ACLP president Madeleine Becker, MD, FACLP, asked the two candidates for the APA’s 2024 President-elect elections to respond to six 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 are:
APA members are reminded that voting closes at 11:59pm ET Wednesday, January 31st. For more information about the election and the candidates, see 2024 APA Election on the American Psychiatric Association’s website.
Maintaining the gains with Collaborative and Integrated Care: 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?
MISKIMEN RIVERA: As the leading psychiatric organization globally, the APA leverages its resources in numerous ways towards the advancement of our profession. In the area of maintaining and advancing integrated behavioral care, including collaborative care, the recent partnering with the American Medical Association (AMA) and six leading medical associations to form the Behavioral Health Integration Collaborative, is a clear indicator that the impetus for integration of mental and physical health care remains a high priority for the organization. This think-tank structure has been hard at work garnering the expertise of psychiatric and non-psychiatric medical organizations to overcome implementation barriers to integrated behavioral health care and develop sustainable payment models beyond academic centers into the daily practice of medicine across the nation. One product from this collaboration consists of a tool-kit available online for community-based practices detailing a road map on how to implement integrated care. I believe that this joint approach must be an integral component of the APA’s long-term strategic plan to advance evidence-based, culturally relevant, and financially viable integrated models in the years to come.
The APA has, and continues to be, an influential agent in promoting awareness and disseminating the value and gains of integrated care innovations via their strong media presence and education infrastructure. These elements are critical in broadcasting best-practices and implementation tools to medical professionals beyond the psychiatric community utilizing forums such as webinars, remote learning, and periodical series. I fully support the APA’s continued investment in conveying to the non-psychiatric medical community the advantages of including mental health care in all aspects of health care.
The APA, with its proven track record developing data-driven policies, continues to be positioned to champion the gains of integrated behavioral health care models both at the state and national levels especially at a time when new policies are required with evolving value-based population health management care. The APA’s influence as a voting member of the AMA’s House of Delegates, now joined by the ACLP, has been instrumental in the issuing of new integrated behavioral health care financial codes and is now focusing on incentivizing the widespread adoption of alternative payment models, including bundled payments and shared savings arrangements going forward. Further, our organizations must maintain strong leadership to develop and implement competencies and set performance indicators that could be used to evaluate the ability to practice collaboratively and reflective of effective and viable systems, as we continue to step away from siloed care.
REID: The APA must continue to work with non-psychiatric medical associations, such as the American Medical Association, to address expansion of the integrated care model. APA should also partner with Federally Qualified Health Centers (FQHCs) and Certified Community Behavioral Health Clinics (CCBHCs) to expand this model for populations of persons served primarily by Medicaid and Medicare. Working in an integrated federally funded CCBHC with multiple locations and onsite FQHCs, I have seen the value of integrated and collaborative care models. Outcomes included improved control of diabetes, hypertension and obesity and improved satisfaction with both psychiatric and medical services.
ACLP collaboration with APA: 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?
MISKIMEN RIVERA: I envision that the APA and the ACLP will continue to expand and evolve the numerous touch points between the organizations going forward. The ACLP and C-L psychiatrists will continue to serve as subject and content matter experts in the dissemination and implementation of integrated mental health care models beyond outpatient settings into hospital-based programs including proactive consultation-liaison services for inpatient medical and surgical populations.
Based on my experience, there are many nuances in providing care to patients with comorbid physical and mental health that are only fully met by consultation and liaison psychiatrists. Therefore, while we must continue to explore and invest in strategies to increase the numbers of C/L psychiatrists, we must provide innovative models to expand the scope of influence with nonpsychiatric teams starting at the medical school level. For instance, embed in medical school curriculums education modules, informed by C/L experts, to develop relationships of trust among the medical and psychiatric teams. This can be further strengthened by incorporating training to create environments of interprofessional education and collaboration aimed at increasing the knowledge base of the value of interdisciplinary partnership. In my opinion, this type of initiative will gradually move the field away from a predominantly reactive consultation environment and move towards proactive care before a crisis emerges, in alignment with a person-centered approach and working towards decreasing stigma for patients with diagnosed psychiatric disorders in various medical settings.
I believe that one tangible joint program could focus on the development and viability assessment of hospital-based proactive models of care including demonstration projects tracking outcome measures such as decreased length of stay. Such projects can provide the foundation to replicate and expand successful models to inform long-term strategic planning at a legislative level.
REID: At the present time we need more collaboration with organizations that primarily treat underserved populations such as FQHCs and CCBHCs. The APA should have closer collaboration with the National Council on Mental Well Being, the Substance Abuse and Mental Health Services Administration and the National Association of Community Health Centers (NACHC) who represent or fund FQHCs and CCBHCs. For example, one project to expand integrated and collaborative care would be for the APA to closely collaborate with the NACHC to implement collaborative care in FQHC settings.
Workforce Development: 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?
MISKIMEN RIVERA: I am in favor of “fast-tracking” fellowship training to other subspecialties as one of various approaches to address the current workforce crisis. Based on the child and adolescent model, I appreciate how compressing the training timeline alleviates the trainees’ financial burden and having a shortened fellowship experience could attract more candidates. For this alternative pathway to work, residency training directors will need to allocate resources and ensure collaboration with other organizations such as the American Association of Director of Psychiatric Residency Training (AADPRT), the Accreditation Council for Graduate Medical Education (ACGME), and the American Board of Psychiatry and Neurology (ABPN) to explore and decide on how the curriculum will evolve to ensure that the training competencies are met with the new timelines.
The workforce shortage is a complex issue that requires a multi-prong approach. The gains in residency training positions and graduates over the past decade has not been enough to surpass the demand and the increased unmet needs for psychiatric care. As stated above, exploring alternative pathways to increase the interest in pursuing fellowships can result in increased job opportunities and remuneration, ability to pursue personal interests such as reproductive health care and palliative care, and networking opportunities within the subspecialty group.
Another aspect of this multi-prong approach is to explore solutions geared to decreasing administrative burdens for practicing psychiatrists, such as prior authorizations, ever increasing documentation requirements, and the need for improved electronic health record system solutions, among others. These administrative burdens are compounded by the lack of a team-based approach in which coordination of care activities are allocated to the various members of the team further constricting the ability of the psychiatrist to provide direct patient care services.
To date, the adoption of integrated mental health models remains limited, lacking the necessary critical mass needed to change the working environment but research indicates that not only does this model free the psychiatrist to focus on direct patient care, but it also leads to increased access to care and improved time utilization and management. Such an approach aligns with the quadruple aim of improving job satisfaction. In turn, it is possible that by increasing job satisfaction the trend of psychiatrists pursuing early retirement as seen post-pandemic could be averted.
REID: Fast tracking fellowship training must be carefully studied in order to ensure that the duration of the training is adequate to prepare graduates for the workforce. We want to ensure that patients have access to quality care provided by well-trained psychiatrists.
Another way to address the work force shortage in psychiatry is to advocate for comprehensive student loan reform. This will ensure that graduates are able to afford to work in public sector psychiatry where the need is greatest. Also, expansion of the APA pipeline programs to encourage undergraduates to consider medicine and psychiatry is greatly needed.
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 in healthcare organizations. 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?
MISKIMEN RIVERA: It is evident that the ACLP has cultivated a strong reciprocal relationship with the APA. In partnering with the APA, the ACLP will continue to leverage APA’s relationships and influence with payers, stakeholders, and health systems to inform and educate policymakers on the value of advancing payment model reform in view of cost-savings projections when effective integrated mental health models are implemented. Over the past five years we have seen gains in payment reform driven by an abundance of evidence when implementing efficient integrated behavioral health care. Unfortunately, the adoption of alternative payment options has remained low.
Interorganizational initiatives to pull together resources and utilize the collective scale will be instrumental in securing increased adoption of payment reform in the years to come. Another area of innovation might emerge from the PsychPRO registry for research and development of new integrated health quality measures that could help shape the strategic planning to secure sustainable financial models leveraging a population-based framework.
The ACLP can also benefit from the reach of the APA with its online public-facing educational platform which includes video, online resources, and the ability to broadly disseminate organizational views such as the APA Position Statement on Integrated Care. The APA has already commissioned several iterations of an assessment analyzing the potential economic impact of the integration of medical and mental health care financial models. In future iterations there might be room for the inclusion of ACLP specific provisions as part of these assessments.
REID: Integration of the collaborative care model into the FQHC and CCBHC infrastructure where enhanced Medicaid payments cover the true cost of services would be a potential payment model to consider.
Telehealth: How should the APA advocate for the future of telehealth?
MISKIMEN RIVERA: Over the past several years, in my experience, telehealth has been an effective way to secure access and engagement in psychiatric treatment especially among individuals with barriers to care such as transportation, child-care needs, and lack of mobility. I believe that the recent advances in telepsychiatry services have come too far to stop now. To me, it is evident that our patients have benefitted from this service delivery model, and we cannot let those gains slide.
While the pandemic forced a shift towards telepsychiatry, it is my belief that a hybrid approach is needed as we continue to develop, implement, and sustain telepsychiatric models. Having the option of a combined model of in-person and virtual sessions based on acuity of symptoms, personal, and life-related needs will yield better outcomes. The APA is in a position to continue to advocate for the profession at large to enact policies and telepsychiatric services payment reform in going forward.
As a point of reference, we can gain insights from the developments currently taking place at the AMA, where legislative advocacy efforts have led to the introduction of a bipartisan bill in Congress to eliminate the 3.37% Medicare physician pay cut. The APA has participated in this and many other advocacy efforts. This has led to cultivated relationships with key stakeholders and the ability to harness lessons learned and craft an effective messaging to be used in support of sustained telepsychiatric services.
We must continue to collaborate as there is strength in numbers.
REID: The APA should expand partnerships and advocacy for telehealth with SAMHSA, NACHC and the National Council for Mental Wellbeing, whose providers serve many Medicaid beneficiaries across the nation. The APA and these partners speaking with one voice about the value of virtual care would be a powerful and impactful message. In Michigan, using this strategy, we successfully advocated for a reversal of the rules restricting telehealth services for dialectal behavioral therapy and peer support services.
Diversity, Equity, and Inclusion (DEI): 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?
MISKIMEN RIVERA: I can provide a specific example to address the first part of this question. Five years ago, funded by a grant provided by the Physician Foundation, the inaugural Women’s Wellness through Equity and Leadership Project (WEL) brought together six major medical associations, the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), American College of Obstetricians and Gynecologists (ACOG), American Psychiatric Association (APA), and the American Hospital Association (AHA). The goal was to develop a framework and curriculum focused on networking and education around leadership, equity, and wellness for underrepresented groups in medicine, specifically a diverse group of early and mid-career female physicians including representation from ethnic minority groups, rural settings, public and private sectors. The APA continues to serve as a Steering Committee member and the project, currently in its third iteration, has expanded to include 10 major medical associations in the United States. As the APA representative on the Steering Committee and as a Hispanic psychiatrist, it has been a great honor to champion the agenda on how medical associations and health care environments can positively impact the experiences of underrepresented physicians and addressing issues of equity to foster needed and sustained changes. This is the type of interorganizational collaboration that the APA has been and will continue to be supportive of in the years to come. The aspirational goal being to nurture the future leaders from DEI groups considering that DEI representation in health organizations at large ultimately improves patient satisfaction and outcomes.
Regarding how to enhance models of care for Minority and Underserved populations, based on my personal experience and having dedicated my career to providing care to minoritized populations, I believe that health equity must be at the forefront of any strategic planning in health care systems and for leaders to acknowledge and address health inequities as a threat to public health. While health care systems continue to address the grave consequences of biased health care, we have much work to do. It is imperative that all health care leaders and stakeholders initiate any discussion on how to improve the health of nation by acknowledging the current state of health inequities. We have to advance the research and education on the impact of social determinants of health, we have to disseminate information on why health inequity is not a minority problem, it is an “us” problem, we need to secure services for underserved communities, increase the level of trust in our profession and medicine in general among underserved populations, and we have to expand health insurance coverage. The repercussions of health inequities will persist if we do not act now.
In order for all the above priorities and ambitions to materialize, we need a long-term blueprint to follow. The tenure of any single APA president is not long enough to see these changes come to fruition. Therefore, it is critical to reach alignment on what this roadmap should accomplish to be able to measure the progress, learn from any setbacks, and recalibrate from innovation as we move forward year after year.
REID: The best way for the APA to address diversity, equity, inclusion and belonging is to fully implement the existing recommendations and plans developed by of the Presidential Task Force to Address Structural Racism at the APA and Throughout Psychiatry and the APA Division of Diversity and Health Equity (DDHE) strategic plan to work toward achieving diversity and mental health equity.