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COMMITTEE ON LEGISLATIVE CONCERNS
REPORT TO THE EXECUTIVE COMMITTEE
February 1, 1983
SUBMITTED BY: STANLEY BERENT, Ph.D., COMMITTEE CHAIR
I. Committee Membership:
1. Stanley Berent, Ph.D., Committee Chair
Chief of Psychology
Ann Arbor, VA Medical Center
Associate Professor of Psychology
University of Michigan
2215 Fuller Road
Ann Arbor, Michigan 48105
(313) 769-7100, Ext. 485
2. Steven Mattis, Ph.D.
Associate Professor of Psychology in Psychiatry
N.Y. Hospital Cornell Med. School
21 Bloomingdale Rd.
White Plains, N.Y. 10605
3. George Prigatano, Ph.D.
Director of Clinical Neuropsychology
Oklahoma Presbyterian Hospital
NE 13th at Lincoln Blvd.
Oklahoma City, OK 73104
II. Recent Committee Activities:
The Committee on Legislative Concerns was formally established at the Executive Committee Meeting of Division 40 at APA in the Fall of 1982. Since that time,the committee membership has been put into place. The first formal face-to-face meeting is planned for the INS Meeting in Mexico City, February, 1983. Previous to this,several telephone meetings have taken place. Several issues have been defined and actions taken with regards to these issues. These activities will be discussed in more detail below.
The primary agenda for the Mexico City Meeting will be directed towards planning for an effective model through which to carry out the work of this committee and to address defined issues. The membership has suggested a system of sub-committees, designed to address specified issues and to make report to the overall committee for their final action. In addition,a system of contact individuals would be established in order to effect ongoing monitoring of legislative issues at both a state and national level. Finally, these specified activities would be coordinated through at least two annual and overall committee meetings to take place, probably, at APA and at INS.
III. Active Items of Business:
A. State Legislation
1. In order to establish effective communications with regards to legislative activities on the state level, active liasion has been established with the director of the states association program at the American Psychological Association, Mark Ginsberg. The APA State Association Program has been very active in monitoring legislative issues on a state basis, and was able to inform us of current status in these areas. Our association with this office is seen important as it will allow for mutual sharing
of information, input and influence with regards to legislation which may impinge on our area of interest.
2. Sunset legislation has been of some concern to membership in our division. Information obtained throug h APA suggests that legislation of this sort is currently subdued. State legislative bodies prefer more active legislation and are almost all working towards legislation that would preclude such sunset provisions. APA expects such legislative issues to remain quiet at least until the mid 1980's. Currently , APA is directing attention to 4 state s where some activity is still current; however, issues in these states are not viewed as potentially threatening to our interests at this time. These states include Nebraska , where all legislative issues have been deferred for one year and which is likely to establish a licensing law in harmony with APA's policy (this issue commented on further below); North Caro- -- lina, which has revised it's sunset law with a program evaluation provision. In North Carolina, "sudden death" legislation has been abo-lished; Tennessee, which maintains 12 seperate boards for the healing arts. Tennessee is in the process of reviewing it's entire legislation in this area towards establishing one bill for all boards in an attempt to simplify this legislation; Alaska, where the psychology license legislation would sunset during this year. However, a bill to prevent this was vetoed by the governor of Alaska who has indicated t o APA that the sunsetting eventuality will be avoided through soon to be passed legislation.
Overall , APA view t h esunsetting problem as phasing out, although, as already indicated, the problem may renew itself in the mid to late 1980's.
3. The APA policy with regards to licensure was alluded to above. The APA stance is towards generic licensure for psychologist. In most instances, states have enacted such generic licensure. There may be some exceptions. For example, Michigan has a license law which is clearly directed to the applied practicioner. Another example is Virginia, which has two kinds of licensing; one for clinical psychologist and one that is generic; however, both types of licenses in Virginia are largely controlled through the Board of Psychology. (Addended to this report is a summary of State Laws regulating the practice of psychology). See Addendum A.
Licensing in Clinical Neuropsychology is likely to become an increasingly important topic. It would seem that our division in conjunction with related bodies is in the best position to advise with regards to criteria for such licensing legislation. Our committee has referre d APA to the report of the task force on Education, Accreditation, an d Credentialing as our one best set of guidelines at present. This information has been made available both to Mark Ginsberg and to Walter Bachelor, who occupies a position similar to Ginsberg but directed to national issues. According to Walter Bachelor and others concerned with these issues, what is needed is an outline of what is meant by the practice of clinical psychology, preferably with guidelines that include examples of clinical practice, procedures and methods.
In addition to contact with representatives of the American Psychological Association, the committee has attempted to establish contact people in various states, preferably individuals with ongoing influence and input is needed is an outline of what is meant by the practice of Clinical Neuro-
to legislative activities. For example, Jeff Barth has served as our contact person in the state of Virginia. Through this contact, it was learned that the state of Virginia was considering provision of Clinical Neuropsychology in it's licensing law. Subsequently, the board in Virginia deferred action at this time that might change existing state statute. The committee intends to continue and increase activity with such contact people in the future. See Addendum B.
At this point, it would seem that generic licensure in the states would not only be in harmony with APA's preferences, but such legislation would allow for recognition of Clinical Neuropsychology as a function of an individual practitionerc. Increasingly needed will be specific guidelines which specify the criteria of education and training upon which to recognize the individual practitioners claim to such practice. The committee's aim will be to communicate such guidelines in order to influence specific legislation towards appropiate ends.
B. Third Party Coverage for Clinical Neuropsychological Procedures
1. Two items have come to the committee's attention which may require some future thought and possibly action. The first of these has to do with diagnostic codes which are presently employed by major insurance companies towards reimbursing for specific medical and allied services. In part, the potential problem here is a philisophical one. While clinical neuropsychology has it's roots most firmly in mental health and psychological aspects medical care, it's activities have increasingly ventured into more purely medical areas. For example, Clinical Neuropsychologist fairly routinely evaluate the patients with primary medical complaints as might be treated by surgeons and other non psychiatric practicioners. On occassion, this has produced a dilema for insurance companies, patients, and neuropsychologists in that reimbursement for patient expenses might depend upon a psychiatric, diagnostic code. To elaborate upon this point, in some policies there is an overall limit for psychiatric services. If forced to designate a psychiatric code for neuropsychological services, an individual patient's ceiling for such services may have been exceeded. In such a case, reimbursement would not be forthcoming. On the other hand, availability of an alternative code would allow for appropiate reimbursement.
Presently, BlueCross/Blue Shield of Michigan is reviewing several case examples representative of the above problem. This insurance company has been asked to explore the possibility of alternate diagnostic codes as a means of avoiding these potential problems. The committee will monitor the progress of this action and determine future attention to this issue as needed.
2. The general economic decline in our country over the past years has led to increasing attempts at cost-containment by almost everyone. Third-party payers are no exception. Such cost-containment efforts are likely to extend to the future and may lead to increasingly restricted coverages and/or further exclusions of coverage. How such activities will affect the practice of Clinical Neuropsychology will have to be an ongoing monitoring task for the committee. A recent incident brought to the attention of the committee involved one third-party payers demand
that reinbursement for patient care would be based only on the time the Ph.D. Psychologist was actually present in the examination 'room. Since some usual practices in Clinical Psychology depend upon a Psychologist/Technician model,such policy decisions affect the professional practice of Clinical Neuropsychology.
C. Budgeting for Services; Other Actions
Also probably related to cost-containment concerns, some new policies are being enacted that have the potential for impact on the practice of Clinical Neuropsychology. In general, these activities are represented by a move to DRG-type cost-formulas in order to determine medical care costs and budget for them appropiately. DRG (Diagnosis Related Groups,see New England Journal of Medicine, December, 1982 issue for more information) represents a system for determining health care costs in a specific region, district, or individual medical center that will determine not only budget but which also represents an incentive program that could have the poten-tial for disincentive of certain services.
The DRG plan involves statistically sophisticated and somewhat complicated formuli for determining cost based upon discharge diagnosis. Addended to this report is a collection of information pertaining to DRG's. This information contains a listing of guidelines for the formation of DRG's,a listing of some criticisms leveled at this approach, and some additional infomation. See Addendum C. Since procedures are not specified under such systems,a basic question for neuropsychology would seem to be how such procedures can be costed into budget amounts for specific categories,especially those categories which may not reflect obvious psychological input. A related question will be how hospital administrations can be influenced away from possible disincentive for carrying clinical iieuropsychological activities.
Potentially, this type of cost-formula represents a significant problem to be addressed by our specialty area. Currently,the Veterans Administration is moving towards incorporation of DRG's in it's budgeting determinations on a nation-wide basis. Other state-based actions reflect similar moves and philosophies. At present,these activities are aimed towards inpatient settings; however,attention to outpatient activities may also be anticipated. The medicare system has made some similar moves recently. Addended for your information is information concerning reimbursement changes in the medicare system.See Addedum D and Addendum E.
The response of our specialty to these proposed and developing issues will likely need to occur on a variety of fronts and through various vehicles. Individual practicioners will have responsibility in addition to response by organizations. These kinds of activities, for example, underscore the tremendous importance of documentation of individual work in local settings. It seems not unfair to say that psychologists for the most part have been notoriously lax with regards to documenting the delivery of their services. Data bases upon which many of these sophisticated budgeting formuli are derived often do not contain reference to the psychologists! procedures. Organizations, such as our own, may be helpful to the individual with advise and direction; however, individual creativity in documentation of services is also warranted.
This general issue is also being addressed through mutual communication with Walter Bachelor's office at APA. His office, too, is aware of the potential problems in this area and attempting to address these issues. A new health and services support network is being created by APA as a partial response to these concerns. Our committee plans representation in this support network.
In addition, the committee will discuss the possibility of relating to other diciplines and specialties who might be concerned to similar impact on their own activities. Some of these groups potentially include radiologists, anesthesiologists,and electroencephalographers.
In addition,there are some other professional organizations which are attuned to these policy issues and who profess some concerns about their eventualities. One of these is represented by the Association of American Medical Colleges. See Addendum E.
D. Communication and Public Awareness
The committee will discuss an idea of an appropiate vehicle for communication of some of the above and other issues in order to increase public awareness. As indicated above, legistation represents but a part of a solution effecting the delivery of neuropsychological services to the public. Individual practicioners and others are also required to make contribution towards inplimentation of legislation or even to properly interpret such legislation. It is partly in response to such a need that the clinical support network is being created by APA. In addition to relating to this network,the committee will discuss ways in which issues can be addressed on a broader level. Some additional issues that are important in this area include the following:
1. The third draft of the proposed single set of standards for Psychiatric/Substance Abuse Services (PPS) for inclusion in the JCAH Accreditation Manual for Hospitals has recently been circulated by APA. Not only,as pointed out by APA, is it crucial that JCAH continue to hear clearly and loudly from psychological practicioners and groups concerning this greatly improved draft, it is also important that local administrators and other professio-nals become aware of and "properly" interpret such guidelines when they occur in final form. Individual psychologists, also, need to be aware of impact of such guidelines upon their own day-to-day functioning. (Addended to this report is a copy of the JCAH evaluation form, which also summarizes the proposed draft). See Addendum F.
2. Other issues may be somewhat politically sensitive and may even represent
divided opinion within the ranks of neuropsychologists. For example,training
programs in neuropsychology, and in psychology in general,continue to be
diverse in aims and format. Depending upon one's situation many such programs
could be viewed as inappropiate from a legislative and/or professional
standards viwepoint. In addressing such issues,the committee is likely
to attempt to work closely with other committees and tasks force whose
responsibilities bear directly upon such topics.
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