From Experience We Gain Knowledge:
Reflections on Changes in Health Care
Pat DeLeon, PhD. Past President of APA
A Seasoned Perspective, Perhaps: One of the advantages of becoming “senior” is developing an appreciation for how long fundamental change actually takes. Today’s insights are often the musings of the past. In 2003, the Robert Wood Johnson Foundation (RWJ) published one of its anthologies, To Improve Health and Health Care. RWJ began operating as a national foundation in 1972 and by 2003 had grown into the nation’s fifth-largest foundation, with assets of $8 billion. Its mission is to improve the health and health care of all Americans. The then-retiring CEO reflected: “What drew me to medicine was a desire to do good, which came out of a family background steeped in humanism and social justice…. At the Foundation, we’re trying to improve access to care, create better-end-of-life care, reduce smoking, and the like. The results are hard to measure. Many factors contribute to the problems we are addressing…. One realization I’ve come to is that we tend to overemphasize strategy and underemphasize execution. A key component of execution is leadership…. I’ve come to rely less on academics as a stimulus for social change. It’s much more obvious to me that grassroots movements and the media and politics are very, very critical…. I think one of the unattractive aspects of our country is the relative lack of concern about the less fortunate…. I think we kid ourselves when we think there is one big lever. Social change is very hard work. The media – especially TV – has so much power, for better or worse….
“In the health area, we’re becoming more aware that many of the determinants of health lie outside the health care system. They depend upon personal behavior. Yet we have a nation that’s becoming more overweight and less physically active, and there’s growing evidence that physical activity may be as important in preventing illness and improving functioning as not smoking. Trying to change personal behavior, however, is very, very hard. We’re also beginning to understand that being connected to one another may have an important role in health.”
This Fall during our Uniformed Services University of the Health Sciences (USUHS) health policy seminar, LTG Patricia Horoho, the 43rd U.S. Army Surgeon General (and the first female and first non-physician SG in its history — which dates back to July, 1775) expressed a similar view as to the importance of focusing upon the behavioral and psychosocial elements of health care, including sleep, nutrition, and exercise. Both of these health policy visionaries noted the importance of being willing to take risks and of appreciating the social and political context within which one is operating. The clinicians of tomorrow must appreciate, and effectively respond to, the ever-changing health care environment of today and that of the future.
LTG. Horoho’ s Congressional testimony: “Long term success in Army Medicine lies in our ability to effectively impact the ‘Lifespace.’ It is in the Lifespace where the choices we make impact our lives and our health. We understand the patient healthcare encounter to be an average interaction of 20 minutes, approximately five times each year. Therefore, the average annual amount of time spent with each patient is 100 minutes; this represents a very small fraction of one’s life. It is in between the appointments – in the Lifespace – where health really happens and where we desire a different relationship with Soldiers, Families, and Retirees. We need to reach beyond the physical boundaries of our medical treatment facilities. In other words, we want to partner with those entrusted to our care during the other 525,500 minutes of the year where people are living their lives and making their health choices.”
During the seminar, she also addressed the critical issue of paying for preventive and behavioral health services. Under her leadership, the Army has established an accountability metric which focuses upon patient outcome determinations, such as one’s body mass index (BMI), and thereby allows the system to provide “credit” to the health care facility and provider for the broadly defined health services rendered. This is a highly innovative approach which could well serve as a model for other governmental entities, as well as the private sector, over the next several years. The bottom line, “The Times They Are A-Changin’” and as a nation we must be responsive to the most up-to-date knowledge learned and not remain blindly wedded to the past, no matter how comfortable that might seem.
Systemic Movement Towards Integrated Systems of Care: One of the far-reaching philosophical orientations embedded within President Obama’s Patient Protection and Affordable Care Act (ACA) is the development of systems of seamless care, rather than relying upon historic practitioner-oriented, fee-for-service care. The Patient-Centered Medical Home and the Accountable Care Organization provisions of the law (in neither of which is psychology expressly enumerated in either the statute or implementing regulations) are envisioned as vehicles for providing a wide range of broadly defined health services which are to be delivered by interdisciplinary teams of providers, emphasizing prevention and wellness care, while utilizing cutting-edge technology. The Commonwealth Fund (CWF) recently released a report noting that the percentage of federally qualified community health centers (FQHCs) exhibiting medium or high levels of medical home capacity almost doubled between 2009 and 2013, from 32% to 62%. The greatest improvement was reported in patient tracking and care management, although their ability to coordinate care with providers outside of their system, especially with specialists, had reportedly been diminished.
The Obama Administration estimates that since the enactment of the ACA on March 23, 2010, which heavily relies upon Medicaid as its reimbursement mechanism, approximately 16.4 million uninsured people have gained health coverage with over 12.3 million Americans having been added to the Medicaid and CHIP roles. As Katherine Nordal has consistently stressed during her exciting APA/APAPO annual state leadership conferences, Medicaid remains the single largest payer for mental health services. FQHCs provide comprehensive primary care, behavioral health services, and dental care to all patients regardless of their ability to pay or their health insurance status. Created during the Great Society Era of President Lyndon Johnson, they are located primarily in medically underserved areas and are regarded as a core component of the health delivery system for low-income and minority populations.
In 2012, 21 million patients, the majority of whom were either uninsured (36%) or publicly insured (49%), made 85.6 million visits to the nation’s nearly 1,200 FQHCs operating in 8,500 sites. For example, in Hawaii each of the islands has at least one FQHC; one even offers innovative prescribing psychologist services. In addition to clinical health services, the center staff provide patients with insurance eligibility and enrollment assistance, case management, language interpretation, and transportation services. They also provide access to the nonmedical services that many low-income people need, such as nutritious food and supportive housing. The CWF survey found that a greater percentage of centers that serve as medical homes provide whole-person care, including mental health and dental services, which can improve patients’ overall health status and their ability to take care of themselves.
CWF identified 12 core functions indicative of medical home capability across six domains: patient access and communication, patient tracking and registries, care management, test and referral tracking, quality improvement, and coordination with external providers. A health center was considered to have high medical home capability if it could perform at least nine of the 12 core functions, medium capability if it performed six to eight functions, and low capability if it performed fewer than six functions. Between 2009 and 2013, the percentage of centers exhibiting high medical home capability more than tripled. In 2013, most centers (62%) reported a medium or high level of medical home capacity, whereas in 2009 only 32% did.
Transforming a practice to a medical home can be an arduous and painful process, with the changes required being disorienting and demanding to staff. Nevertheless, CWF found that 47% of health centers that met the definition of high medical home capability reported improved or much improved provider and staff satisfaction over the past two years, compared with only 39% of those with medium capacity, and 27% of those with low capacity. Those with high medical home scores also reported improved or much-improved ability to recruit and retain physicians, nurses, and support staff. This suggests that while high staff turnover may be a barrier to effective transformation, it is not necessarily a symptom of the transformation process itself.
A Grand Vision: Two of the true pioneers of the psychopharmacology movement, Elaine LeVine and Elaine Foster, have recently joined together to address the challenge of Global Mental Health. According to the World Health Organization (WHO), half of all countries in the world have less than one psychiatrist per 100,000 people and a third of all countries have no mental health programs at all. While access and quality of care issues are extremely critical within the United States, they are even more striking in middle- and low-income countries. Our two colleagues have undertaken to provide expanded training for mental health providers worldwide utilizing the WHO concept of “task shifting.” Through expanded training for the health care workforce, the goal is to empower less specialized health workers, such as counselors and social workers, to better assist those in need.
In many countries, there are few medical practitioners or doctoral level psychologists available to provide care, and the populations they serve are so vast that they are often not able to provide day-by-day care services to their patients. Task shifting allows a mental health worker to make recommendations to a primary care provider regarding treatment options, based on augmented training in psychopharmacology, from a psychobiosocial perspective. The mission of their recently established nonprofit organization, RxP International, is to provide training in psychiatric medications as an adjunct to the many types of therapies that can be used in place of medicine. Helping midlevel practitioners gain the information and skills necessary is clearly a social justice concern with the focus being on teaching people to better help themselves.
Our colleagues have designed specific teaching modules that can be provided through distance learning and an open communication forum. These will target the most commonly diagnosed conditions such as anxiety, depression, and psychosis, along with special populations such as the elderly and children. Their online forum will be actively managed to assist student-providers in sharing their unique experiences and needs from their place in the world. These personal interactions will provide a better understanding of the mental health needs and interests around the globe. Their website can be accessed at www.rxpint.org for those who are interested in obtaining APA CE credit, by taking individual courses or pursuing a certificate.
Unique Perspectives: One of the most intriguing questions asked at our USUHS seminar was: Whether being the first nurse or the first female selected to serve as Surgeon General was more significant? From the perspective of a world-wide audience the answer was fascinating. “And if we get any knowledge, then we gain liberation” [George Harrison]. Aloha,
Pat DeLeon, former APA President – Division 29 – November, 2015