linkages; and III. Special Populations in Hospital Practice. In Part I there are chapters on rural hospital psychology, medical or professional staff membership, and psychology's contribution to the hospital during health market change. The three chapters provide the basis for establishing hospital practice. In Part II, there are chapters on collaboration with primary care physicians, collaboration with community mental health centers, and the rural hospital emergency room. Material in the chapters provides information on collaboration and linkages with other health care professionals. Examples of how psychological treatment can aid special populations in rural hospital practice is provided in Part III. Chapters cover Clinical Neuropsychology, Wellness for Women, and Addiction Screening and Treatment. The book costs $19.95 and is the second book in the "Rural" series developed by the APA. The first is "Caring for the Rural Community: An Interdisciplinary Curriculum" (1995, $14.95). Both books are available from American Psychological Association Books. They can be ordered on the world wide web at http:www.apa.org/books or by calling 1.800.374.2721. Campaign Kit Gets Rural Ball Rolling The APA public education campaign depends on grass roots psychologists throughout the country to educate the general public, health policy makers, and opinion leaders about the value of psychological services. To aid this process, rural practitioners have access to a free campaign kit filled with tools and information needed for media relations, advertising, and other outreach activities. Request a kit by calling the campaign's toll-free information line, 800.964.2000. Many rural practitioners get started by assessing their interests and talents in reaching out to local businesses, civic groups, and other community organizations which they have or want to establish a relationship. Taking this step makes it easy to connect to public education campaign activities. The practical "how to" information and ready-to-use materials in the free kit are designed specifically to help APA rural members activate the campaign. Rural Health Bulletin is published by the Practice Directorate of the American Psychological Association. Russ Newman, Ph.D., J.D. Gil Hill 202.336.5857 APA Practice Directorate Persons interested in submitting articles to the Rural Health Bulletin should contact: Gil Hill, 202.336.5857.
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