Dr. Pat DeLeon

Dr. Pat DeLeon

The Department of Veterans Affairs (VA)

The VA is the largest employer of psychologists and nurses, and over the years has done an outstanding job of providing high quality health care while simultaneously furthering the utilization of non-physician providers of all disciplines. Thanks to the vision of Toni and Bob Zeiss and the support of Ken Jones, the VA, which has long supported psychology internships, is expected to provide approximately 440 postdoctoral positions in the coming academic year. This spring the VA proposed to amend its regulations to permit full practice authority for advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment. “This would permit VA to use its health care resources more effectively and in a manner that is consistent with the role of APRNs in the non-VA health care sector, while maintaining the patient-centered, safe, high-quality health care that veterans receive from VA.” At the closing of the public comment period on July 25, 2016, over 214,000 comments had been received. The American Medical Association (AMA) urged the VA “to maintain the physician-led model within the VA health system to ensure greater integration and coordination of care for veterans and improve health outcomes.” One political pundit opined that the AMA had as much credibility on this issue as the NRA did on gun control.

Under the leadership of APA immediate Past-President Barry Anton and President-elect Tony Puente, 16 former APA Presidents submitted a letter in support of the VA’s proposal:

Dear Mr. Secretary: As former Presidents of the American Psychological Association (APA), the nation’s largest organization of psychologists with over 117,000 members, we urge you to ensure that the Department of Veterans Affairs (VA) allows its professional staff to work to the full scope of their practice to improve access to timely, effective, high-quality care for Veterans. We, and the current leadership of APA, believe that expanding prescriptive authority within the VA for qualified nurses and doctoral-level psychologists is a fundamental and urgent component of a redesigned, improved ‘MyVA’ integrated plan.

One of the key recommendations from the landmark Institute of Medicine (IOM) report ‘The Future of Nursing’ stated that “nurses should practice to the full extent of their education and training.” As colleagues equally committed to providing care for Veterans both inside and outside the VA system, we concur with the IOM that “nurses can and should play a fundamental role” in transforming care in this country, and that “the power to improve the current regulatory, business, and organizational conditions does not rest solely with nurses; government, businesses, health care organizations, professional associations, and the insurance industry must all play a role. Working together, these many diverse parties can help ensure that the health care system provides seamless, affordable, quality care that is accessible to all and leads to improved health outcomes.” Mr. Secretary, you have been instrumental in keeping the VA focused on what is best for the Veteran, and we believe that to do so requires the VA to ensure that its clinical staff is operating at its highest capacity.

In a similar vein, we expect that the VA also will soon make the internal policy changes necessary to recognize prescriptive authority for appropriately trained and certified psychologists within the VA system. The Department of Defense (DoD) has granted this authority to its specialized psychologists for over 18 years, with zero adverse effects or complaints during this entire period. The U.S. Public Health Service Commissioned Corps similarly allows psychologists with specific training beyond their doctoral degrees to prescribe a set of medications and meet the urgent needs of their populations, which include citizens in Indian Country. Illinois became the latest state to grant this authority to psychologists with additional degrees in psychopharmacology and certification. It is clear that the VA, in the face of increasing demand for mental health care and recognized access difficulties in rural areas specifically, must remain a pioneer in the health care arena by allowing nurse practitioners and psychologists to serve Veterans with the expertise and dedication they employ in the DoD, USPHS, and private sectors.

We would be happy to meet with you and your Undersecretary of Health, Dr. David Shulkin, to discuss the implementation of prescriptive authority within the VA. . . .

Two additional Presidential colleagues requested being added to the letter; however, the submission date had already passed. Our sincerest appreciation to APA’s Heather O’Beirne Kelly for her outstanding assistance in making our collective voice heard on behalf of our nation’s Veterans.

A similarly supportive endorsement was submitted by Dr. Lucinda Maine, Executive VP and CEO of the American Association of Colleges of Pharmacy.

The American Association of Colleges of Pharmacy (AACP) appreciates the opportunity to comment on the proposed regulation… and is supportive of the proposal to “permit full practice authority for all Veterans Administration advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.” We draw upon significant experience with advanced practice authority for pharmacists and other health care providers in preparing these comments.

AACP recognizes that APRNs are increasingly important providers of primary care services in the non-VA health care sector and applauds the VA for integrating these skilled health professionals into the VHA. We view this as an excellent opportunity to “wisely manage its resources and fully utilize the skills of its health care providers to the full extent of their education, training and certification.” We support the VA taking the initiative to “establish additional professional qualifications an individual must possess to be appointed as an APRN with VA.” The VA’s proposal to standardize the APRN full practice authority by reducing the confounding factor of state regulation is an important step that allows for more consistent management of patient, provider and administrator expectations within the VHA. This action is an important step in increasing patient access to primary care services, especially, as you recognize, in medically underserved areas.

AACP is a strong proponent of patient-centered team-based care. As a founding member of the Interprofessional Education Collaborative (IPEC) we have worked closely with our colleagues across academic medicine, nursing, dentistry and public health to teach future health professionals how to most effectively work together. Quite recently the IPEC organization expanded to include 9 additional health professions education associations. As this includes the Association of Schools of Allied Health Professions, IPEC now includes virtually all the health disciplines. Optimizing the deployment of every clinician is the only pathway to insuring access to care for all, especially special populations like veterans who so often are in rural or otherwise underserved communities. Translating this work into the care delivery systems our graduates will serve is also a high priority for IPEC.

AACP shares the VA’s concern about the timely provision of high-quality care, particularly primary care, by qualified healthcare professionals in locations readily accessible to the larger percentage of veterans. Towards that end, AACP also encourages the VA to consider proposing a similar set of rules for pharmacists. Like APRNs, pharmacists in the VHA are subject to the congressionally mandated qualifications. The VA… is authorized to regulate the professional activities and establish qualifications and conditions of employment of pharmacists as it does APRNs. Your proposal reflects a model that is well established in the Indian Health Service where guidance was issued in 1996 regarding designating pharmacists as primary care providers with prescriptive authority (Special General Memorandum 96-2).

The VHA has been a valued partner with academic pharmacy for decades and VA leadership recognizes the value pharmacists add to the health care team through their collaborative approach to patient care. The Patient Aligned Care Team (PACT) provides ample evidence that pharmacists provide great, and could provide even greater, value to veterans and other members of the primary care team if they were consistently supported and privileged in a manner similar to that proposed in this rule for APRNs.

With an academy of researchers and practitioners focused on care improvement and team-based care, AACP offers the VA the opportunity to initiate a discussion that can create even greater support for and value in the proposed rules related to APRNs through collaboration with pharmacists and other non-physician providers that are authorized with “full practice authority.”

A particularly significant supportive communication also came from the Federal Trade Commission (FTC).

Interesting Reflections

From Floyd Jennings:

The year was 1988—now 28 years ago—and I had been appointed as Chief, Behavioral Health Services at the PHS/IHS Santa Fe Service Unit, in Santa Fe, New Mexico. Limited, dependent prescriptive privileges (RxP) were granted to me by the Medical Director; i.e., a limited formulary excluding scheduled drugs, and dependent upon his supervision. I had the support of the IHS Albuquerque area psychiatrist with whom I spoke regarding every case; review and support was granted by the New Mexico Psychological Association ethics committee. Slightly less than two years later I was to leave that post—by which time, after being invited to speak before the U.S. Senate Committee on Indian Affairs, thousands of letters of complaint had been sent to the Medical Director of IHS by psychiatrists across the nation, though over three hundred patients had been seen, with no adverse effects (and with enormous support from the physicians working in IHS). Note that in the years subsequent, there has been no nimiety of psychiatric physicians seeking to work or even volunteer in those pueblos of the Albuquerque area!

From those turbulent beginnings, and due both to vision and persistence, psychologists have been given authority to exercise prescriptive privileges in Iowa, Illinois, New Mexico, and Louisiana, as well as in the Public Health Service, the U.S. military, and Guam. A cursory look at the New Mexico Board of Psychologist Examiners website reveals 40 names of persons with active certification as prescribing psychologists. Though by no means thorough, an internet search turns up approximately 11 who are in PHS/IHS, state or federal agencies, or mental health facilities. Many psychologists having national prominence in this area have now completed careers in federal services in the almost 30 years since those days in PHS/IHS. We have indeed “come a long way!”

Yet there is much to be done. For example, in Texas alone, 185 of the 254 counties have no psychiatrist. Nurse Practitioners have been quite successful in extending their scope of practice to include prescriptive privileges—in many venues. In fact, the future of primary care may well transfer to nurse practitioners, with the increasing specialization of medicine and the decreased number of young persons seeking careers in primary medicine, where reimbursement rates are far less than in high technology. Yet, in Texas, and in many other states, the likelihood of expanding the scope of practice for psychology is not great. I argue that is far more likely to occur when the basis is need (rather than greed). Wouldn’t it be interesting if there were many programs to train psychologists to prescribe—at no cost to the person—in return for a two-year commitment to work in an underserved area? Wouldn’t it be exciting if there were a national recognition of the absolute necessity to increase the array of health resources in now underserved areas—of which psychology could be a part? At 75, I expect that I shall not live to see it, but I can dream, can’t I?

And, from Ray Folen, Executive Director of the Hawaii Psychological Association: “Over the last 10 years while at Tripler Army Medical Center I had written 3,178 prescriptions and my colleague Mike Kellar had written 5,780. No adverse events.” Psychology prides itself on being one of the learned professions. Yet, whenever Beth Rom-Rymer provides an update on the exciting implementation of her Illinois success, one of our largest Divisions declines to publish her comments on their e-mail list serve; notwithstanding that RxP is APA policy. She notes, “Our progeny have stars in their eyes. Let’s help them realize their dreams.” Perhaps this Division hopes to protect their membership from the future? I am reminded of the line, “You don’t know what I’ve done”—but let us work together to change that sad reality.

Aloha.