Posted with permission
One direct consequence of the advent and steadily increasing presence of technology within the health care arena will be the need for psychology to finally seriously address the issue of licensure mobility. The Department of Veterans Affairs (VA) recently announced its plan to increase veterans’ access to mental health care by conducting more than 200,000 clinic-based, telemental health consultations by mental health specialties this fiscal year. Earlier the VA indicated that it would no longer charge a copayment when veterans receive care in their homes from VA health professionals using video conferencing. The Secretary: “Telemental health provides Veterans quicker and more efficient access to the types of care they seek. We are leveraging technology to reduce the distance they have to travel, increase the flexibility of the system they use, and improve their overall quality of life. We are expanding the reach of our mental health services beyond our major medical centers and treating Veterans closer to their homes.” Since the start of the VA Telemental Health Program, VA has conducted over 550,000 patient encounters.
The Fiscal Year 2013 budget request for the Office of Rural Health Policy, which is located within the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services, notes that there has been a significant Departmental focus on rural activities for over two decades. Historically, rural communities have struggled with issues related to access to care, recruitment and retention of health care providers, and maintaining the economic viability of hospitals and other health care providers in isolated rural communities. There are nearly 50 million people living in rural America who face ongoing challenges in accessing rural health care. Rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than their urban counterparts. Rural areas also continue to suffer from a shortage of diverse providers for their communities’ health care needs and face workforce shortages at a greater rate than their urban counterparts. Of the 2,052 rural counties in the nation, 77 percent are primary care health professional shortage areas (HPSAs), where APA’s Nina Levitt reports that psychologists are eligible for the National Health Service Corps Loan Repayment Program which places health professionals in underserved rural communities.
HRSA’s Telehealth Grants initiative is designed to expand the use of telecommunications technologies within rural areas, seeking to link rural health practitioners with specialists in urban areas, thereby increasing access and the quality of healthcare provided. Telehealth offers important opportunities to improve the coordination of care in rural communities by linking its providers with specialists and other experts not available locally. The strengthening of a viable rural health infrastructure is viewed as critical for long-term success, including facilitating distance education experiences. The budget request for the office of rural health office once again proposed $11.5 million, which has subsequently been approved by the Senate Appropriation Committee, and thus allows the continuation of the Licensure Portability Grant initiative, in order to assist states in improving clinical licensure coordination across state lines. This particular initiative builds on HRSA’s 2011 Report to Congress indicating: “Licensure portability is seen as one element in the panoply of strategies needed to improve access to quality health care services through the deployment of telehealth and other electronic practice services (e-care or e-health services) in this country…. Overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals in order to address workforce needs and improve access to health care services, particularly in light of increasing shortages of health professionals. ”
For some colleagues, and particularly for those who are not comfortable with fundamental change, the relationship between telemental health and licensure mobility might seem to be a tenuous one. And yet, we would suggest that they are intimately linked. The public policy rationale for professional licensure is to protect the public from untrained and/or unethical practitioners, not to enhance the status or economic well-being of the profession. Historically, and we would expect for the foreseeable future, licensure decisions and qualification criteria have been made at the individual state level, where each of the professions plays a major role in determining its requirements for membership and its scope of practice, albeit through the political process. Within the federal system the governing statutes and implementing regulations generally require licensure in at least one state (regardless of practitioner geographical location) and facility approval (i.e., being credentialed). As improvements in technology allow for increasingly higher quality utilization, the congressional committees with jurisdiction have been systematically “cleaning up” potential lingering statutory restrictions. And, at both the state and federal level, expanding reimbursement paradigms are evolving. APA estimates that 13 states now require private sector insurance companies to pay for telehealth services. Over the years, we have not been aware of any objective evidence which suggests that the quality of care being provided via telehealth is in any way compromised. To the contrary, as the VA, the Department of Defense (DoD), and the federal criminal justice system are demonstrating, access has been significantly enhanced and new state-of-the-art clinical protocols have been developed and implemented.
A First Hand View -- From Tripler Army Medical Center: “I joined the Telebehavioral and Surge Support (TBHSS) Clinic in February, 2011 during its infancy. At that time, the program was fully staffed with providers and support staff, making us 24 strong. TBHSS provides healthcare access by connecting eligible beneficiaries to providers who are able to indentify and treat their clinical needs. These services are provided through secured video technology which allows accessibility from remote locations worldwide. I was very excited to have the opportunity to work in a clinic that has the ability to reach out to those off island, typically in areas where the demand for services is far greater than that of the availability. To date, the clinic has been able to support Alaska, Texas, Korea, Japan, Okinawa, and American Samoa, as well as various sites on the island of Oahu and in the Continental United States. As a provider, it was refreshing to be able to provide multiple services such as therapy, consultation, administrative evaluations, and both neuropsychological and psychological assessments. In addition, we provided surge support during different points within the ARFORGEN cycle whenever there was a need for augmented behavioral health resources. In February, 2012 I was fortunate to be commissioned in the USPHS as a Lieutenant (0-3) and detailed to Tripler. As a clinical psychologist, I was able to utilize all the skills within the Department of Psychology that I acquired from my time at TBHSS. Recently, I had the honor to be promoted to the position of Clinical Director of TBHSS. Returning back to my roots has been exciting as I get to work with individuals who have a passion and commitment to serve service members and their families. My journey as a clinical psychologist civilian contractor to active duty clinical director has just begun and I am looking forward to the ongoing relationships that the TBHSS team forges with the different regions” [Sherry Gracey, Lt. USPHS].
ASPPB: We were very pleased to learn from Steve DeMers that the Association of State and Provincial Psychology Boards (ASPPB) was successful in its application this year for one of the licensure portability grants issued by HRSA. ASPPB will receive approximately $1 million over the next three years to provide support for state psychology licensing boards addressing statutory and regulatory barriers to telehealth, focusing upon continuing the development and implementation of its Psychology Licensure Universal System (PLUS) initiative. As an integral means of addressing the present barriers associated with telepsychology, ASPPB has developed an on-line application system, the PLUS, that can be used by any applicant who is seeking licensure, certification, or registration in any state, province, or territory in the United States or Canada that participates in the PLUS program. This also enables concurrent application for the ASPPB Certificate of Professional Qualification in Psychology (CPQ) which is currently accepted by 44 jurisdictions and the ASPPB Interjurisdictional Practice Certificate (IPC). All information collected by the PLUS is deposited and saved in the ASPPB Credentials Bank, a Credentials Verification & Storage Program (The Bank). This information can then be subsequently shared with various licensure boards and other relevant organizations. Therefore, streamlining future licensing processes.
ASPPB is an active participant in the APA/ASPPB/APAIT Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, established by former APA President Melba Vasquez and co-chaired by Linda Campbell (APA) and Fred Millan (ASPPB). The members have backgrounds, knowledge, and experience reflecting expertise in the broad issues that practitioners must address each day in the use of technology -- ethical considerations, mobility, and scope of practice. Several of the meta-issues discussed to date center on the need to reflect broadness of concepts when incorporating telecommunications technologies and to provide guidance on confidentiality and maintaining security of data and information. In addition, a number of meta-issues focus on the critical issue of interjurisdictional practice. The underlying intent behind the proposed guidelines is to offer the best guidance to psychologists when they incorporate telecommunication technologies in the provision of psychological services, rather than be prescriptive. The Task Force met twice in 2011, June of 2012, and plans to meet once more this Fall. Feedback on their recommendations will be sought at the Orlando convention, throughout the APA governance, and continuously from the membership at large. Their goal is to have the guidelines adopted by APA as policy and approved by ASPPB and APAIT sometime in 2013.
The U.S. Supreme Court: As we all must be aware, this summer the U.S. Supreme Court upheld the underlying constitutionality of the President’s landmark Patient Protection and Affordable Care Act of 2010 (ACA), including it’s far reaching individual mandate provision, by a 5-4 vote. For legal scholars, the most critical issue was probably the Court’s deliberations regarding the federal government’s power to regulate Commerce vs. its power to raise Taxes, as a government of limited and enumerated powers. “We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation’s elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions.
For health policy experts and practitioners, the Court’s musings on our nation’s health care system makes for particularly intriguing reading. * “Everyone will eventually need health care at a time and to an extent they cannot predict, but if they do not have insurance, they often will not be able to pay for it. Because state and federal laws nonetheless require hospitals to provide a certain degree of care to individuals without regard to their ability to pay, hospitals end up receiving compensation for only a portion of the services they provide. To recoup the losses, hospitals pass on the cost to insurers through higher rates, and insurers, in turn, pass on the cost to policy holders in the form of higher premiums. Congress estimated that the cost of uncompensated care raises family health insurance premiums, on average, by over $1,000 per year.” * “Indeed, the Government’s logic would justify a mandatory purchase to solve almost any problem…. (M)any Americans do not eat a balanced diet. That group makes up a larger percentage of the total population than those without health insurance. The failure of that group to have a healthy diet increases health care costs, to a greater extent than the failure of the uninsured to purchase insurance…. (T)he annual medical burden of obesity has risen to almost 10 percent of all medical spending and could amount to $147 billion per year in 2008. Those increased costs are born in part by other Americans who must pay more, just as the uninsured shift costs to the insured.” * “In enacting [ACA], Congress comprehensively reformed the national market for health-care products and services. By any measure, that market is immense. Collectively, Americans spent $2.5 trillion on health care in 2009, accounting for 17.6% of our Nation’s economy. Within the next decade, it is anticipated, spending on health care will nearly double. The health-care market’s size is not its only distinctive feature. Unlike the market for almost any other product or services, the market for medical care is one in which all individuals inevitably participate.” * “Not all U.S. residents, however, have health insurance. In 2009, approximately 50 million people were uninsured, either by choice or, more likely, because they could not afford private insurance and did not qualify for government aid.”
Bringing Psychology To The Table – State Leadership In Health Care Reform: At this year’s impressive State Leadership conference, Katherine Nordal exhorted our state association leaders to appreciate that: “We’re facing uncharted territory with proposed new models of care delivery. New financing mechanisms that we’re going to have to understand and appreciate, and the ways that they are going to impact practice, whether it’s private practice or institutional practice. We know that the states are in the drivers’ seat, and most of what happens about health care reform is going to happen back home. We know that we can’t do it alone. Our advocacy depends on effective collaborations and effective partnerships. We have to be ready to claim our place at the table. We need to be involved at the ground level. You’ve got to get involved in coalitions. If we don’t participate, then we abdicate our responsibility there and we let other people – physicians, nurses, social workers, MFTs, whoever – define what our future is going to be as a profession. And that’s just not an option for us. If we’re not at the table, it’s because we’re on the menu…. When you get home and you turn your focus to health care reform, I want you to remember that other groups don’t automatically think about psychology and invite us to the table when they’re having these discussions. We have to identify health care reform initiatives that impact psychological practice and our patients and get involved in those in a proactive way. If you wait….” Aloha,
