How Social Policy Impacts Private Practice
Social policy is a tool in a behavioral health practitioner’s cache. Social policy shapes all aspects of care through legislation, regulation, payment, delivery systems, and interdisciplinary collaboration. Behavioral health providers of all backgrounds need to be aware of and shape policy because they are subject to the boundaries imposed by those policies. Concurrent with mental health–specific policy is the concept of parity, which refers to comparability between behavioral health policy components and those of physical health providers. By examining each of the aspects of policy along with the implications of parity, behavioral health providers can examine current forces shaping their practice (who they can see; when, where, and how they can see their clients; and what the mechanisms for payment are) and work for changes to improve practice in the future.
One resource for quality practice is social policy, which has been described as a legislated or organizational formalized structure to ensure goals that benefit society (Midgley & Livermore, 2009). This structure can involve communication, services, infrastructure, and resource allocation. In developed nations, these policies are often codified through legislation and regulation at local, regional, and federal levels.
Practitioners should care about and participate in the formulation of social policy because that policy will ultimately determine the opportunity, scope, and fiscal viability of their practice. Social policy can act as a promoter, inhibitor, or neutral influencer of practice. Policy is derived from perceived needs at either a grassroots or population level. In the United States, social policy regarding healthcare includes several facets: legislation (historical and contemporary), regulations, payers, (p. 620) delivery systems, and interdisciplinary collaboration. While not an exhaustive list, these particular facets are critical to informing clinical practice. We will discuss and give examples of each of these facets.
Many practitioners are simply unaware of the evolutionary legislative history of their current practice, although they spend many years learning their specialty’s specific skills and theoretical rationales. Previous generations of non-physician providers have endured at times titanic political struggles to expand professional “scopes of practice” and to obtain insurance reimbursement for clinical services. Within the mental health professions, it is surprisingly rare for training institutions to provide the social/political context for clinical practice in which their graduates will function for the rest of their careers. The societal good of quality psychological and behavioral health care—not to mention preventive care—has clearly not been a sufficient reason to expect that they will be covered by third-party payers. This is true even if considerable objective evidence exists that in the long term these interventions will be highly cost-effective and meaningful. Only within the relatively recent past have mental health providers begun to consider themselves as “healthcare” professionals. Also, only within the same contemporary timeframe have there been serious discussions by national health policy experts regarding the appropriateness of integrating mental health care into organized systems of care, particularly on an interdisciplinary basis.
Of particular historical interest, Adelphi University and its postdoctoral program in psychotherapy were actually sued, in the early 1950s, by the Nassau County Neuropsychiatric Society for allegedly practicing medicine and founding an institution for medical training without licensure solely because the program was teaching psychologists to do psychotherapy. In 1977, future American Psychological Association (APA) President Robert Resnick became one of the leading psychologists in the landmark “Virginia Blues” case, in which the U.S. Supreme Court ultimately upheld psychology’s autonomous status and further ruled that psychology and psychiatry were indeed competitors. In 1977, Missouri became the 50th state in the nation, along with the District of Columbia, to credential and regulate the practice of psychology. It was also during that era that many health providers, including psychologists, nurses, and mental health counselors, began their systematic quest to become legislatively recognized as autonomous providers under a wide range of federal reimbursement programs, including the Department of Defense CHAMPUS program, the Federal Employees’ Health Benefit Program, Medicare, and Medicaid, as well as to be authorized to serve as expert witnesses before the federal judiciary. For all of these disciplines, it has been a long and arduous journey that continues today, in the face of constant opposition from organized medicine. Advances in access to care can be made by working to the full extent of one’s training and building on the successes of other professions. For psychology, perhaps the next frontier will be obtaining prescriptive authority similar to that already possessed by nursing in all jurisdictions, under varying conditions.
During the tenures of Presidents George W. Bush and Barack Obama one of the most significant societal changes impacting our nation’s healthcare system has been the unprecedented (p. 621) advances occurring in the communications and technology fields, and particularly their increasing use by the federal government (especially by the Departments of Veterans Affairs and Defense). In highlighting the successes of Veterans Affairs, President Bush opined on April 27, 2004, that
[t]he way I like to kind of try to describe health care is, on the research side, we’re the best. We’re coming up with more innovative ways to save lives and to treat patients. Except when you think about the provider’s side, we’re kind of still in the buggy era… . And the health care industry is missing an opportunity… . It’s like IT, information technology, hasn’t shown up in health care yet. But it has in one place, in one department … and that’s the Veterans Department… . By introducing information technology, health care will be better, the cost will go down, the quality will go up, and there’s no telling whether other benefits will inure to our society.
In response to the changing healthcare environment, the various healthcare professions have recently begun to seriously explore under what conditions they would recommend modifying their current licensure act to meet contemporary society’s needs and resources. At the APA’s 2015 annual convention in Toronto, the Council of Representatives voted to endorse, in principle, the Association of State and Provincial Psychology Boards (ASPPB) Psychology Interjurisdictional Compact (PSYPACT), which was developed by the Joint Task Force for the Development of Telepsychology Guidelines, comprising representatives from the APA, ASPPB, and the APA Insurance Trust to facilitate telehealth and temporary face-to-face practice of psychology across jurisdictional boundaries.
Steve DeMers, ASPPB’s chief executive officer, and Martha Storie, ASPPB’s president, envision that the PSYPACT will promote further cooperation and standardization of requirements among psychology licensing boards and consequently will serve to protect consumers of psychological services. An interstate compact is an agreement between states to enact legislation and enter into a contract for a specific, limited purpose or to address a particular policy issue. They are unique in their duality as statute and contract. ASPPB will be working with the Council of State Governments to create a resource kit to serve as an informational document in support of this development. The compact will standardize practices that are currently jurisdiction-specific, such as how many days of face-to-face practice are permitted in a state where the psychologist does not hold a license, and credentialing and authorization to practice telepsychology from an identified “home” state with a client in a state that has joined the compact. The PSYPACT would need to be adopted by state legislatures; the compact would establish further rules and regulations regarding interjurisdictional practice. The American Mental Health Counselors Association has advocated for similar standardization and clarification of licensure, training, and payer recognition of mental health counselors in all 50 states (Colangelo, 2009).
Policy advances at the federal level are often followed by the private sector, and an increasing number of state legislatures have recently begun requiring insurance companies to pay for telehealth (i.e., telepsychology) services. In 2015, more than 200 telehealth bills were introduced in state legislatures. As of 2016, 29 states and the District of Columbia had enacted parity laws that require insurers to reimburse telehealth providers exactly as they would for an in-person visit. (p. 622) Historically, it has been the responsibility of the various states to determine the conditions under which healthcare providers may practice (including what their educational requirements will be and which services can be provided) within their geographic boundaries. This has, not surprisingly, resulted in a variety of restrictions on non-physician providers (for political reasons), notwithstanding the lack of any supporting objective evidence. Accordingly, with the advent of increasingly sophisticated technology and the excellent quality of care being demonstrated in the federal system, societal pressure has been steadily building to make legislative adjustments that would allow the expansion of necessary clinical expertise across historical geographic boundaries. Interestingly, back in 1998, the Pew Health Professions Commission had raised the underlying issue of whether the nation was ready to enact national health professions licensure laws (O’Neil, 1998).
The compact approach in psychology is developing and is conceptually very similar to that being proposed by professional nursing (adopted by 25 states) and organized medicine (currently 11 states, with more expected over the next year); physical therapy and emergency medical technicians are also exploring this approach. ASPPB had received a grant from the Health Resources and Services Administration (HRSA) to facilitate its efforts to address licensure mobility, with telepsychology representing one aspect of this larger vision. Change always takes considerable time, and as the various health professions experiment with their implementation and political details, modifications will undoubtedly evolve.
Practice regulation is statutorily defined by state legislatures with oversight provided by practice boards. Practice boards determine scope of practice, specific rules and regulations, and licensure requirements, so the membership of these boards is critical. The agendas of the individuals or organizations represented on these boards can have far-reaching impact on clinical practice. As mentioned earlier, compact agreements are working to create consistency, reciprocity, and geographic parity of scope and quality of care. However, while such reciprocity is defined nationally, it is interpreted locally. One example within social work is that the number of internship/supervised hours needed for licensure varies state by state, and those hours are not necessarily recognized or transferable by or between states. In another example, Maryland is a compact state for nursing. This means that Maryland recognizes registered nurse (RN) licensure from other compact states. However, an RN who moves to Maryland from a compact state and wishes to practice in Maryland will need to obtain Maryland licensure as an RN and not simply renew his or her RN license from the compact state. Knowing who controls the legislative process that sets criteria for and scope of practice is critical, as well as who has routine oversight and regulation of the legislated practice.
Along similar lines, mental health professionals of all backgrounds are subject to regulatory control at the state level (Colangelo, 2009). Additionally, organizations like the National Association of State Mental Health Program Directors (2014) seek parity of recognition, oversight, and payment between mental health and other health providers.
(p. 623) As parity of payment and access are critical subjects for groups lobbying on behalf of mental health providers, it is logical to view other non-physician provider groups’ reports and advocacy as a societal and policy “canary in the coalmine” to indicate policy trends. For example, the importance of identifying and monitoring regulation of practice can be seen through Federal Trade Commission’s report on competition and regulation (Gillman & Koslov, 2014). This report (the focus was on advanced practice registered nurses, but the statement has implications for behavioral health providers) states that regulation of scope of practice should be set to provide healthcare consumers with the best and safest care. However, regulations that limit or set up barriers to practice that are not based in evidence can create harm and potential healthcare disparities for the very people the legislation is intended to protect. One provider group’s fears and agenda are not evidence sufficient to limit the practice parameters of another group. The Federal Trade Commission approaches regulation of practice from a marketplace perspective wherein a larger spectrum of qualified providers creates a competitive arena in which patients and communities benefit from choice. Regulation is then a point within social policy where the regional need for healthcare services, legislated scope, and credentialing and broader national forces meet to create practice.
Another facet of social policy involves those who pay for healthcare resources. President Obama’s landmark Patient Protection and Affordable Care Act (ACA) envisions the development of unified systems of coordinated care (e.g., accountable care organizations and patient-centered medical homes) that would provide comprehensive care, including mental health care, for all their enrollees. Those administering the implementation of ACA envision an era of hospitals and other larger health organizations “buying up” smaller private practices to create accountable care organizations. For some, this will be reminiscent of the health maintenance organizations of President Richard Nixon’s era and the managed care focus of President Bill Clinton’s administration. Capitalizing on the advances in communications technology, electronic health records would ensure that clinicians have ready access to all aspects of their patients’ health records. Mental health services would be fully integrated into primary care and would no longer be viewed as a “standalone specialty.” Further, the ACA provides significant resources for interdisciplinary training efforts, with additional financial support for research targeting modifications in the federal reimbursement system (i.e., Medicaid and Medicaid) that will be necessary to provide coverage for this care, including faculty supervision of trainees. Historically, Medicaid has been the single largest payer for mental health services. The ACA has also created stipulations for the need for adequate coverage; specifics are determined by the states and the various managed care plans.
Those with a broader public health perspective can appreciate that the ACA’s emphasis upon interdisciplinary (or interprofessional) collaboration was not developed in a policy vacuum but instead is based on changing societal dynamics and considerable thoughtful deliberation among national health policy experts, such as those within the Institute of Medicine (recently renamed (p. 624) the National Academy of Medicine). In 2015, the Institute of Medicine released its report on interprofessional education, noting that
[i]nnovators at that time  stressed the importance of “patient-centered care,” while today they think of patients as partners in health promotion and health care delivery. Patients are integral members of the health care team, not solely patients to be treated, and the team is recognized as comprising a variety of health professionals. This changed thinking is the culmination of many social, economic, and technological factors that are transforming the world and forcing the fields of both health care and education to rethink long-established organizational models. (p. xv)
Widespread adoption of a model of inter-professional education across the learning continuum is urgently needed. An ideal model would retain the tenets of professional identity formation while providing robust opportunities for inter-professional education and collaborative care. Such a model also would differentiate between learning outcomes per se and the individual, population, and system outcomes that provide the ultimate rationale for ongoing investment in health professions education (Institute of Medicine, 2015, pp. xv–xvi)
To a very real extent, this evolution toward direct involvement by patients in shaping their own individual healthcare undoubtedly reflects the increasing educational level of the nation’s population (i.e., “educated consumers”).
That need for interprofessional preparation and the expectation that mental health will be an integral part of the care team raises again the need for parity in patient access as well as reimbursement. Mental health agencies and programs can draw from the experiences of clinical pharmacy, which has been in the forefront of this movement. The efforts of the School of Pharmacy at North Dakota State University are a prime example:
With more than 80 telepharmacy sites in the state, it is one of the largest (if not the largest) telepharmacy networks in the U.S., if not the world. Thirty-six of North Dakota’s 53 counties are designated by Health and Human Services as “frontier counties” which is defined as less than six people per square mile. So we are very rural and have a very large geographic area that is considered “medically underserved” with many people having problems accessing even basic health care. Telepharmacy has worked very well for us. It has established or restored access to pharmacists and pharmacy services in areas of the state that had no services or had lost their services. The North Dakota Board of Pharmacy established rules for telepharmacy practice that are now the standard of practice in delivering pharmacy services to remote rural communities. Our research has demonstrated that the quality of services being delivered through telepharmacy vs traditional pharmacy services is the same including medication error rates. All telepharmacy sites are receiving standard reimbursement for pharmacy services from third party payers and federal programs and all sites are still up (p. 625) and operational, not one has been lost, so our model has demonstrated that it is economically viable and sustainable. Telepharmacy has increased the profit margins of pharmacists practicing in rural locations thus keeping our rural pharmacy businesses strong. We have developed our telepharmacy services in both community and hospital settings. We have developed a mobile wireless telepharmacy unit (R2D2 robot) for critical access hospitals that can provide 24-hour access to a pharmacist to any location in the hospital (emergency room, nursing station, patient bedside, pharmacy). (Dean Charles Peterson, personal communication, November 2015)
Mental health clinicians of all disciplines, particularly those in rural America, will soon be faced with the challenge of being responsive to the changing expectations (i.e., demands) of increasingly educated consumers/patients who have experienced the willingness on the part of other healthcare providers to be responsive to their individual circumstances. Effective clinicians of the 21st century will have to be demonstrably aware of the evolving practice patterns of the entire healthcare system, not just their own professional specialty.
Attempts to meet growing consumer, economic, and political demands for healthcare must include building more efficient combinations of healthcare providers and healthcare delivery models. For example, access to basic healthcare for most underserved and vulnerable groups falls under the HRSA, an agency of the U.S. Department of Health and Human Services. The ACA endorses key expansion of components of the HRSA-supported safety-net clinics for these underserved groups. The Health Center Program, the National Health Service Corps, and other forms of health workforce programs are key components of how the ACA is shaping delivery models to meet increasing demands on an already burgeoning healthcare system. These changes are significant, as the introduction of the ACA potentially adds about 3 million newly insured patients representing impoverished populations, underserved minorities, residents of rural areas, and populations with language barriers (HRSA, 2015). While these changes will bring about an increased demand for primary care providers and delivery systems, there is estimated to be a shortage of primary care physicians of over 7,550 by 2025 (Auerbach et al., 2013). This lack of access to primary care is also associated with over 9 million costly non-urgent visits to emergency departments in the United States every year (Auerbach et al., 2013).
The implications for mental health providers are just as startling. ACA mandates adequacy of care, and Massachusetts Commonwealth Care is an example of how this is interpreted by states (Miller, Gordon, & Blover, 2014). Adequacy of behavioral health care consists of a choice of at least two providers who are within 60 minutes or 60 miles, among other provisions. These provisions do not create additional providers but do fund access, leading to a need to find new models to do more with less.
Healthcare policy change through the ACA has kick-started innovative changes to healthcare delivery models and opened windows for alternate provider types such as nurse practitioners and (p. 626) physician assistants. This is a particularly salient point for mental health providers as it signals an expansion of the healthcare team beyond a physician-driven and fee-for-service model. A major concern influencing some change has been the overreliance on costlier, less efficient specialty care services to the detriment of primary care delivery models (Naylor, 2006). Nurse practitioners, practicing independently or with physicians in primary care, are uniquely prepared to offer alternate healthcare delivery models, especially in community settings less favored by traditional medical practices (U.S. Government and Accountability Office, 2008). Use of these diverse provider mixes and alternate models of healthcare delivery has the potential to improve access to primary care, decrease costs, and change healthcare patterns in the United States (U.S. Government and Accountability Office, 2008).
Capitalizing on the availability of a diversity of potential healthcare delivery models, the ACA explicitly included nurse practitioners as providers in multiple sections. These changes implemented by the ACA have great potential to influence the delivery of healthcare, especially in underserved areas. These ACA programs specific to nurse practitioners include a test program for a payment incentive and service delivery model that uses physician- and nurse practitioner-directed home-based primary care (Section 1866D), a 10% Medicare bonus payment for primary care providers in underserved locations (Section 5501), and funds to support nurse-managed clinics (Section 5208). Mental health providers would do well to monitor these non-physician–driven models as the models will be able to provide a basis for parity and a practice template.
As defined by the ACA, a nurse-managed health clinic is “a nurse practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center, or independent health or social services agency” (42 U.S.C. § 330A–1, 2010). These nurse-managed clinics, also referred to as nurse-managed health centers, provide primary care, management of chronic diseases, family and reproductive health, disease prevention, and health promotion to vulnerable populations in multiple venues in underserved areas. These clinics also contain multidisciplinary members such as psychologists, community outreach workers, consulting physicians, and researchers and also are linked with local universities to fill an additional role in training future health professionals.
The National Nursing Centers Consortium is a nonprofit organization that supports over 250 successful nurse-managed health centers. Over 2.5 million patients from vulnerable urban and rural neighborhoods are served by these centers. Services are based on community needs and are accessed through close cooperation with community members and outreach workers.
Another alternative model of delivering primary healthcare is a walk-in clinic run by nurses. These clinics, which have been implemented in some areas, can decrease costs for patients and healthcare systems while expanding access to quality care. These clinics also reduce the burden placed on emergency departments in terms of both volume and patient safety. A study in California found that emergency department crowding was associated with significant increases in mortality, length of stay, and cost, supporting the need to divert these non-urgent visits to a more appropriate level of care (Sun et al., 2013). From an economic perspective, a nurse-run walk-in clinic in Rhode Island treated non-urgent medical issues with an average return on investment of over $2 for every $1 spent. When preventive services were included in the equation, the (p. 627) return increased to $34 for every $1 invested, as compared to using emergency departments for these non-urgent services (Bicki et al., 2013).
As the ACA is implemented, millions of patients will enter the healthcare system, increasing the demand on already stressed delivery models. Evolving healthcare delivery models must provide vital, expeditious, and cost-effective care while addressing the shortage of primary care physicians. Healthcare centers recognize the need to provide comprehensive care tailored to unique patient population needs and the need to decrease expensive and inappropriate levels of care. Healthcare systems with the appropriate mixture of providers and the utilization of alternate delivery models, such as nurse-run clinics, offer a mechanism for reducing burdens on healthcare resources while meeting patient care needs.
All Western healthcare fields are exhibiting shifts toward complexity and systems interconnectedness. The past 30 years have seen the rise of the field of psychoneuroimmunology, advances in therapies for psychiatric trauma, and a veritable explosion of psychotropic medications. With the variety of these clinical tools comes a variety of clinicians with expertise to wield them and a marketplace and legislative dictate to use them comprehensively. Just as ACA is expanding and redefining care delivery systems, it is also giving providers the opportunities to redefine clinical practice. That redefinition begins with training.
As a result of the visionary efforts of Don Peterson and Nick Cummings, psychology’s professional school movement began in the late 1960s. By 2016, there were 379 APA-accredited graduate programs (clinical, counseling, school, and combined), more than 70 of which would be considered professional programs (most granting the PsyD degree). These programs now graduate the majority of the nation’s psychology practitioners. Under the newly adopted APA accreditation standards, they will soon be called “programs in health service psychology.” Only recently, however, has there been any concerted effort to foster a culture of interdisciplinary collaboration within psychology’s training initiatives. One notable exception is the efforts of Gill Newman at the Wright Institute, which emphasizes training within its local community health center network—a national program established by President Lyndon Johnson as a component of his Great Society legacy. We would suggest that most clinicians, even those being trained today, have not been exposed to the language, culture, and expertise of other mental health disciplines, particularly during their formative years. Nevertheless, as a direct result of federal legislation, we expect that this landscape will dramatically change over the next five to 10 years.
Partnerships are now not looking for transmission between specialty silos of care but are expanding beyond geographic and historical boundaries into more complex and comprehensive structures. Embedded and co-located mental and physical health services, pharmacy as a part of primary care visits, email correspondence, and electronic transmission of real-time data are all part of current practice, as previous discussions of telepsychology and telepharmacy have emphasized. A solo provider will have an increasingly difficult if not impossible task given the emphasis by the healthcare system, payers, and the government on quality, comprehensive (p. 628) care. For example, if it is to survive, a solo or specialty niche practice must draw patients from a source and account for a continuum of care from chronic to acute and along the lifespan. These niche practices may also benefit from individuals who want to create their own path forward and are willing to pay out of pocket for all services. Each visit must reflect current standards of care, must be clearly documented, and must be accurately coded and submitted for reimbursement.
Social policy, the political aspect of healthcare, includes legislation (historical and contemporary), regulations, payers, delivery systems, and interdisciplinary collaboration. Each of these informs the others and derives priorities from population, institutional, historical, or economic influences. While not an exhaustive list, these particular aspects are critical to shaping clinical practice. Mental health providers have unprecedented opportunities for regulatory and reimbursement parity with physical health professionals and would do well to learn from them. During this tumultuous time, mental health providers must always keep in mind that clinical practitioners either can help shape policy or must be content to be shaped by others.
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