635ADVOCACY FOR THE GROWTH OF PSYCHOLOGY

Advocacy: The Key to the Survival and Growth of Professional Psychology

Ronald E. Fox The Consulting Group of HRC

Active participation in professional advocacy activities is essential for psychology to have a viable future. Advocacy efforts thus far in professional psychology are reviewed, and a discussion of how strong advocacy efforts will be required to advance the interests of the profession in the future is presented. Making psychology a true health profession, securing legislative authority to prescribe in all states, confronting and overcoming business and regulatory constraints on practice, and providing sufficient services to meet the growing diversity of the general population are discussed as examples of professional issues whose resolution will require significant advocacy efforts. Recommended steps are provided for developing a strong, national advocacy program.

Keywords: advocacy, political action, prescriptive authority, professional involvement

The very survival of psychology as a profession may well depend on the development and implementation of a successful advocacy program. Without it, psychology is destined to remain a minor player in the nation’s heath care market. Unfortunately, psychology is poorly positioned to conduct the comprehensive, coordinated, and expensive effort that is needed.

Despite their many political successes over the past several decades, psychologists remain reluctant participants in the advo- cacy process (DeLeon, Loftis, Ball, & Sullivan, 2006). For the present purpose, advocacy is defined as the use of political influ- ence to advance the profession through such means as political giving, legislative lobbying, and other active participation in the political decision-making process. Psychologists’ level of giving for advocacy has not increased with their growth in numbers and remains far below that of comparable health care professions (Pfeiffer, 2007). The need is manifest, the potential rewards are there for the taking, but the will to act often lies dormant.

Successfully addressing each and every one of the issues dis- cussed in this special section of the journal are cases in point. Establishing psychology as a primary health care profession al- ready has required a great deal of advocacy effort and even more will be needed in the future (Wright, 2001). The same is true for prescriptive authority (RxP) legislation and the management of its impact on both society and the profession. Managed care and the evidence-based practice movements have brought major opportu- nities and threats to psychology that will require strong political advocacy to establish appropriate boundary conditions for cost and

accountability measures whose unintended consequences can be disastrous. The increasing diversity of patients requires expanded skills and training for practitioners and the creation of better access to services.

Political action will be necessary to put in place the policy changes and funding opportunities needed. The future of our profession can be bright. The road to it runs directly through the social and political arenas. A brief review of some of the history and background of these issues will help clarify why the need for major advocacy mechanisms is so critical to the future develop- ment of the profession of psychology.

Psychology as Health Care Profession

Several presidents of the American Psychological Association (APA) have created initiatives to help establish psychology as a health profession (e.g., Jack Wiggins, Pat DeLeon, Norine John- son, Ron Levant), which is very good and necessary. But much remains to be done. In order to make psychology a true health care profession providing services that are both accessible to the gen- eral public and affordable, those services will need to be reimburs- able in the same manner as other health care. This requires the inclusion of psychological care in the myriad health and rehabil- itation services reimbursed by public and private carriers.

Early advocacy efforts to gain recognition and reimbursement were first initiated in the 1970s by a group of activist practitioners known as the “Dirty Dozen” (Fox, 2001). This group also founded psychology’s first advocacy organization outside of APA, the Council for the Advancement of the Psychological Professions and Services, or CAPPS (not to be confused with CAPP, or the Committee for the Advancement of Professional Practice, the oversight group for the APA Practice Directorate, which was established much later). These psychologist advocates also suc- cessfully pressured APA to establish a Committee on Health Insurance (COHI) and ultimately an advocacy program within APA itself, thus recognizing the legitimacy of such efforts by psychologists.

RONALD E. FOX received his PhD in clinical psychology from the Univer- sity of North Carolina in Chapel Hill. He is executive director of The Consulting Group, a division of HRC (a multidiscipline practice in Chapel Hill, Durham, and Raleigh, North Carolina), and a clinical professor at the University of North Carolina. His areas of professional interest include professional education, practice standards, advocacy, and professional de- velopment. He is a past president of the American Psychological Associ- ation (APA) and a member of the APA Council of Representatives. Dr. Fox may be contacted by e-mail at drronfox@nc.rr.com

Professional Psychology: Research and Practice Copyright 2008 by the American Psychological Association 2008, Vol. 39, No. 6, 633-637 0735-7028/08/$12.00 DOI: 10.1037/0735-7028.39.6.633

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The numerous successes brought about by these early pioneers, which remain impressive over 40 years later (Fox, 2001), include passage of the first “freedom of choice” legislation, ultimately enacted in numerous states, requiring insurance carriers doing business in a state to reimburse for the services of psychologists if they reimburse other providers for mental health care; convincing a major carrier for federal employees’ comprehensive health plan to cover psychological services; a class-action lawsuit forcing the U.S. Civil Service Commission to recognize psychologists as independent and reimbursable providers in their contracts; pres- suring the Civilian Health and Medical Plan for the Uniformed Services (CHAMPUS) to reimburse psychologists for both outpa- tient and inpatient services (subsequent legislation extended the same access to beneficiaries of deceased veterans) (Wiggins, 2001); passage of the 1975 Vocational Rehabilitation Act, placing mental health on a par with physical health and granting parity to psychologists for reimbursement; and the establishment of psy- chology’s first full-fledged doctoral program explicitly devoted to training practitioners, the California School of Professional Psy- chology (Cummings, 2001). Many similar schools, which were subsequently established in other states, award the Doctor of Psychology (PsyD) degree. In 1976, Cummings convened the first meeting of what was to become the National Council of Schools of Professional Psychology (NCSPP), which 20 years later became the first national training council to identify “advocacy training” as a core professional value for the professional graduate curriculum.

More recent APA advocacy successes include the modification of Social Security administrative law to allow psychologists to qualify as “medical examiners,” thus legitimizing a major role of psychologists in preventing or ameliorating the disabling effects of physical illness and injury (Wiggins, 2001). In 2002, advocacy led to the creation of the Graduate Psychology Education Program within the Bureau of Health Professions of the U.S. Department of Health and Human Services as the first and only federal program dedicated solely to the education and training of psychologists (Wiggins, 2001). In recent years, the APA Practice Web page (www.apapractice.org) has announced congressional approval for the Department of Defense Graduate Psychology Education Pro- gram to address the behavioral health care needs of service mem- bers and their families; the creation of new treatment codes for psychological assessments and neuropsychological testing; and approval for payment of neurobehavioral examinations, which is an acknowledgement of the advanced training and skills of psy- chologists, to mention only a few examples.

As gratifying as these successes may be, much more remains to be done. Psychological care is almost unique in its ability to help patients retain, enhance, or gain their functionality throughout the health care spectrum: prevention, detection, diagnosis, treatment, and rehabilitation. To capitalize on this potential, psychology must institute a variety of efforts to cement, expand, and protect new markets. Funds for training, demonstration projects, and new treat- ment centers will be required in both the public and private sectors. Extensive education efforts will be needed to inform the public about the effectiveness of psychological care. Treatment and di- agnostic codes must be revised, federal and state agencies must be changed, new laws enacted, and so on. Addressing such an agenda will require social and political advocacy, political giving, and coordinated public information programs far beyond the scope and magnitude of all of our past efforts put together. Without them, the

health care market, which is changing rapidly, may well pass the psychology profession by.

Prescription Privileges

Prescriptive authority for psychologists has come to be viewed by many practitioners as the major vehicle for securing the pro- fession’s role as a major health care profession. See Fox (2003a, 2006) for a brief review of the history of RxP efforts by psychol- ogists. The lifting of the U.S. Food and Drug Administration’s ban on direct marketing of drugs to the public in the 1990s increased the public demand while accelerating the push for prescriptive authority by several other health professions and increasing the pressure on psychology to do the same.

APA’s Committee for the Advancement of Professional Practice (CAPP) has assumed the challenge at the national level to coor- dinate and assist state efforts to secure the right of appropriately trained licensed psychologists to prescribe. Impressive and persis- tent grass roots efforts with the assistance of grants and informa- tion sharing and education from CAPP helped advocacy efforts that successfully passed enabling legislation in New Mexico, Lou- isiana, and Guam. Ongoing, well-organized initiatives to pass similar legislation in a dozen other states were underway by 2007. In 1996, APA’s Council of Representatives adopted a model curriculum for RxP training as well as model licensing laws to encompass the new practice parameters. Most of the points made earlier regarding the need for advocacy in establishing psychology as a health profession obviously apply here as well.

Provider Restraints

The rapid rise in health care costs over the past half-century has taken a tremendous toll on the nation’s fiscal resources and placed U.S. businesses in an increasingly unfavorable competitive posi- tion in world markets due to the ever higher costs of employee health plans. Unable to agree on the basic changes needed in the health care system as a whole, insurers and the government have used various efforts to control costs without addressing the under- lying problems in the health care system as a whole.

The most prominent, and perhaps most widespread, cost-control strategy has been the “managed care” systems devised by insur- ance carriers and sold to employers for their company health care plans. Through such means as reducing benefits, tightening pro- cedures, lowering provider reimbursement, requiring second opin- ions, and transferring approval of claims from the providers to insurance company employees (who may or may not be health care providers), carriers succeeded in holding down and sometimes lowering health care costs in the short term. But the demand for services, the increasing availability of new and expensive proce- dures, and the press for ever higher profit margins for the carriers have tempered the initial claims of success, leaving patients with more barriers to care, providers with less compensation, markedly higher administration costs, and a health care system that is easily the most expensive of any nation on Earth without evidence that it is also the best. In fact, the United States now ranks last among industrialized nations on most measures of good health care (e.g., infant life expectancy; Commonwealth Fund Commission on a High Performance Health System, 2006).

634 FOX

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Managed care, higher co-pays, and provider restrictions and accountability may be useful tools to control costs when used appropriately and judiciously, but they often have been misused and abused to the detriment of patients, providers, and society. APA, along with other professional groups, patient advocates, and some states, has brought successful lawsuits to force some man- aged care firms to cease various egregious practices. But the fact of the matter remains that the nation’s health care system is broken and in need of a major overhaul, rather than the piecemeal tactics discussed here.

Health Care System in Disarray

A recent report by The Commonwealth Fund Commission on a High Performance Health System, 2006) documents the fact that the United States ranks near the bottom on numerous health indices when compared with other wealthy nations in everything except cost. We pay far more for care and get less in return. We rank last on all measures of equity. Below-average income workers are much less likely to see a physician when sick and are more likely not to get a recommended test, treatment, or follow-up care; not to fill a prescription; and not to see a dentist when needed because of the cost.

Our wealthy citizens do not fare much better, despite seeking care early and showing better follow-through with treatment rec- ommendations. The United States and Canada rank lowest on prompt accessibility of appointments with physicians, but Canada achieves the same rank at less than half the cost! According to the report, the U.S. system is so poorly organized that much of what would be good care is negated despite the huge amounts of money poured into health care. The U.S. health care system is technolog- ically and organizationally backwards.

Other countries are further along in using information technol- ogy and a team approach to manage chronic conditions and coor- dinate care. In countries such as Germany, New Zealand, and the United Kingdom, modern information systems enable a physician to better identify and more efficiently treat and monitor chronic care patients. Physicians also are able to print out lists of the medications that all physicians have prescribed for a patient. In the United States, primary care physicians and specialists are typically poorly informed or not up to date on what other health providers are doing due to a lack of mutually accessible medical records. Records are not computerized in the United States, forcing physi- cians to rely on written records in a computer age. According to the report, the U.S. Department of Health and Human Services esti- mates that as much as 30% of U.S. health care spending (about $300 billion) is inappropriate, redundant, or unnecessary, and the U.S. Institute of Medicine estimates that 98,000 people die each year from medical errors—both of which would be significantly reduced with a nationwide, integrated, computerized patient infor- mation system.

The only area in which the United States was not ranked last was in preventive health care, although it still trailed Canada and Australia. The bottom line is that despite spending nearly $2 trillion annually, the United States consistently underperforms on most dimensions of performance related to other countries (Com- monwealth Fund Commission on a High Performance Health System, 2006).

The point of this rather lengthy discussion of the current state of U.S. health care is that most informed observers now seem to agree that the United States needs a new, integrated national health care system and that fundamental changes are likely. As all the forces and influence groups marshal their resources to debate the relative merits of government-based health insurance versus some form of public and private insurance, psychology must be an active par- ticipant. The profession cannot afford to watch from the sidelines as a new system is put into place and then spend the next several decades trying to modify what has been done to allow our partic- ipation as happened when Medicare was first established. Psychol- ogy must move boldly to be included from the start in whatever new system is developed if we truly intend to be a major health care profession. It will require organized advocacy on a national scale to make it happen, but it can be done.

Diverse Patients, Diverse Providers

The increasing diversity of the U.S. population requires no documentation and must be taken into account in future advocacy plans of the profession. In terms of a national strategy, it will be necessary to address the broad challenges that the changing com- position of the population presents: appropriate access to services, recruitment of more minority students, and enhanced training for all providers.

Major public education efforts designed to reach specific cul- tural and ethnic populations will be needed to promote better, more responsible psychological care; to provide information on where and how to secure help; to reduce resistances; and to encourage psychologically healthy prevention measures. Like any other pub- lic health program, the cost of such efforts will far exceed the resources of a single profession. Public funds and support must be a significant part of the mix, but they are unlikely to be put in place unless psychologists themselves take the lead in advocating for them.

It is hard to disagree with the idea that a greater diversity of psychology practitioners will be required to meet the needs for services in the future. Some progress has been made as the results of previous advocacy efforts at both the state and federal levels to increase the number of minority psychologists through targeted scholarships and training programs. Though laudable, it seems unlikely that we will be able to train enough ethnic minority practitioners, and even if it were possible, it will be decades before enough students are recruited and trained to meet current demands. Therefore, it is clear that many current practitioners must gain the knowledge and skills required to work effectively with a diverse patient base. Obviously, major funding will be required for retool- ing current practitioners to deal with both current and immediate future realities. In addition, a quantum leap in funding for schol- arships and demonstration projects for services targeted to minor- ity clients will be essential.

The social need for a diverse profession with programs for a diverse population and the potential benefits to society as a whole are obvious. Once again, it is not conceivable that the commitment of the financial and human resources required will ever be put in place without the strong advocacy and leadership of the profession.

635ADVOCACY FOR THE GROWTH OF PSYCHOLOGY

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