The Fall 2015 Register Report is an extraordinarily strong issue. In it, we present—as we do each autumn—Dean Steve Smith’s analysis of decisions of the last Supreme Court term that affect psychological practice and mental healthcare in general. As Dean Smith points out, this term was a particularly momentous one for American healthcare and American psychology. First, in King v. Burwell, the court emphatically dismissed challenges to the Affordable Care Act that were based on linguistic interpretations of the law. As you may remember, the short phrase in question pertained to the eligibility of “exchanges established by the state” for federal subsidies. The court ruled, in a 5-4 decision, that this applied equally to federally- and state-established exchanges. While some opponents argued that this was an egregious case of judicial overreach, the truth was far less sinister. As Dean Smith noted, “state” and “federal” were inaccurately used in an interchangeable fashion throughout the law, and the court found that the intent of the act was clear in spite of “sloppy” drafting.
The landmark Obergefell v. Hodges decision, establishing the right of same sex couples to wed, was an important civil rights decision, but also had some implications for providers regarding informed consent and insurance coverage for same sex partners. More importantly for psychology, however, was the decision in North Carolina State Board of Dental Examiners v. Federal Trade Commission. In this antitrust ruling, the Supreme Court held that certain actions of professional licensing boards could be construed as restraint of trade. Indeed, absent a “non-active-market participant” (i.e., someone not a member of the regulated profession) supervising the activity of the professional board, the Court held that such boards could be liable for restraint actions. This is an extremely interesting opinion for psychologists seeking to expand their scope of practice, and one we should watch very closely. The ruling has already begun to have a legal impact. Recently, a telehealth company sued the Texas State Board of Medical Examiners, which had established regulations limiting teleheath practice in that state. In response, the Texas Attorney General argued that since the state medical board is subject to judicial review, the “non-active market participant” requirement has been met. It will be interesting to see if this argument advances. Please refer to Dean Smith’s article for a complete analysis.
Also in this issue we have two of the leading educators and practitioners in integrated care: Dr. Bob McGrath and Dr. Neftali Serrano. Both Drs. McGrath and Serrano have provided us with introductions to integrated care that are as practical as they are scholarly. Dr. Serrano’s article examines different models for building integrated practices, and points out advances in clinical research that have, at long last, begun to allow us to demonstrate not only the utility but the cost-efficacy of integrated healthcare markets. As in the somewhat parallel data set concerning combined pharmacological and psychological interventions has also taught us, sometimes we have difficulty proving what we know works clinically, simply because we’re asking the wrong questions. If we use outmoded investigative rubrics to assess new practices, our answers will rarely be accurate. Dr. Serrano describes our current understanding of integrated care in light of recent investigations using up-to-date research strategies. On a side note, Dr. Serrano has recently taken a position with the Center of Excellence for Integration, a program of the North Carolina Foundation for Advanced Health Programs.
Also writing on integrated healthcare, Dr. Bob McGrath’s contribution focuses on how integrated care models can tear down existing “silos” that impede the delivery of behavioral healthcare in the primary care setting. Often these silos develop for economic reasons, such as the behavioral healthcare “carve-out” strategies employed by HMOs. But oftentimes these silos develop from our own inability to think broadly about how to best integrate care, an idea which is not new, but one we have not yet completely embraced as a field. Registrants will be pleased to learn that we will be working closely with Drs. McGrath and Serrano in putting together a 10 hour program in integrated health service delivery that will be offered to Registrants and other psychologists in either continuing education or a certificate program formats. Comprising taped lectures and associated background and reference material, we are targeting a Spring 2016 release date for this material.
Our colleague, Richard Ruth, a longtime professor at The George Washington University and an outstanding proponent of multicultural practice and research, has provided us with an excellent, clinically driven series of vignettes that explore intersections between multicultural principles and practice and how culturally-inflected attitudes can result in unintended consequences in supervision and practice. An excellent way to fulfill ethics CE requirements! In addition to his professorial duties, Dr. Ruth is core faculty in G.W.’s LGBT certificate program and is on faculty at the Washington School of Psychiatry.
Finally in this issue, Drs. Eklund, Embse, and Minke point out the extremely important role that doctoral-level school psychologists play in the delivery of mental healthcare services to the approximately 20% of American schoolchildren with mental health problems. As these authors note, an extremely large number—more than 16,000,000 American children—have become eligible for mental health services under the Affordable Care Act. Since many of these children make at least initial access into the mental health system via the schools, school psychologists are playing an increasingly important role in managing the growing gap between available mental health services and unmet demand.
I am also very pleased to note that Mr. Titus Hamlett, the graduate student who graced the cover of the Spring 2015 Register Report with its focus on increasing the presence of African American males in the profession, is now Lieutenant Titus Hamlett. LT Hamlett has been accepted in to the Navy’s competitive predoctoral internship training program in Bethesda, Maryland, and I had the pleasure of performing the commissioning ceremony for him earlier this summer.
You will note that the back cover of this month’s report is dedicated to an announcement for the Register’s recently established Internship Partnership Fund. The Register worked with the American Psychological Foundation to establish this fund, as we believe it is a part of the mission of the organization to assist in solving one of the most difficult problems in professional psychology training: the persistent and growing gap between the number of students seeking accredited internships and the availability of those internships. Although in the past several years, the gap has shrunk somewhat, the numbers that we often see are somewhat misleading in that they refer to students placed in all internships, not just APA- or CPA-accredited internships.
The internship “gap” is a problem entirely of our profession’s making. We simply have not paid sufficient attention to the clinical training needs of graduates of accredited psychology doctoral programs. Without sufficient numbers of licensed psychologists, the profession will never become a key player in the healthcare market. Additionally, the demand for psychological services continues to grow, and the profession, like other mental health professions, is not growing sufficiently rapidly to meet new demand. Most accountable care organizations cannot currently meet the demand for expanded mental health coverage under the Affordable Care Act, indeed, some estimate that less than 20% of accountable care organizations are adequately equipped to meet expanded mental health coverage requirements. If we do not fix the internship gap, our presence as a healthcare provider group will shrink and we will, in effect, have decided to withhold valuable psychological services from patients in need.
For example, in 2015, we were advised that the “gap” had shrunk to approximately 650 students. While this is excellent news, the sad reality is that more than 1,500 students are awaiting placement in accredited internship sites. As we all know, accreditation is increasingly important for predoctoral internships, as graduates of non-accredited sites cannot obtain highly desirable employment in the Veteran’s Administration and other large healthcare delivery systems. The American Psychological Association’s Board of Educational Affairs has made available seed money to unaccredited predoctoral internship sites; those funds are designed to assist such sites in seeking accreditation. This is a long and arduous process, however, and the Register believed that targeting already accredited sites and providing them with the ability to expand existing training slots would be an expeditious method for closing the “gap.” We are in our initial fundraising phases of this, and have attracted close to $200,000 in cash and short-term pledges. We have established a goal of $500,000 to be reached by the end of 2016. This is the minimum needed to provide meaningful distributions in a manner that can be sustained over time. We urge your contributions to this important endeavor. Each contribution is tax-deductible as a charitable donation to the maximum extent provided by law. We also can provide estate planning services for those individuals wishing to make advance bequests. Registrants who donate or pledge $10,000 (which can be distributed over 5 years) will receive lifetime recognition from the American Psychological Foundation, including priority seating at each APA convention’s opening ceremony, and other public recognition by both APA and the Register. If each Registrant contributed only $100, we would have well over $1,000,000 to sustain this fund. Thank you in advance for your contribution to this extremely important initiative.