ACLP president Philip Bialer, MD, FACLP, asked the two candidates for the APA’s 2022 President-elect elections to respond to seven issues of concern to the Academy. The questions and their responses are below, which are intended to help you be as fully informed as possible about the candidates’ views on these matters as you make your choice in the election.
The issues of concern to the Academy involve:
The candidates, in alphabetical order, are:
APA members are reminded that voting closes at 11:59pm ET Monday, January 31st. For more information about the election and the candidates, see 2022 APA Election on the American Psychiatric Association’s website.
Maintaining the gains with Collaborative and Integrated Care: The past several years have seen significant progress in terms of defining and supporting the roles of psychiatrists in integrated care settings, especially collaborative care (e.g., the collaborative care payment codes). Our members are uniquely trained to be successful in practicing in primary care settings but are also active in integration of behavioral health services into specialty medical settings (e.g., transplant, oncology, rehabilitation settings). Another innovative approach is proactive consultation in inpatient settings which has been shown to decrease length of stay for inpatient medical patients. What are your thoughts on how APA can maintain and extend the gains made in supporting the roles of psychiatrists in integrated care settings? How can the APA promote collaboration with non-psychiatric medical organizations to promote awareness and value of integrated care innovations?
LEVOUNIS: The APA’s Council on Advocacy and Government Relations has been spearheading bipartisan legislation for further integration of behavioral health with primary care. The Psychiatric Collaborative Care Model (CoCM) can be greatly enhanced—and funded—by successfully passing and implementing such legislation. We already have the support of the American Academy of Family Physicians, the American College of Physicians, and the National Association of Social Workers among many others. Let’s capitalize and expand on these critical collaborations.
Furthermore, the APA is now in a unique position to leverage large-scale data sets to support our mission. For example, the clinical and financial gains of our C-L expertise can be greatly substantiated with PsychPRO, the APA’s Mental Health Registry, which is a CMS Qualified Clinical Data Registry (QCDR). Such evidence can strengthen our voice and help us argue what we already know: psychiatric consultations have downstream clinical and financial benefits that are both quite significant and measurable.
POTASH: I thoroughly agree with all of the above [stated in the question]. At Johns Hopkins I am pleased that we have work going on in all of the areas mentioned here. We have psychiatrists supervising counselors in the primary care setting, others working in specialty clinics including, for example, transplant, gastroenterology, and sickle cell disease, and proactive teams working hand in hand with colleagues in medicine. The APA has been very active in promoting the Collaborative Care Model, which serves as an important way to extend our reach and our expertise into the primary care arena. It has the great advantage of having billing codes attached to it, which are currently reimbursed by many payers around the country. But there are still also a number of payers in a number of states that do not currently reimburse for it. We need to advocate for more states to adopt the APA’s model legislation for private insurance coverage of these codes. On the education front, the expansion of these new practice environments means that residencies need to prepare people in innovative ways to be able to function most effectively within them. The APA can advocate with the ACGME to strengthen residency requirements in this area. The APA, as the largest and most influential voice for psychiatry in America, is ideally suited for advocacy with other organizations. We do need to be advocating for heightened collaboration with non-psychiatric medical organizations to promote an awareness of and the value of integrated care innovations. Much of this occurs through the APA’s advocacy staff, and it is guided by the APA’s Council on Advocacy and Government Relations. One avenue through which these kinds of cross-organizational relationships are nurtured is the Mental Health Liaison Group, in which the APA plays a leading role. This is a coalition of national organizations that includes the American Mental Health Counselors Association, the American Psychiatric Nurses Association, and the Clinical Social Work Association, among others. All are seeking ways to influence legislation and regulation for the sake of better mental health services. We need to come together to find the common ground we share around issues of care integration in the interest of better access to care for our patients. We need to support collaboration across mental health disciplines while maintaining the unique role of the psychiatrist and advocating for appropriately high standards for groups like nurse practitioners and physician’s assistants.
ACLP collaboration with APA: The APA Council on Consultation-Liaison Psychiatry (CoCLP) has been very active in APA affairs and there are a significant number of ACLP members in CoCLP who have been involved in the creation of resource documents, action papers, and articles for Psych News. The ACLP has also collaborated with APA on a successful monograph on dissemination of integrated care. There is a strong relationship created when APA’s size and advocacy experience is combined with subspecialty subject matter expertise. What do you see as the future role of ACLP and C-L psychiatrists in APA’s ongoing initiatives to advance the field of Psychiatry? Are there any specific ideas, positions or projects that you can see as an opportunity for continued collaboration between our organizations?
LEVOUNIS: Subspecialty organizations within psychiatry, such as ACLP and my own subspecialty group—the American Academy of Addiction Psychiatry (AAAP), are becoming increasingly important in defining and promoting the work of the APA. For example, ACLP, through its HIV Steering Committee, has set the agenda for the psychiatric response to the HIV epidemic. We will now rely on the Consultation-Liaison know-how to shape the APA’s priorities on the psychiatric dimensions of the current pandemic. The APA’s advocacy, education, and research efforts with respect to COVID-19 will be smarter and stronger the closer we work with the subspecialty organizations, primarily ACLP.
What we have not done as successfully is collaboration among subspecialty groups. I was delighted to see the CoCLP taking the lead in collaborating with the Council on Addiction Psychiatry on a resource document for the treatment of Opioid Use Disorders in the general hospital setting. I hope that ACLP will take a similar initiative in collaborating with the American Academy of Psychiatry and the Law (AAPL) to help us navigate the shifting medico-legal landscape of the COVID world.
POTASH: I couldn’t agree more with the idea that combining APA’s size, advocacy experience, and influence with subspecialty subject matter expertise is the right recipe for success in moving the field in positive directions. The strong relationship between the ACLP and the APA Council on Consultation-Liaison Psychiatry exemplifies the kind of role I think the APA should play in amplifying the messages of experts in our subspecialty areas, and bringing them to broader attention in the field. C-L psychiatry provides our best opportunity to promote greater centrality for us in the House of Medicine. More attention needs to be paid to developing new initiatives that capitalize on the increasing recognition for the need for C-L services and their ultimate cost-effectiveness. We should consider projects that help to understand the social determinants of health as they relate to patients seen in C-L setting, and those focused on the disparate impact on marginalized communities of recent (and likely continuing) stresses imposed on health care organizations by COVID.
Psychiatric Fellowship Training: Our organization is deeply committed to psychiatric education, at the medical school, residency, and fellowship level. What is your opinion of the value of fellowship training for psychiatry as a field, and what is your philosophy on the role of subspecialists in Psychiatry?
LEVOUNIS: The APA is also deeply committed to psychiatric education at the three levels you mention above. However, current circumstances mandate us to take our passion and expertise a step further—in a major way. Accelerated by the pandemic, our colleagues from our other medical specialties, non-physicians in behavioral help professions, politicians, journalists, scientists, teachers, and parents, to name a few, have been asking for guidance in addressing mental health. Psychiatry is taking the lead in responding to this “ask,” and we need all the help we can get from subspecialists. Who would be better to address opioid overdose prevention than a subspecialist in Addiction Psychiatry? Who will educate people about the psychiatric aspects of long COVID better than a subspecialist in C-L Psychiatry?
Ultimately, this question is tightly related to the next question, the one on workforce development. The demand for psychiatric expertise far exceeds its supply, so we need to adopt a “train the trainer” philosophy—including subspecialty training—to start bridging this critical workforce gap.
POTASH: On the one hand, psychiatry residencies provide good training in every aspect of what it takes to be an effective psychiatrist. And this includes experience in doing consultation-liaison psychiatry. The majority of psychiatrists providing C-L services in America are not fellowship trained. On the other hand, we absolutely need sub-specialty fellowship training because every niche within our field has nuances to it, and depth to it, which is far from fully plumbed in residency. C-L psychiatry is no exception, and fellowship training allows for the development of a level of mastery of key principles, like in medical ethics, and experience in the many niches—like HIV psychiatry, psycho-oncology, and women’s heath– that make up the field. Fellowships, of course, provide clinical expertise, and they also help us to create the researchers who will develop the next generation of best practices, the thought leaders who will disseminate best practices, and the educators who will teach the next generation. Subspecialists are indispensable if we are to continue to innovate in our field. Yet we have serious workforce and recruitment issues in filling C-L fellowships. The national fill percentage is not where it should be. There are a number of reasons for this, including competition with other fellowships, rising salaries for adult residency graduates going straight into practice, and overall workforce shortage issues (see next question).
Workforce Development: ACLP, similar to other psychiatry subspecialties, presently and into the future, faces a critical workforce shortfall. ACLP is working with other psychiatry subspecialty organizations and APA Councils in consultation-liaison psychiatry, geriatric, and addiction psychiatry to address this workforce shortage. One idea being discussed is expanding the concept of “fast-tracking” fellowship training (overlap with residency), as organized in child and adolescent psychiatry, to other subspecialties. What are your thoughts about this proposal? What other ideas do you have to address the workforce shortage in psychiatry and its subspecialties?
LEVOUNIS: I can see a few pros and cons of the “fast-tracking” fellowship training idea. Colleges and medical schools increasingly warm up to three-year curricula. A four-year general and subspecialty psychiatry training program would align with this trend in education, help our workforce shortage, and partially relieve the exorbitant medical school loans that early career psychiatrists face. On the other hand, supervised psychotherapy training takes time and would likely suffer from a shortened general psychiatry program. Furthermore, reducing or eliminating elective rotations is problematic. During my fourth year of residency at Columbia, I was fortunate to take invaluable electives in college mental health, neuromodulation, and brief psychodynamic psychotherapy.
We may also need to expand our subspecialty training options through innovative and flexible alternatives. For example, our Executive Fellowship in Addiction Medicine (E-FAM) at Rutgers allowed junior faculty to continue practicing as attendings while concurrently pursuing additional training in addiction.
POTASH: These are important issues for our field, and important issues from a public mental health perspective for patients in need of high-quality care. With regard to the field in general, estimates suggest a national shortfall of at least 14,000 psychiatrists over the next several years. Clearly, we need to train more psychiatrists. That requires funding for more residency training slots. There is reason to be hopeful here as the Build Back Better Act, currently before the Senate, includes a new provision that would provide 4,000 new, Medicare-supported residency slots, with a chunk of them slated for psychiatry. The APA is strongly supporting this. With regard to the subspecialties, one important thing that we need to do is advocate for the survival of existing fellowship programs and creation of new ones. This means advocating for grant programs and resource allocation that support these positions. Another key is lessening the financial burdens associated with doing a fellowship, through loan repayment. There are programs in the addictions and child and adolescent psychiatry arena that are pursuing this path, but we need to push for more to be done here. Advocating for supplementing salaries is another approach that makes sense. The “fast-tracking” route similarly reduces the financial, and time, burdens associated with sub-specialty training, and it is an interesting concept that is well worth careful consideration. It would certainly increase the appeal of fellowship for some people, and increase the number of people who choose this route, which is a big reason to take the concept seriously. Downsides include the decrement in overall mastery resulting from a year’s less training and the workforce challenges created within residencies by the loss of person-power. As President-Elect and President, I would hope to work with ACLP leadership to see what ideas you have to make fellowship and C-L practice more attractive.
Financial Models: C-L psychiatrists have traditionally been of financial value to health care organizations by a) adding overall value to health care outcomes, and b) driving cost savings. These factors often far outweigh the ability of our members to bring in substantial reimbursements. APA has conducted benchmarking activities and other advocacy-related activities to help with efforts to support financial positions of psychiatrists. ACLP has also conducted benchmarking activities, the results of which are not yet in. Do you have thoughts about how APA’s experience might help with the Academy’s efforts to be more effective in developing credible financial models for C-L psychiatrists in their organizations?
LEVOUNIS: As mentioned above, the APA can leverage data from its own Mental Health Registry, PsychPRO, to support and expand on the Academy’s benchmarking and financial models. In addition, the APA has partnered with other medical specialty organizations, as well as the American Medical Association (AMA), on several projects to promote common goals. We can use these professional relationships to gain access to data that will further establish the clinical and financial value of our work.
On the local level, the APA can provide a common methodology to help individual departments of psychiatry show—specifically—how psychiatric consultations translate into direct benefits for medical, surgical, and OB-GYN departments. While this work is already under way for transplant and neurosurgical teams among others, the APA can catalyze such efforts across all specialties and subspecialties in the House of Medicine.
POTASH: Good points. We all know that C-L psychiatrists add tremendous value clinically when it comes to ensuring patients get the kind of comprehensive care that they need. And we know that non-psychiatric physicians value the contributions C-L psychiatrists make immensely. On the clinical front, there are outcomes data to support the added value. The financial piece is often a challenging one, as all of us in psychiatric leadership positions know, because our hospital administrators and leaders don’t always recognize the big picture financial advantages that C-L psychiatry brings. They don’t always see that although hospitals need to provide direct subsidies, they derive indirect benefits, from, for example, shortened lengths of stay. I think having the APA bring its mental health services financing savvy, and its savvy in communications and advocacy, to bear here makes a lot of sense. I would have liked recently to have a one- or two-page APA document in hand when I was making the case to my hospital leadership for an additional proactive consultation team. Having a financial model readily available to support the argument would greatly enhance our ability to persuade hospital leaders to make important investments in this critical area. Having such data available for Collaborative Care has had a powerful impact on developing those services.
Telehealth: Telehealth played a crucial role in our ability to provide care to our patients during the COVID-19 health emergency. Some states are now cutting back on reimbursing for telehealth services and the continued Federal support for Telehealth services remains unclear. How should the APA advocate for the future of Telehealth?
LEVOUNIS: The evaluation and treatment of psychiatric disorders lends itself to telemedicine perhaps better than any other medical specialty, and the APA should be at the forefront of securing the future of telehealth. A three-prong approach can help us achieve maximum benefit from this relatively new modality beyond the emergency provisions relating to COVID-19:
1. At the federal level, the APA advocates for permanently removing geographic, site-of-service, and audio-visual (as opposed to allowing audio-visual as well as audio-only) restrictions for all mental health services. If we are successful, such legislation will be particularly helpful to our older adult and economically depressed patients, who already face problems accessing critical psychiatric care.
2. At the state level, positive telehealth laws, both in terms of lifting restrictions and securing reimbursement, are being threatened. The APA has already facilitated and should continue to actively support the work of district branches in their advocacy efforts. We are getting there: the APA’s model telemedicine legislation has been adopted by over half the states.
3. As exciting as telehealth is, most psychiatrists are not familiar with its inner workings, its full potential, or its significant limitations. The APA should provide extensive guidance to its members on the clinical aspects, ethics, and logistics (confidentiality, prescribing, billing, etc.) of practicing telepsychiatry.
POTASH: No doubt about it. Telehealth has been a remarkable means to improve access, and it will continue to be a valuable way for us to address psychiatric needs that can sometimes be otherwise difficult to meet. Additionally, on our side of the equation, the rule changes have enabled some psychiatrists to practice from home, and this has allowed them flexibility that has been welcome. Rolling back these changes could be disruptive for us, as well as for our patients. The emergency flexing of telepsychiatry has helped to ease the strain of the last couple of years, but the end of some of those temporary rule changes and the potential for more of them to end creates the possibility that more people will find it difficult to access our care. The recent CMS ruling to remove geographic restrictions for telepsychiatry and to, at least temporarily, extend reimbursement for it under Medicare, is a fantastic step in the right direction, made possible in part through the hard work of people within the APA. The APA and district branches absolutely need to advocate for laws and regulations that preserve our ability to make full use of telepsychiatry. This is a situation where the APA needs to support the district branches as robustly as possible, because so much of this process plays out at the state level.
Diversity, Equity, and Inclusion (DEI): The past few years have highlighted the dynamic of systemic racism in our society. This extends to leadership of professional organizations and the healthcare of Minority and Underserved populations. What can the APA do to address DEI within our profession and what are your thoughts on how to enhance models of care for Minority and Underserved populations?
LEVOUNIS: As a gay man, I have experienced stigma and discrimination both in professional and social settings. I have also worked within the APA governance, the APA Publishing, and the Association of LGBTQ+ Psychiatrists (AGLP) to address health disparities in minority populations. At the same time, the APA as an organization has been taking a hard look at its own systemic racism.
We are now at a point where we can use the considerable lessons we have learned from our work with different underrepresented and underserved groups to build a culture of diversity, equity, and inclusion that will serve as a model for other medical specialties. Moreover, if we work together, our psychiatric appreciation of the historical, psychosocial, and cultural complexities of racism may very well provide invaluable insights that will help the US move the needle on social justice.
POTASH: I applaud the work that has been done over the last couple of years to talk honestly about the APA’s flawed history and to work constructively towards ensuring that we make the present and the future better than the past for people of color in our profession and in the APA. This includes valuable efforts aimed at ending structural racism within the APA, with the establishment of committees that are carrying this forward, the work of which I firmly support. One priority is that the APA should continue to make efforts to bring people from under-represented groups into leadership. I am also enthusiastic about efforts to exert an impact far earlier in the pipeline, to encourage more people of color to come into our field. At Johns Hopkins, for example, we have faculty going to historically black colleges and universities to encourage people to seek out psychiatry for residency. It is also important to have residency curricula across the country include education in cross-cultural psychiatry and in mental health services for people from minority and underserved populations. This is good for patient care and for training excellent clinicians, and it can also attract more people of color into the field, as it makes a statement that our values and interests lie in a place that feels welcoming and compelling. Another thing I’d like to explore is the possibility of creating a student loan repayment program for young people of color coming into our field. That is something that could make a very tangible difference. With regard to models of care, I think broader implementation of the Collaborative Care Model will have an impact on improved access to care for minority and underserved populations. Studies have shown that the model results, for example, in better clinical outcomes among African-American and Hispanic patients with depression.
I want to close by thanking you for your leadership in this distinguished and important organization. I know it has been led by very talented people, including current and former colleagues of mine at Johns Hopkins and at the University of Iowa. The ACLP’s wonderful work in promoting the integration of medicine and psychiatry is praiseworthy and plays a role in shaping the next-generation version of our field.