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 THE NEWSLETTER OF THE RHODE ISLAND PSYCHOLOGICAL ASSOCIATION WINTER 2015
Continuing Education
March 6, 2015, Friday

"Detecting and Arresting Interpersonal Violence:  What Every Clinician Needs to Know"

Robert Kinscherff, Ph.D., JD
(6 CE Credits) 

April 17, 2015, 
Friday 

"A Primer On The ICD: What You Need To Know For Your Behavioral 
Health Practice"

Carol Goodheart, Ed. D.
 (6 CE Credits)
 RIPA BOARD
 
Peter Oppenheimer, Ph.D.
President 
[email protected]

Ben Johnson, Ph.D.,ABPP 
President-Elect
[email protected]

Lisa Rocchio, Ph.D.  
Secretary  
[email protected]

Abbe Garcia, Ph.D.  
Treasurer  
[email protected]

Lisa Gallagher, Ph.D.  
Board Member
[email protected]

Ryan Haggarty, Ph.D.  
Board Member  
[email protected]

Karen J. Gieseke, Ph.D. 
Board Member
[email protected]

Jami Wilder, Psy.D.
Early CareerBoard Member  
[email protected]

Wendy Plante, Ph.D.  
Federal Advocate  
[email protected]

Louis Turchetta, Ed.D 
APA Council Representative
Committee Chairs

Megan Spencer, Ph.D.
Colleague Assistance


 Ryan Haggarty, Ph.D. 

Communications

Clifford I.Gordon,Ed.D.  
Henry Lesieur, Ph.D.
Leslie A. Feil, Ph.D.
Ethics

Peter Erickson, Ph.D. 
Insurance

Peter Oppenheimer, Ph.D. 
Becca Laptook, Ph.D.


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Jack Hutson
Executive Director
1643 Warwick Avenue
PMB 103
Warwick, RI  02889



President's Message
Colleague Assistance Committee Update
Ethics Corner-Ethical Challenges in Integrated Primary Care
Continuing Professional Education Committee - Survey Results - RIPA Member Interests
Communications Corner: Update Your Referral Listing in "Find a Psychologist

President's Message

 

 The fall election and actions of the Supreme Court clouds the future of the Affordable Care Act. Even though the ACA institutionalizes the role of for-profit insurance companies, hospitals and suppliers (pharmaceuticals and devices) and mandates people purchase from them; business interests and their proxies have continued to seek to overturn and undermine the law. Clearly the law as it is does not satisfy them, and they are unwilling to accept that they gained major concessions in the compromise the became the ACA. 


Our experience over the past four years has been that the details of ACA implementation have not been clear from the onset. The law provided a general direction, but there was much to be worked out. In Rhode Island state policy makers and stakeholders have been largely faithful to trying to work out the details in a constructive way. The state put a lot of money and effort into a functional health insurance exchange that worked last year. Our Healthcare Taskforce members have attended copious meetings about the implementation of healthcare services over the past years. There are many groups involved and some of these efforts run at cross purposes or are redundant, but at least there is interest and effort.

So what could happen?

I expect there will be efforts in Congress to repeal the law as a whole that won't succeed. The President would veto those bills. However, there is risk that aspects of the law could be undermined in legislation that does get through or possibly by withholding funding for implementation of the law.

The other looming threat is the decision of the US Supreme Court to hear King V. Burwell. If SCOTUS finds in favor of the plaintiff, the proponents suggest it would undermine state regulation of insurance and the ability of the federal government to provide subsidies to people who purchase insurance through federally run exchanges. That would not directly impact Rhode Island as Healthsource is a state run exchange, but it would undermine the goal of trying to make insurance affordable so that more people participate paying premiums and utilizing the coverage.

What would the Republicans do if they could?

There is no consensus Republican plan besides "repeal." Some members proposed a "plan" in January. Among items proposed by Republican Members of Congress:

* Allow the purchase of insurance plans across state lines
* Repeal or rollback preexisting condition rules
* Shift Medicare to a voucher (and people would have to make up    the gap that would grow between the value of the voucher and    the premium)
* Shift Medicaid to block grants and roll back eligibility criteria
* Reduce FDA regulations on pharmaceuticals and devices so that    they could be put on the market quicker
* Provide limited tax credits instead of deductions to self-             insured for buying their own health plan

These ideas have been around for a while. Back in 2005 there was a bill, the Health Insurance Market Modernization Act (HIMMA) sponsored by Republican members. It was clear to us then that the proposed changes would undermine the protections provided to Rhode Islanders and Rhode Island health care professionals provided under Rhode Island law. Much of the relative stability we have experienced over the years has been due to Rhode Island's regulation of insurance companies. I expect that holds today as it did then.

Then there are the long-term policy issues we have been trying to address for years:

Medicare rates have dropped 35% since 2001 and every year we are faced with the potential that rates will be cut by about a quarter due to the Sustainable Growth Rate (SGR); a formula that is supposed to limit the growth of Medicare costs. We have been relieved of the SGR every year, but that has sometimes been technically after it had been imposed.

The Medicare rates themselves are set in a secretive process. CMS has given the authority to develop the procedure codes and rates to a committee of the American Medical Association called the Relative Value Unit Committee (RUC). The formal RUC is comprised solely of physicians with only consultative input for professional associations such as the APA. There is no transparency to the RUC process. Look at your insurance premiums and look at your insurance rates over the past 20 years? Where is the money going?

Psychologists are still not included in the definition of "Physician" under Medicare. That means that sometimes psychologists are required to have physician supervision for activities that are clearly within our scope of practice (not a big issue locally), and we are excluded from other functions such as supporting our use of electronic medical records.

It is very clear to me that if behavioral health professionals are supposed to be part of the "integrated care" part of integrated care that we need access to the information technology that hospitals and physicians use. We need medical records that interface with their systems. The records needed for behavioral health may be less complex than physician and hospital systems but they must work together. There is still no standard, but a standard will come.

Physicians receive federal funding to support their use of EMR, psychologists do not. That is technically because we are not included in the defection of physicians under Medicare.

The elephants in the room are the Anti-trust laws. The laws were intended to protect "competition" by not allowing companies to monopolize commerce or multiple companies to collude in cartels. It was supposed to protect the little guy from the big guy. It's obvious to many of us that is not how it works in healthcare. The laws as applied have protected the insurance companies from independent healthcare professionals. The government has also allowed the large corporate providers to merge into dominating entities that hold great sway in their markets. In Rhode Island we have two insurance companies and two provider chains who dominate the market. These entities are in position to absolutely dominate their markets for the foreseeable future. The Federal Trade Commission and the Department of Justice, the agencies tasked with overseeing the law, have not intervened to protect "competition." There is no reason to expect that is going to change in the future.

So we have spent a lot of time over the past six years figuring out how we will need to adapt to changes in the healthcare system to survive and possibly do better than that. For the past four years we have had a decent sense of direction even though the exact destination has been undetermined. Now we face greater uncertainty and the potential for significant changes in direction to future plans (few of them are likely to be to our benefit). That makes planning for the future that much harder. Our Healthcare Task Force and COMHPRI will continue to focus on deciphering what is going and on figuring out how we can best act to contend with what lies ahead.


 
Best wishes to you all,


 
Peter Oppenheimer

 President


 

Colleague Assistance Committee Update:
Professional Care Plan   
by Megan Spencer, Ph.D.
The Colleague Assistance Committee is pleased to announce that a Professional Care Plan template in now available on the CAC webpage. A Professional Care Plan is used to identify designees, who in the event of an emergency, prevents you from managing your business and patient affairs. The document outlines the logistical and business considerations which need to be discussed with your designee. RIPA members are eligible to file their Professional Care Plan at no cost with the RIPA CAC.

APA has also recently published a comprehensive Professional Will template which is available to APA members. A Professional Will, like a Professional Care Plan, represents a contingency plan in the event of an emergency. Please visit the CAC webpage for more information.

Ethics Corner: 

"Ethical Challenges in Integrated Primary Care"

by Wendy Plante, Ph.D.

RIPA Ethics Committee 

It has been estimated that 70% of all primary care visits are for diagnosis and treatment of behavioral health problems. Our health care system is going through many changes, including an emphasis on integrated care - interdisciplinary teams caring for people's physical, psychological, and social in medical homes or integrated primary care settings. Much has been written about integrated care models, competencies for psychologists working in such settings, and potential physical and behavioral health outcomes and cost savings. However, little has been written about ethical challenges for psychologists in integrated primary care. With increases in coordinated care, psychologists will face ethical challenges in these settings with increasing frequency. Some of the challenges may be associated with differences between primary care behavioral health services and specialty mental health treatment; some may be associated with being a member of an interdisciplinary team. While broadly written, the APA Ethics Code was developed with the specialty mental health setting (e.g., psychology private practice, mental health clinic) in mind. Furthermore, the psychologist in primary care will be working with professionals whose own discipline's code of ethics, guidelines for professional conduct, and even relevant state and federal laws may differ from those guiding the psychologist. Ethical issues relating to "who is the client?", competence, multiple relationships, consent, confidentiality (especially with increasing use of electronic health records), and competence with diverse populations can arise.

In 2013, Families, Systems, and Health (March 2013, volume 1) released a special issue, edited by Christine Runyan, PhD, ABPP, Patricia Robinson, PhD, and Debra A. Gould, MD, MPH, devoted to Ethical Quandaries When Delivering Integrated Primary Care.

The editors argued that identifying gaps in ethical standards for behavioral health clinicians and their primary care physician colleagues is an important step in advancing the field and developing guidance for interdisciplinary primary care teams. The articles use cases to highlight ethical dilemmas, describe professional ethical standards pertinent to the case, identify gaps in the available guidance, offer feasible recommendations for deciding an ethical course when guidance is lacking, and then demonstrate and apply the recommendations to the case example. Here are a sampling of the thirteen articles included:

* An article on ethical considerations in conducting behavioral health research in the medical home (Goodie, Kanzler, Hunter, Glotfelter, & Bodart, 2013) highlights challenges related to maintaining the work flow and efficiency of the clinic, providers and staff who might not be familiar with all regulatory and research requirements, lack of relationship with an institutional review board (IRB), securing funding, and maintaining the integrity of interventions in a "real world" clinical setting. They end with ten recommendations for promoting effective and ethical research by integrated psychologists in medical homes.

* An article by Hodgson, Mendenhall, and Lamson (2013) discusses differences in how medical professionals and behavioral health clinicians approach issues of consent, confidentiality, and perceived or actual mistakes by clinicians. They provide a helpful table describing how the codes of various disciplines and HIPAA laws address informed consent, confidentiality, and patient grievances. The authors point out that keeping mental and medical providers, records, and treatments separate can stigmatize mental health and substance abuse treatment and fragment care, while asking patients to sign multiple consents can be burdensome and confusing. Integrated care providers need to be thoughtful in honoring patients' rights to confidentiality and autonomy, while promoting best practices in coordinating their care.

* Similarly, Hudgins, Rose, Fitfield, and Arnault (2013) provide an overview of federal regulations governing confidentiality for substance abuse programs (42CFR Part 2), HIPAA laws, select state laws, and case law relevant to informed consent and confidentiality in integrated primary care. They discuss the unique role of behavioral health clinicians in primary care. While they may operate similarly to their medical counterparts in their focus on somatic symptoms, short-term and often behavioral focus, the lower sensitivity of information that may arise in their interactions with the patient, and a less intimate relationship with their patient, their patients still may be more willing to confide sensitive information to them than to their primary care clinicians. From a HIPAA and 42CFR Part 2 perspective, they may operate like physicians, and state law may say little about psychologists, but until state licensing boards and regulations provide guidance to the psychologist practicing in integrated care, it might be most prudent to practice as psychologists when devising informed consent and confidentiality policies and protocols.

* The ethics of complex relationships are described by Reiter and Runyan (2013). They point out that more often than in a psychology private practice, primary care tends to be team-based, longitudinal, focused on the whole family, and on a high volume of patients. Because of high volume, over time there are plenty of opportunities for family and community ties to collide in the clinic. The authors provide case examples for each of these dimensions differentiating primary care from specialty mental health settings and they recommended changes to the APA Ethics Code that would be helpful to psychologists in integrated primary care settings.

* In the realm of colleague assistance, a case vignette describes a colleague-physician seeking assistance from a primary care psychologist for emotional distress (Kanzler, Goodie, Hunter, Glotfelter, & Bodart, 2013). Issues around multiple relationships, confidentiality, and prevention of potential harm to others are presented.

There are also articles addressing the specific ethical quandaries arising in the contexts of primary care in military settings, rural settings, chronic pain, and end of life.

In their introduction to the Special Issue, Runyan, Robinson, and Gould present a Four Box Method (from Jonsen, Siegler, and Winslade, 2010) for sorting out ethical dilemmas versus communication problems versus lack of knowledge and resources, and, if a quandary is found to be an ethical one a method for weighing various ethical principles. Finally, the editors recommend a number of practices for addressing ethical issues in integrated care: 1.) "When you don't know, ask someone!" and "Communicate, communicate, communicate". 2.) "Learn, learn, learn". Learn about the medical code of ethics and those of other disciplines. Take advantage of internal and external education and training opportunities, and encourage colleagues to do the same. 3.) Consider a monthly interdisciplinary meeting for reviewing ethics cases.

"If we all exit the historic silos of our own discipline and meet in the common hallways of collaborative team-based practice, not only will mind body dualism dissolve, but patient outcomes will improve. Primary care will be redefined in a way that necessitates interdisciplinary training and service delivery."  (Runyan, Robinson, & Gould, 2013)
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RIPA members are reminded that they may access a consultation from the Ethics Committee by calling the RIPA Office at 401-736-2900 for referral to the Ethics Committee member on-call. After obtaining information about the ethics situation from the caller, the Ethics Committee member will consult with the Ethics Committee and then offer a response to the caller. Caller identity is kept confidential, and specific identifying information is not sought.

Continuing Professional Education Committee Update:

Survey Results - "RIPA Member CPE Topic Interests"

By Ann Frank, Psy.D. 

At the end of June, the Continuing Professional Education Committee launched an online survey to discern the current interests of RIPA members.

"To date, we've had 31 respondents. The sample size is small compared with a membership of 181; that said, we find the trends interesting," reports committee chairperson, Clifford I. Gordon, Ed.D.

Nearly two-thirds of the respondents (64.52%) indicated a desire for a workshop on Acceptance and Commitment Therapy. Other desired topics include: psychology of happiness, and Dialectical Behavioral Therapy for non-borderlines (both at 41.94%); grief and loss, integrating behavioral health and primary care practice, and mindfulness (all at 35.48%); and less than one-third were interested in workshops focused on positive psychology; child, adolescent, and family psychology; or health psychology. Additionally, there were a half-dozen write-in requests for programs about forensic psychology, couples therapy, cognitive reprocessing or mentalization, sleep, the treatment of gambling, and sports/performance psychology.

An overwhelming majority (90.32%) preferred getting all CE information by email instead of the U.S. Postal Service. An all-day workshop format still edges out a half-day morning session (55.17% versus 37.93%). Friday is still the preferred day of the week (60.71%). The Providence Metropolitan Area remains the favored geographical location (83.3%), as does the Radisson Airport Hotel (83.3%) in particular.

We continue to work towards discovering topics that RIPA Member Psychologists consider important to their practice - along with speakers to provide the program to attendees.  If you have a suggestion for a topic of interest you can email your thoughts to [email protected] or CLICK HERE to take the survey.  Thank you!


 

Communications Corner: 
Update Your Referral Listing in "Find a Psychologist"
by Ryan Haggarty, Ph.D.
I would like to encourage everyone to look at their current RIPA profiles and update your information, especially types of referrals you accept, office location, and hours. We continue to have the "Find a Psychologist" feature on our website which can be a great resource for those looking for a provider with a particular specialty or in a specific area of the state. If you are not finding anyone after using this search feature, then the listserv can be a nice secondary option in order to connect with potential psychologists to refer to.

As I look to the upcoming year, I am planning on sending out a survey in order to assess the needs of the membership on the communications front. My role as Communications Chair is a work in progress and I am always open to hearing your feedback. Feel free to contact me with any suggestions or concerns at [email protected]