Ronald H. Rozensky, PhD
This article is based on the opening presentation by the author to the Association of Psychologists in Academic Health Centers’ 5th National Conference, ‘‘Preparing Psychologists for a Rapidly Changing Healthcare Environment’’ held in March, 2011. Reviewing the patient protection and affordable care act (ACA), that presentation was designed to set the stage for several days of symposia and discussions anticipating upcoming changes to the healthcare system. This article reviews the ACA; general trends that have impacted healthcare reform; the implications of the Act for psychology’s workforce including the growing focus on interprofessional education, training, and practice, challenges to address in order to prepare for psychology’s future; and recommendations for advocating for psychology’s future as a healthcare profession.
Changes to the healthcare delivery system as detailed in the patient protection and affordable care act (ACA; Public Law No: 111–148, Mar 23, 2010) focus on efficient, effective, and affordable quality healthcare, a transparent and accountable healthcare system, prevention of chronic diseases, expansion of eligibility for publically supported health care programs, patient involvement in their own care, and the expansion of the healthcare workforce that is educated, trained, and prepared to practice in an interprofessionally focused, team-based delivery system.
Each of these adjustments, modifications, or transformations to the healthcare system certainly has implications for patients, their families and for those who provide services within a truly comprehensive, integrated healthcare system. Over the past 100 years, 10 US presidents, Theodore Roosevelt, Franklin Roosevelt, Harry Truman, Dwight Eisenhower, John Kennedy, Lyndon Johnson, Richard Nixon, Jimmy Carter, Bill Clinton, and Barack Obama, have advocated for some type of national healthcare system. Today’s ACA, and the upcoming implementing regulations and rules that will translate the act into day-to-day practice, might not provide all the discussed, debated, or wished for changes in our national healthcare system, but, as crafted and passed, the questions that ACA raises for the healthcare workforce can provide for psychology the opportunity to think about its own readiness for these changes.
By reviewing various societal and healthcare trends, this paper articulates questions that psychology must address regarding the implications of those trends, psychology’s training model, its readiness for enhanced interprofessionalism in healthcare, and how the profession is perceived by consumers and colleagues within the healthcare system, including decision-makers who establish mechanisms for reimbursement for healthcare services. Answers to those and other questions elaborated below can help psychology with preparing its strategic plan that will assure adequate education and training dollars, support for evidenced-based psychological services research, and reimbursement for service provision.
A trend is a pattern of change over time. Observing trends can help us describe possible scenarios - that is, interactions of trends - that can provide possible alternative views of the future and thus assist us in strategically thinking about those futures. Numerous trends, nationally and within psychology itself, relate directly to the advent of the ACA and to psychology’s challenges and opportunities within the evolving healthcare system. Space does not allow a detailed discussion of each of these trends as each could stand as a paper itself. Be that as it may, the following trends, in italics, are offered to help stimulate both discussion and strategic thinking about possible scenarios in healthcare that can lead to planning for psychology’s successful future.
The US population is changing. The population is aging, there are projected shifts in the demographic picture of the country, and the percentage of those with chronic diseases is increasing. The US Census Bureau states that ‘‘between 2010 and 2050, the US is projected to experience rapid growth in its older population’’ (Vincent & Velkoff, 2010; p. 1) with a doubling of the number of those over the age of 65 from 40.2 million in 2010 to 88.5 million by 2050. Further, ‘‘an increase in the proportion of the older population that is Hispanic and an increase in the proportion that is a race other than White’’ (p. 8) is projected. This is consistent with the 2010 census (US Census Bureau, 2011) that found that half of the growth in the US population between 2000 and 2010 was due to the increase in the Hispanic population which grew 43% resulting in 50.5 million in 2010. Additionally, 13% of the population was African American and 5% was Asian with a population growth itself of 43% in that same time period. Taking into account overall population growth rate and international migration, Ortman and Guarneri (2009) state that the ‘‘racial and ethnic diversity of the US population is shown to increase’’ well into the future with the percentage of White-only population decreasing. In her discussion of a diversity science, Plaut (2010) acknowledges the impact of this changing picture of the US population on healthcare disparities and access to care, amongst many political, cultural, and social issues. The challenge to truly recognize the impact of diversity presents professional psychologists the opportunity to build on psychology’s strong commitment to multiculturalism as a core competency (e.g. Rogers, 2009) and take a lead in assuring this as a focus in the new healthcare system—including the appropriate education and training of our students in preparation for these societal changes.
The American Psychological Association (APA) reaffirmed its commitment as a healthcare profession by adding health to its bylaws in 2001 (Rozensky, Johnson, Goodheart, & Hammond, 2004). Bodenheimer, Chen, and Bennett (2009) note that in 2005, 133 million Americans had at least one chronic medical condition and predicted this to increase to 157 million by 2020. Those with multiple chronic illnesses numbered 63 million in 2005 with a predicted 81 million in 2020. While aging accounts for some of this increase in chronic illness, behaviorally-related risk factors such as obesity and tobacco use are responsible for adding to this rate. Bodenheimer et al. (2009) raise concerns about increased healthcare costs due to these multiple chronic healthcare problems and wonder if ‘‘robust public health measures’’ (p. 66) could flatten the cost curve by addressing and preventing many behavioral health risk factors.
The ACA does provide a focus on issues of public health, health promotion, and disease prevention in its Title IV—Prevention of Chronic Disease and Improving Public Health. This section of the act discusses the proposal of evidenced-based approaches to health promotion and a national disease prevention model for the public health. Along with psychology’s traditions of efficacy, effectiveness, and community-based research and treatment, we also should prepare some of our next generation of psychologists to engage in population-based approaches to the scientific study and treatment of the human condition. As our healthcare system evolves, this range of data from the bedside and consulting room to the community and population (Rozensky, 2008) will position psychology to use its critical thinking and research skills to bring important changes to the delivery system and, of course, highlight psychology’s leading role in understanding health behaviors. The US Government’s Healthy People 2010 and 2020 (US Department of Health and Human Services (DHHS), 2000) has long had a focus on the importance of health behaviors in health promotion. More recently the DHHS’ Advisory Committee on Interdisciplinary Community Based Linkages (2011) focused its 10th annual report to the Secretary of DHHS and Congress on the importance of the education and training of the entire interprofessional healthcare workforce to adequately address health behavior change in order to enhance the quality and cost-effectiveness of the US healthcare system.
While much of the accountability in the ACA has to do with tracking clinical outcomes, issues of a financially accountable healthcare system, the possibility of enhanced pay for performance schemes (Rosenthal & Dudley, 2007), and containing healthcare costs are major foci as well. Volumes have been written on the subject of healthcare finances, some are recommended as informative and entertaining (Reid, 2009); others informative and plodding (not to be named). Either way, professional psychology must use its scientific acumen to collect and publish outcome data to illustrate that psychological services within the evolving healthcare system are cost effective and produce cost-savings for the healthcare system and have effect sizes (e.g. Ferguson, 2009) that equal or surpass medical procedures where little question is raised about whether those treatments will be reimbursed. These data should include services for traditional mental health care, services to those with medical illnesses, and for disease prevention and health promotion.
Orszag and Emanuel (2010) describe how the ACA is projected to lower healthcare expenditures by 0.5% (as part of the gross domestic product) and reduce the federal deficit by more than $100 billion over its first decade and then $1 trillion between 2020 and 2030. They go on to say that this decrement in costs will result from ‘‘dynamic and flexible structures (italics added) that can develop and institute policies that respond in real time to changes in the system in order to improve quality and restrain unnecessary cost growth’’ (p. 601). This includes savings generated by more efficient information sharing via electronic health records, one of the impacts of the digital age, and through ‘‘greater integration’’ (p. 602) of care across the system (hospitals and outpatient services) and amongst providers (interprofessionalism).
The digital age and growth in technology is reflected in Shachak and Jadad’s (2010) discussion of the passage of the American reinvestment and recovery act and how it has infused more than one billion dollars into the US economy to stimulate the ‘‘meaningful use” (p. 452) of electronic health records.They state that along with costs savings, the adoption of an integrated, electronic healthcare record keeping system, at the local and national level, can contribute to health promotion and quality care while enhancing patient centered care. They warn, however, that ‘‘excessive preoccupation with privacy may interfere with quality service’’ (p. 453) that can be enhanced with efficient electronic information sharing. Sittig and Classen (2010) recommend systematic monitoring to assure that rapid adoption of electronic record systems is done safely. Richards (2009) attempts to strike a balance between professional psychology’s focus on its ethical responsibilities for maintaining patient confidentiality, the requirements of the health insurance portability and accountability act regarding the sharing of patients’ personal health information (HIPAA, 1996), and the possible complications for psychologists working within an integrated, interprofessional healthcare work environment with medically ill patients versus those seeking only psychological care. Richards recommends discussion of information sharing, especially regarding electronic healthcare records, when discussing with patients the limits of confidentiality. As the ACA calls for enhanced interprofessional practice, psychology is well advised to clearly provide guidance for itself, per Shackak and Jadad’s concerns about not limiting information exchange, so that psychological services can be truly integrated into the expanding interprofessional healthcare milieu.
Possibly the most far reaching functional change to healthcare is the ACA’s focus oninterprofessionalism. Wilson, Rozensky and Weiss (2010) describe the history and current development of Federal policy recommendations supporting ‘‘the integration of interprofessional education (IPE) into health professions education as a means of assuring a more collaborative health care workforce’’ (p. 210). Interprofessionality has been a response to ongoing fragmented healthcare practices (multidisciplinary care) and ‘‘is defined as the development of a cohesive practice between professionals from different disciplines. It is the process by which professionals reflect on and develop ways of practicing that provides integrated and cohesive answers to the needs of the client/family/population’’ (D’Amout & Oandasan 2005, p. 9). Schuetz, Mann, and Evertt (2010) describe the education of health professionals collaboratively for team-based primary care and how such team-oriented, coordinated care, provides better clinical and financial performance while reducing clinician workload. This approach is based on four shared competency domains; values and ethics, roles and responsibilities for collaborative practice, interprofessional communication, and team work and team-based care. These are applied across disciplines and practiced within an integrated, team-based healthcare system with the full range of healthcare professions committed to developing these interprofessional competencies (Interprofessional Education Collaborative, 2011; Interprofessional Education Collaborative Expert Panel, 2011).
The ACA recognizes the importance of this interprofessional care and its impact on quality and cost savings in Section 3502, Establishing Community Health Teams to Support the Patient-Centered Medical Home. Here the act describes the funding of grants or contracts for communitybased interprofessional teams of healthcare providers supporting primary care. Those teams may include behavioral and mental health providers (including psychologists). Further, in Section 935, the act recognizes provision of interprofessional, integrated disease prevention and health promotion services and provision of interprofessional treatment of chronic diseases. Section 747, Primary Care Training and Enhancement, discusses clinical teaching settings and interprofessional models of health care including integration of physical and mental health services.
The act is focused on affordable care but it truly focuses on accountability to assure affordability. It describes the advent of structural changes to the system with accountable care organizations (ACO) and patient centered healthcare (medical) homes (PCMH) built on the foundation of interprofessionalism. Rittenhouse, Shortell, and Fisher, (2009) see the ACO concept as aligning financial incentives and accountability across the care continuum while the PCMH emphasizes strong primary care services as the key to delivery system reforms. For these authors, successful ACOs require a strong primary care base while the successful PCMH must have a comprehensive delivery system beyond its primary care core. Fisher, Staiger, Bynum, and Gottlieb, (2007) recommend that ACOs utilize an extended hospital medical staff model, in concert with hospitals themselves as the hub of the wheel, to assure continuity of care designed to accomplish the mandates of the ACO concept—includingperformance measures that hold the healthcare professionals (professional staff) and hospitals accountable for quality, cost effective care. Hospital based ACOs, most likely, will require enhanced accountability including explicit credentialing of providers; credentialing that will require graduation from accredited education programs and with an increasing expectation of specialty board certification - routine expectations of hospital based healthcare providers. These system-based expectations should stimulate professional psychology to review its training models, commitment to universal accreditation of its training programs, and taking a hard look at the importance of both the general practice and specialized practice of psychology.
The PCMH is seen as a major improvement to primary care delivery given its focus on access, coordination and comprehensive/integrated care, and the sustained (long term) personal relationship between patient and provider(s) with patients actively engaged in a healthcare partnership (Nutting et al., 2011). The Carter Center, (2011) provided recommendations regarding the education and training of the healthcare workforce to ensure the successful future of primary care. These recommendations include encouraging health profession education programs to (1) include education about the demographic, socioeconomic, financial, quality, political and cultural issues affecting healthcare services, (2) educate students about development of high-functioning teams in primary care, and (3) educate providers about the incidence and prevalence of behavioral conditions in primary care settings. The Carter Center also recommends that the healthcare system (4) redirect resources to establish appropriate training settings and curricula to prepare the primary care, interprofessional workforce and (5) develop a research agenda to inform changes to curricula, methods, and processes of healthcare education including measurement of outcomes.
As the Institute of Medicine, (2001) recommends in its classic Crossing the Quality Chasm, successful healthcare outcomes can be best accomplished by the practice of evidenced-based healthcare.Psychology has embraced evidence-based practice (EBP) with its own conclusion that EBP ‘‘is the integration of the best available research with clinical experience in the context of patient characteristics, culture, and preferences’’ that assures effective psychological practice and enhances public health (APA Presidential Task Force on Evidence-Based Practice, 2006; p. 280). While evidence-based psychological treatment outcome research provides robust data to support inclusion of such services within the evolving, integrated, interprofessional health care system, clinical outcomes that arecost effective and actually can contribute to cost savings in this accountable system will be expected and beneficial to the field. Thus, continued collection of medical cost offset research data that supports psychological services (Chiles, Lambert, & Hatch, 1999; Tovian, 2004) should be (1) built into routine program evaluation, (2) be a core skill taught to the next generation of healthcare psychologists, and (3) routinely reported in the literature, so that advocates for psychology can use that information in discussions with policy makers.
Key to psychology’s successful future will be the continued preparation of the next generation of psychologists using competency-based education and an appreciation of the issues of developing apsychology workforce that will be responsive to evolving healthcare demands of the country. Roberts, Borden, Christiansen, and Lopez, (2005) have focused on the trend towards developing a culture of competency in professional psychology while other authors have highlighted the need for the use of consistent, agreed upon and measureable competencies in psychology (Fouad et al., 2009). Measurability will be increasingly important in the accountable care system that will include a healthcare workforce with shared, interprofessional competencies (D’Amout & Oandasan, 2005).
The last trend to consider then is the actual supply and demand for psychologists who are prepared to work within the evolving, accountable healthcare system. We must have an accurate accounting of the current psychology workforce and an understanding of its readiness for the upcoming changes to the healthcare system. We must have a clear picture of the future demands for psychological services so the field can prepare the accurate number of psychologists needed with the requisite special(ist) skills required by healthcare reform. Some authors (e.g. Stedman, Schoenfeld, Caroll & Allen, 2007) offer suggestions for limiting a possible oversupply of psychologists while others (Rozensky, Grus, Belar, Nelson, & Kohout, 2007) advocate for a systematic workforce analysis to provide a data-based approach to plan for the future of education and training programs in psychology. The American Psychological Association’s (APA, 2009) Center for Workforce Studies (CWS) survey reported that the majority (54.5%) of psychologists work in a wide range of institutional work environments as their primary place of employment while 45.5% indicated their work setting was private practice. It remains to be known if this is the appropriate number of psychologists and if they are working in the correct healthcare venues in anticipation of the evolving healthcare system demands.
Challenges for Psychology to Address to Prepare for the Future
As we address the upcoming transformation of the healthcare system, including the range of social, scientific, and economic trends that have led to recommended changes to services delivery and organizational structures, we must consider healthcare reimbursement mechanisms, the call for robust interprofessional competencies, and the growing expectations for accountability and quality assurance. Psychology has many questions to answer (Rozensky, 2011) as it prepares its strategic plan for the future. These questions can serve as a catalyst for discussion for the profession in general, and for each individual psychologist, to help assess readiness for the next epoch of healthcare in the US:
- Does the current distribution of workplace settings of psychologists meet the service needs of the US population?
- How many psychologists (supply) will be required to meet needs (demands)? The US Bureau of Labor (BLS) Statistics suggests there will be a 7–13% growth rate of the number of psychologists between 2008 and 2018? Is that accurate? If policy makers use that BLS data, is that helpful to psychology when advocating for education and training funding, research dollars, or service reimbursement?
- For which practice specialties and for which settings should we prepare new psychologists? How do we assure that the clinical competencies psychologists bring to the evolving healthcare system are appreciated, reimbursed, and open for expansion now and in the future?
- How is the clinical practice of psychology seen by our professional colleagues who work throughout the health services sector? How do government policy makers and government and private sources that fund education and reimbursement for services see the need for psychologists in the evolving interprofessional care system? What data do we need to communicate to the public about who we are, what we do, and the effectiveness of our services?
- Over the next 5 or 10 years, what will be the psychological service demands of the US given the changes to the health care system based upon the ACA? How is each individual psychologist prepared for the second decade of the 21st Century and beyond?
- How will the newly instituted ACA impact the future of psychology’s role in healthcare? How can psychology educate the policy and rule makers—who will turn the Act into rules (actions)—about the strong contributions psychology makes within the overall healthcare system and to the quality of life of the general population?
- As described in the ACA, will the PCMH and the advent of the ACO become the new institutionalbased healthcare practice settings of the future? How might that impact the existing institutional practice of psychology and those in independent practices? What do we need to do to prepare for these systemized, structural changes to healthcare organizations?
- What will be the psychological and behavioral health services needed within those evolving organizations and how will those services be reimbursed?
- To what extent will the independent practice of psychology be assimilated into these new institutional structures because of continuity of care regulations or in response to changes in reimbursement rules and mechanisms?
- Are we preparing the next generation of psychologists to work in these venues where services will be provided? Is the current psychology workforce prepared to practice within these new institutional structures?
- How should we integrate interprofessional and team-based competencies into our education, training, and practice for psychology and other health professions?
- Do we have the professional development and continuing education opportunities in place to assure a competent workforce of psychologists (both current and future) to meet these changes?
- For those already in academic healthcare settings or other organized healthcare settings, what must be done to assure psychology’s administrative autonomy (Rozensky, 2004) while simultaneously taking an increasingly strong leadership role in interprofessional, team-based healthcare?
- Do we have a robust workforce research mechanism within professional psychology that can accurately scan, assess, categorize, predict, and strategically plan for the required psychology workforce of the future so that we actually can answer these questions?
The recent enactment of the ACA, with its implications for each of the healthcare professions, provides an opportunity for the field of psychology to highlight its strengths to the public and policy makers. In this way, psychology can take proactive action to assure that the patient care system includes the best of psychological care integrated within the interprofessional, team-based services of tomorrow.
Healthcare reform also challenges each of the healthcare professions to ask questions about themselves to assure that each is prepared to meet the challenges of accountability, competence, and quality. Psychology should take this opportunity to review itself and provide answers to those questions and take action then to assure its readiness to respond to the Rapidly Changing Healthcare Environment— the focus of the Association of Psychologist in Academic Health Center’s 2011 conference.
Ronald H. Rozensky, Ph.D., ABPP, is Professor in the Department of Clinical and Health Psychology at the University of Florida. He is past chair of the US Department of Health & Human Services’ Advisory Committee on Interdisciplinary, Community-Based Linkages and participated in making recommendations to Congress on healthcare reform and topics that included interprofessional education & training and the importance of addressing health behaviors in integrated health care. Dr. Rozensky is the founding editor of the Journal of Clinical Psychology in Medical Settings.
About This Article
The Association of Psychologists in Academic Health Centers (APAHC) convened its 5th national conference in Boston on March 3 - 5 2011. The conference and its theme, ‘‘Preparing Psychologists for a Rapidly Changing Health Care Environment,’’ focused on how psychology can adapt to and help lead health care efforts in the face of health care reform. A series of papers based on presentations offered at the conference were compiled as part of a special March 2012 issue of the Journal of Clinical Psychology in Medical Settings. This paper authored by Ron Rozensky is one of many papers in this special issue.
Other topics covered in the March 2012 JCPMS include specialization in psychology and its relevance in the context of health care reform, disparities in health care, challenges and opportunities for psychologists in integrating their services into different medical specialties, and state of the art information about the assessment and treatment of pain and sleep disorders. To access these additional articles go to www.springerlink.com/content/1068-9583/19/1.
The 6th national APAHC conference, ‘‘Applying the Science of Psychology in Academic Health Centers: Implications for Practice, Teaching, Research and Policy’’ will be held in Nashville, January 31 - February 2013. For more information on the next APAHC conference go to www.div12.org/section8/events.html
This article was originally published in the Journal of Clinical Psychology in Medical Settings (2012) 19:5-11 and is reprinted with permission. CPMS is the official journal of the Association of Psychologists in Academic Health Centers (APAHC).
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