NP July/Augist 2011

Psychologists push for spot early in health care reform

By Paula E. Hartman-Stein, Ph.D.

                To avoid being left out of the federal health care reform as they were for 25 years under Medicare, APA and other national and state organizations are pushing to gain full participation for psychologists in one of the latest health care entities – Accountable Care Organizations (ACOs).

                Without quick and decisive action, the organizations fear a bitter repeat of 1965 when failure to act in a timely manner denied psychologists eligibility for payments under Medicare for a quarter of a century. 

                ACOs will play a key role under the 2010 health care reform. An ACO is defined in the Affordable Care Act as a network of health care providers and hospitals that agrees to manage all the health care needs for a minimum of 5,000 Medicare beneficiaries for at least three years.

                “This time we hope to be building the ACO train rather than missing it,” said Peter Kanaris, Ph.D., a participant in a recent New York State Psychological Association (NYSPA) Health Care Reform Think Tank.

                On April 7, 2011 The Federal Register published a proposed rule that supplements the Affordable Care Act and contains provisions relating to Medicare payments to providers of clinical services participating in ACOs. If an ACO demonstrates that it can improve care and do so for less than the projected cost, then a share of the savings goes to the ACO as a bonus.

                James Georgoulakis, Ph.D. a health care attorney and psychologist in San Antonio, Texas who has spent time studying ACOs, predicts they will become operational soon. In a recent interview, he said, “My understanding is that psychologists can participate in an ACO, but there are a number of unresolved issues surrounding the ACOs.”

                The bottom line involves defining the specific clinical and administrative roles psychologists will have in ACOs and whether they will be able to share potential bonuses with hospitals and physician groups if cost savings occur.

                State laws may present an obstacle for psychologists to be equal partners in the ACO model. In a recent phone interview, Kanaris said, “In New York we cannot incorporate with physicians. Working toward changing state law may be a necessary first step.”

                Individuals or groups were able to respond to the proposed rule in The Federal Register through June 6. In a letter to Health and Human Services Secretary Kathleen Sebelius dated June 3, Norman Anderson, Ph.D., CEO of APA and Katherine Nordal, Ph.D., executive director of the Practice Directorate, advocated for clinical psychologists to be incentivized to provide care as part of an ACO primary care team.

                The letter also argues that psychologists not included in an ACO could still participate because the coordination of health care “entails referrals to Medicare providers, such as clinical psychologists outside of the ACO, when necessary.”

                The National Register of Health Service Providers in Psychology, the Association of Psychologists in Academic Health Centers and Greg Greenwood, Ph.D., of the Human Capital Specialists submitted comments advocating for psychologists to be full participants in ACOs.

                According to Crain’s Cleveland Business on the web (May 19, 2010), in January University Hospitals in Cleveland and Summa Health System in Akron, Ohio are two of 20 health systems across the country that have come together to form ACO collaboratives.

                In a phone interview, David Brinkman-Sull, Ph.D., vice-chair of psychiatry and chief psychologist for Summa Health System, said the model has added a greater role for psychologists but integration with primary care has not yet occurred.

                “We are up against the wall,” he said, “because we are still operating in a fee-for-service world.” In the Summa model ACO, psychologists are not helping to structure the model. “We had to push for one of our psychiatrists to work with the team,” he said.

                Pat Deleon, Ph.D., former president of APA who is on the staff of U.S. Sen. Dan Inouye, D-Hawaii, wrote on his internet blog on April 11, 2011, “It is important for organized psychology to enter into the policy debate, at both the local and federal level, especially in determining the fate of non-physician providers.

The role of state psychological associations

                NYSPA, under an initiative of President Donna Rasin-Waters, Ph.D., is taking a pro-active role in health care reform. Despite a shoestring budget, on June 3, 2011 NYSPA sponsored the Health Care Reform Think Tank with 28 individuals taking part in the half-day program. In a phone interview, Rasin-Waters said, “We should not wait for an ACO to be shaped; we should shape it.”

                With encouragement from Joy Dryer, Ph.D., who facilitated the session, Rasin-Waters’ goal was to lead the integrated mental and behavioral health platform. “The first step is to do advocacy to get us written into the ACO piece,” she said. “We’re hoping to have a voice. We have the skill set to walk into the ACO bringing our science and our evidence base to the program.”

                According to Rasin-Waters, “Health care reform will play out on a state level.” She hopes that NYSPA’s efforts will create a tool box for New York psychologists and a model other states can use as a base.

                The think tank identified six groups to work with the Integrated Health Care Task Force in areas such as training and education of members, public education and ensuring that psychologists have options towards developing competencies in integrated behavioral health. The think tank will reconvene in the fall.

                According to Georgoulakis, there will be additional roles for psychologists in ACOs beside patient care. ACOs will focus on improving care coordination and delivery, data analysis, evaluating current resources and staffing levels etc. “ACOs are going to require well-designed analytics to understand opportunities for improving outcomes and demographics. Psychologists maybe have the best skill sets for ACO development, implementation and monitoring.”

                In preparing for the next wave of health care reform, Georgoulakis compared aspects of the ACOs to the Physicians Quality Reporting System (PQRS) that offers incentives to clinicians who routinely use quality measures. “If one reviews what has happened over the last few years, you can see that providers who participated in the PQRS program have a leg up over everyone.”

                Robert McGrath, Ph.D., director of the clinical psychology program at Fairleigh Dickinson University and a participant in the NYSPA Think Tank, said, “I’ve come to believe many psychologists find the uncertainty of what is happening anxiety-provoking and want to sit on the sidelines. Everyone shares in this uncertainty, and this is exactly the time we can play our biggest role by informing state authorities about the importance of behavioral health care for the emerging system.”

                 Paula E. Hartman-Stein, Ph.D., is a consultant in Kent, Ohio, who served as chair of the first PQRS work group for psychology. She can be reached through her website,

 July/August 2011, National Psychologist, Vol. 20, No. 4, p 1,3.