Author Archives: Susan

Can Louisiana Fully Embrace Integrated Healthcare?

by J Nelson

For decades now, psychological scientists have demonstrated that savings from 30 to 60
percent in medical costs and much better health outcomes are possible if we give up the
biomedical model and embrace the psychological-social-biological framework instead, called
integrated care. But can Louisiana make this change? In this article we review where we are
and where we’re going, and some of the barriers to change that seem to persist.

If the famous axiom is right, and we have to hit bottom to get better, Louisiana should be due
for improvements in its health and healthcare system. Last year U.S. News & World Report
ranked 50th overall with a 45th in healthcare. The rank included a 43rd place in mortality, a
46th in infant mortality, a 50th in obesity, and a 43rd rank in smoking. At the same time,
Louisiana’s costs are high–the Report placing the state at 45th in health care affordability.

This pattern of poor health outcomes and high costs reflects the country as a whole. The
United States ranks 50th out of 55 industrialized countries in a measure of life expectancy
and medical care spending, according to Bloomberg, who concluded the U.S. is the “least efficient” health-care system in the world.

Yet, healthcare is the largest industry in the country, accounting for almost $3.5 trillion in sales in 2016,according to the National Health Expenditure Data from CMS. More recently, the  industry is now also the nation’s largest employer.

The sheer size and complexity of the healthcare industry would suggest that innovations would  be challenging, but change may be even more unlikely because of the political power yielded by the industry. Last year the pharmaceutical industry, Blue Cross/Blue Shield, the American Hospital Association, and the American Medical Association were the 4th, 5th, 6th, and 7th highest contributors to Congress, and the year before that pharmaceuticals and insurance was 1st and 2nd.

Given this, it is surprising that the American Psychological Association (APA) recently managed to grab a little territory for psychological assessment, now finally considered as a “thinking” valued activity, in the newest Rules. A feat which required behind closed-door negotiations.

Healthcare is a Closed System

The medical-pharmaceutical-hospital-insurance industrial complex has a firm hold on the prices and services in this country, through the “CPT Codes” and the “Relative Value Scale Update  Committee” or RUC. These groups decide what services are allowed and how much they are reimbursed.

Three hundred “Advisors and Experts,” primarily from the American Medical Association’s House of Delegates, representing 109 medical specialties, attempt to influence an “Editorial Panel,” composed of representatives from medical societies, insurance companies and the government.

This panel conducts closed meetings and decides on what healthcare services are paid for, and  which are not, by way of the complex set of codes known as CPT or “Current Procedural Terminology.” CPT is owned by the Center for Medicare and Medicaid Services (CMS), leased to the American Medical Association (AMA), who then copyrights it and strictly controls the development of new codes. The RUC assigns the value to the service, and somehow this is not considered price-fixing or restraint of trade.

The system includes the FDA, which receives 40 percent of its funding from the pharmaceutical companies, Dr. Irving Kirsch, Associate Director of the Program for Placebo Studies at Harvard Medical School, has explained. Kirsch has also laid out evidence that drug companies and the FDA skew research to approve drugs that have little actual value.

At a 2015 meeting of the Louisiana Psychological Association, Dr. Tony Puente, now a past-president of APA, was one of the two outsiders allowed to participate in the CPT process. “Essentially,” he said, “the CPT tries to divvy it up in a way that is theoretically and empirically, and diplomatically and politically,  correct.” Participants must sign a strict AMA confidentiality
agreement and declare, “I will not disclose, distribute or publish confidential Information to any party in any manner whatsoever.”

To decide on reimbursement, 28 voting members on RUC, representing medicine specialties  such as anesthesiology, cardiology, neurology, neurosurgery, obstetrics, oncology, psychiatry, and so on, meet and decide how much each service is worth, and how much is to be paid.

An underrepresentation of primary care in this system and an undervaluing of their contribution, has lead to high-cost specialists and a shortage of primary care physicians, according to the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. This has been shown to negatively impact outcomes. In a special issue of the American Psychologist on Primary Care and Psychology, Dr. Susan McDaniel and primary care leader Dr. Frank deGruy reviewed evidence that for each primary care physician added to a social system, “all-cause mortality decreases by 5.3 percent.” Conversely, for every specialist added the mortality rate goes up 2 percent.

Healthcare is a Misnomer

“Health is a misnomer, because most activity involves illness. Health care and medical care are not synonymous,” said Hamilton Moses and co-authors in, “The Anatomy of Health Care in the United States,” in a 2013 article of the Journal of the American Medical Association (JAMA).

Prevention requires tools that are often unfamiliar because educational, behavioral, and social interventions, not usually considered to be part of medicine, may be most effective for many diseases,” Moses wrote.

While medical costs are driven by chronic disease, it is not due to an aging population, even though age is often cited as the cause. The JAMA authors show that about 80 percent of the total health care cost is accounted for by those under 65, and relate to psychological, social and behavioral elements. The CDC estimates that lifestyle factors account for 80 percent of heart disease and stroke, 80 percent of type 2 diabetes, and 40 percent of cancer.

“Behavioral intervention is the foundation for lifestyle medicine,” writes Dr. John Caccavale, author of Medical Psychology Practice and Policy Perspectives. “Of the top four classes of medical problems in America – metabolic disorders, respiratory disease, cardiovascular disease, and mental disorders – physicians will have great difficulty demonstrating that they are improving patient health by utilizing medications as a first-line treatment for these classes of disorders,” writes Caccavale.

For decades now, psychological scientists have known that behavior is the key to costs. In an interview with primary care psychologist, Dr. Michele Larzelere, she explained that psychological scientists have agreed that those using an integrated care model can expect a 30 to 60 percent reduction in medical use costs.

And, unlike medical care which carries a large risk, behavioral treatments have few side effects. The author of Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, Martin Makary, MD, found that medical error, unrelated to the illness or injury, is the third cause of death nationwide, following only heart disease and cancer deaths.

“It boils down to people dying from the care that they receive rather than the disease for which they are seeking care,” Makary said in a report by The Washington Post. Health is woven into a complex set of social and psychological behaviors, not a single cause. “Socioeconomic status is one of the most powerful predictors of all cause mortality,” says Dr. Chris Leonhard, health psychologist and Professor at the Chicago Professional School at Xavier.

“New Orleans is a startling example of this,” Leonhard said. “Life expectancy at birth in the Tremé where the average household income in 2010 was about $26,000 is 55 years, while in Lakeview, the average 2010 household income $75,000, and life expectancy at birth is 80 years.”

Outdated Treatment Models: The Opioid Crisis Example

A dramatic example of flawed decisions in the medical/pharma industrial complex is the opioid  crisis. Twenty years after a marketing blitz aimed at convincing physicians that opioids were safe and effective, the over-prescribing of this heroine-type drug has catapulted overdose deaths to a rate higher than auto fatalities, HIV or gun deaths.

Louisiana is in the middle of the crisis, with some of the highest opioid prescribing rates in the nation and an escalating death rate from overdose. Last year in a Louisiana House Health and
Welfare Committee hearing, Representative Helena Moreno told members that there are “… more opioids prescribed in Louisiana than are people in this state.”

Despite the flood of legal opioids into the society, the CDC reported no change in pain that would meaningfully drive the prescribing: “…there had not been an overall change in the amount of pain that Americans reported.” The CDC found that there was no long-term benefit for opioids compared to no opioids. However, they did find ample evidence for harm.

In contrast, the CDC did find that psychological and physical treatments for pain were beneficial (“CDC Guideline for Prescribing Opioids for Chronic Pain”). This despite the fact that these non-medical approaches are rarely integrated into treatment programs.

“It is now widely accepted that pain is a biopsychosocial phenomenon,” clinical health psychologist and Past-President of the Southern Pain Society, Dr. Geralyn Datz, told the Times. “For many years the biomedical model of treatment has prevailed as a way to treat pain patients,” Datz said. “This model is based on some very early research about acute pain,” she said. Things are very different now. “We know that chronic pain is a complex and dynamic process, and it involves a person’s thoughts, beliefs, experiences and these all can influence pain for better or worse. In addition, conditions such as depression and anxiety can arise from the presence of pain, and these also can worsen pain through interactions of the brain with the body.”

Louisiana’s Challenges

The intentions to blend psychological factors with traditional healthcare seem sincere in Louisiana. In the Medicaid Annual Report for 2017, the Medicaid Director Jen Steele wrote of her mission to improve quality, patient experience, outcomes and lower costs. And, some progress with Patient Centered Medical Homes has come about.

However, making significant changes may be challenging. Using data from both Medicare and Medicaid use, Louisiana’s costs are above expected in a number of areas. The Kaiser Family Foundation looked at data from 2014 and Medicare spending per enrollee, and found that Louisiana ranked 10th in Medicare spending compared to other states, with New Jersey, Florida, New York, Maryland and Connecticut at the top five.

Data from Dartmouth Atlas of Health Care found that Louisiana has a high average number of inpatient days per beneficiary. In a detailed breakdown from 2012, Dartmouth found that  Louisiana had the highest number of inpatient days per person compared to all other states.
Louisiana averaged 6.0 days per beneficiary while the average across the nation was 4.6 days.

In a group for comparison of multiple chronic conditions Louisiana fell above the 90th percentile again with an average of 20.8 days, while the average was 17 days. For dementia the average number of inpatient days was 30.5, and national average was 22.5.

The Alexandria, Monroe and Shreveport regions are some of the highest areas of hospital usage, based on Medicare data collected by Dartmouth.

Dartmouth found that in 2015, the national average of hospital usage was 254 per 1,000 Medicare enrollees. Louisiana averaged 279.8, and some regions were the highest in the country Alexandria was 335.4, Monroe 325.0, Slidell 320.5, and Shreveport was 294.

Dartmouth researchers note that, “Regional variation in hospital and physician capacity reveals the  irrational distribution of valuable and expensive health care resources. Capacity strongly influences both the quantity and per capita cost of care provided to patients.”

In the Louisiana Medicaid 2017 Annual Report, the top 10 provider types, ranked by payment, were first, hospitals, at $1.3 billion, and second, pharmacy, at $726 million. Dentists were third at $162  million, then mental health rehabilitation at $140 million, nurse practitioners at $115 million, and behavioral health rehabilitation agencies at $114 million. Distinct psychiatric hospitals were next at $76 million and freestanding mental health hospitals at $69.7 million.

In comparison, other providers, which include audiology, chiropractic, personal care attendant, physical and occupational therapy, psychology, social work and other services not covered  otherwise, totaled $917,000.

The need may not be being met, even in this picture. In a 2018-2019 Combined Behavioral
Health Block Grant Plan, published in late 2017, the state noted that the number of persons being served was 3.29% of the estimated prevalence. The estimated number of children/youth with serious emotional disorders was said to be 38,803 and only 1,370 had been served. The prevalence estimate for adults with serious mental illness was 192,019 and only 7,590 had been served.

In the grant report, the state confirmed that it was building its workforce and ability to function in an integrated care environment. The state has indicated progress in developing  integrated care in some ways, looking for its managed care companies to advance the plans.

However, in a list of “Specialized Behavioral Health Services CPT Code” and reimbursements, effective July 2018, the fee structures provide little in the way of reimbursement for health and behavior, or any clear mechanism for integrated services. The “health and behavior” services pay between $12 and $15 and are only listed for a psychiatrist, nurse/physician’s assistant, medical psychologist, and a psychologist. There are none listed for clinical social workers or counselors.

Some codes and fees are listed for psychotherapy. Individual psychotherapy is reimbursed at  69.76 for psychiatrists for 45 minutes, $55.81 for nurse practitioners and physician assistants,
$55.81 for psychologists, and $48.83 for social workers, counselors, and marriage and family
therapists. But this may not translate to integrated care. And group therapy, a valuable therapy mode for many issues, is paid at only $23.23 to $18.58 and there is no reimbursement for the social worker or counselor listed on the current fee schedule.

These arrangements may explain why there are few providers who  chose to participate. Access to care and rates have been a problem nationally, with nearly half of all providers not offering Services to Medicaid patients. Nationwide, Medicaid fees are about 72 percent of Medicare, which is about 80 percent of private pay. Only about 130 psychologists were listed as providers on the 2014 Medicaid rolls, according to a report at that time.

One Representative’s Efforts

During the Louisiana 2016 Regular Legislative Session Representative Barbara Norton from Shreveport put forth a measure, House Bill 1164, to create a task force to study the delivery of
integrated physical and behavioral health services for Medicaid enrollees who suffer with serious mental illness.

Norton brought together an array of associations and state agencies from across disciplines and from across the state to look at ways to improve the care offered by Medicaid.
She told the Times, “This was an opportunity to pull so many people together, at no cost. I met with many of these people who felt as I did, that this would be a great piece of legislation, that they want to help the state of Louisiana and health, and make a real difference.”

The bill passed committee with a 10 to 0 favorable vote. But then, on the House floor, it failed with 51 nays and 33 yeas. Five of those who had supported it in committee switched their votes on the floor and twenty did not vote. Why? Representative Norton thinks it might have been political. “We still feel the Medicaid belongs to President Obama but it belongs to all of us and we’ve not started to understand the significance of these issues.”

Representative Norton tried again in 2017, this time passing a measure as a Concurrent Resolution, asking again for the study of the issue by a comprehensive task force, HCR 55. The
measure passed easily and task force was formed. However, she said that the task force met only twice. The Representative will be calling another meeting in December in Baton Rouge, she said. “It has not been given a fair shake.”

“My goal is to go back with whomever and find out what we can really do for the people because the problems in this area are so serious,” she said. “We’ve not even started to understand the significance of what this should be about and the more we look––the shootings the mental health issues––the more it’s necessary that we reach out to all the people and look at all the facts that there are, and continue to work. Because we’re talking about peoples lives.”

“I understand that sometimes people don’t know the type of leadership it takes but if people want to be on the committee, and care to discuss these real issues, then it’s not the type of thing where a person can call in or send information. We need to discuss ideas and plans,” Norton said.

“I do believe that at the end of the day, with the help of leadership, we may turn some thinking around, and clearly understand why it is so important to look at all these things. I promise you I’m going to work with this until we see some differences, and people see some hope.”

 

Gov. Edwards and First Lady Travel to Israel, Meet with Prime Minister

JERUSALEM, Israel — On October 31, Gov. John Bel Edwards met with Israeli Prime Minister Benjamin Netanyahu as part of a weeklong Louisiana economic development mission in Israel, according to the press release on the same day. Following a photo session, the two discussed Louisiana’s strong relationship with Israel, as well as trade and economic development issues of mutual importance to Israel, the United States and Louisiana.

“This long-awaited meeting is the result of many years of friendship and partnership. On behalf of the people of Louisiana, I was proud to share with Prime Minister Netanyahu that Louisiana stands with Israel, and we will always remain faithful to our staunch ally in the Middle East,” Gov. Edwards said. “Over the years and during this mission, I have come to appreciate how alike our two lands are – similar in industrial strength and similar in economic priorities. But beyond that, Israel and Louisiana are inhabited by warm and welcoming people with a strong desire to succeed and innovate, to leave the legacy of a better way of life to their children and grandchildren. I’m sure this is a source of tremendous pride for Prime Minister Netanyahu, as it is for me. Our delegation has enjoyed learning everything we can about this great nation, and I hope the unique Louisiana culture of innovation that we are sharing in Israel has been equally enjoyed by our hosts.”

Prime Minister Netanyahu has an extensive history of service in the Israeli government and the private sector. He first served as prime minister from 1996 to 1999, and then again from 2009 to the present. He has also held the positions of Minister of Finance, Minister of Foreign Affairs, and Ambassador of Israel to the United Nations. His private sector works includes service with the Boston Consulting Group, and he holds degrees in architecture and business management from MIT. Netanyahu and Edwards are both Army veterans of their nation’s military: Netanyahu served in the Yom Kippur War of 1973. A 1988 graduate of the U.S. Military Academy at West Point, Gov. Edwards commanded a rifle company in the 82nd Airborne Division at Fort Bragg, North Carolina, before completing his military service, graduating from the LSU Law Center and setting up a civil law practice.

Of key interest to Israel and Louisiana on the trip are exploring ways to expand trade and  foreign direct investment activity between the two partners, according to the press release. While substantial, trade between Louisiana and Israel is small in scope compared to overall trade volume with other nations. For instance, Louisiana ranks as the No. 9 exporter to Israel
among U.S. states, with approximately $200 million in exports; that’s a small portion of the over $57 billion in total Louisiana exports. Israel’s more than $60 billion in annual exports includes nearly $22 billion in shipments to the U.S., though Louisiana’s share of Israeli imports is less than $150 million, with fertilizers, mineral and metals among the leading categories.

Talks between Gov. Edwards and Prime Minister Netanyahu are expected to open new avenues of trade and investment growth in commodities where Louisiana is a leader, such as oil and gas; along with applied research areas in which both Israel and Louisiana are emerging, such as water management; and defense and technology related fields where Israel is an innovation leader and Louisiana is an emerging force, such as cybersecurity.

Gov. Edwards also is meeting with key Israeli cabinet officials on the trip, including Deputy Minister Michael Oren in the prime minister’s office; Minster of Energy Yuval Steinitz; and Advisor to the Minister of Energy on International Developments and Foreign Affairs Benjamin Weil.

With Israel playing a central role in global cybersecurity, the delegation met with cybersecurity companies in Israel on Wednesday, with additional exchanges occurring on Monday at the nation’s CyberSpark Industry Initiative in Beersheba and a visit to Twistlock’s Tel Aviv operations planned on Thursday. In April 2018, Twistlock announced the opening of a global solutions engineering center at the LSU Innovation Park in Baton Rouge.

In Israel, cybersecurity exports generate an estimated $6.5 billion in economic activity annually, with Israel attracting $815 million or 16 percent of all global investment in cybersecurity ventures during 2017, second only to the U.S., according to the Israeli innovation partnership Start-Up Nation Central.

Psychologists and Students Present at National Assn of Neuropsychology in NO

The National Academy of Neuropsychology held its 38th Annual Conference in New Orleans at  the Sheraton Hotel, October 17-20, 2018. The theme of the conventional was “Becoming Agents of Change.”

Psychologists from the New Orleans area who presented at the conference included Dr. Kevin Bianchini who spoke on “Pain in the Medicolegal Context.

Dr. Lisa Settles and Dr. Margaret Hauck, along with colleague Dr. Mary Gleason, presented “Early Childhood Brain Development: A Clinical View of Exceptions to Typical Brain
Developmental Trajectories.”

Students presenting included Scott Roye, Alyssa De Vito, and Andrea Smith, all from Louisiana State University, and with co-author Matthew Calamia, PhD, Assistant Professor in Clinical
Psychology, Louisiana State University.

The National Academy of Neuropsychology (NAN) is a non-profit professional membership association for experts in the assessment and treatment of brain injuries and disorders. NAN members are at the forefront of cutting-edge research and rehabilitation in the field of brain behavior relationships.

For her presentation, Lisa D. Settles, PsyD, Assistant Professor of Psychiatry & Pediatrics at Tulane University School of Medicine, Tulane Center for Autism and Related Disorders, reviewed the diagnostic criteria of Autism Spectrum Disorders (ASD), basic neurobiological basis of ASD, specific symptoms of language impairment, social impairment, and RRBs and how the brain contributes to the deficits in youngsters.

Dr. Settles included reviews about issues of social communication delays and restricted, repetitive behaviors. She told the audience about how deficits in ASD are due to connections, activation, structures, and lack in these elements. She said there was difficulty studying young
children using imaging techniques that require stillness and following directions and noted that new information is forthcoming regularly and even weekly.

Margaret Hauck, PhD, neuropsychologist and Assistant Professor of Psychiatry at Tulane University School of Medicine, spoke on “Normal Development,” including cortical development, and explained that different regions follow different patterns. She reviewed how asymmetry appears early on, and how in the third trimester, the cortex is starting to learn. She told the audience how the newborn brain is prepared to experience, and is also prepared by experience. She also included how the greatest plasticity is in early years. She covered memory, encoding, retention, retrieval, autobiographical memory, attention, executive functioning, social and emotional development and other factors.

Dr. Gleason covered the prevalence of adversity in early childhood, the clinical correlates of  adversity and trauma-exposure in very young children, factors related to the presentation of
psychopathology in early childhood, and clinical implications of psychopharmacologic treatments.

She summarized that early childhood development is impacted by adversity and protective  actors in the caregiving environment. Mechanisms of these impacts is complex and includes direct and indirect influences, she explained. Therapy is safest and best supported treatments, while medications may play a role but large gaps in knowledge limit use.

Kevin Bianchini PhD, ABPN, FACPN, presented ” Pain Psychology for neuropsychologists: An Update.” He is a board certified Neuropsychologist and Clinical Psychologist, and is with Jefferson Neurobehavioral Group.

In his presentation, Dr. Bianchini covered the clinical circumstances of pain psychological evaluations, including predicting response to procedures or rehabilitation, understanding difficult-to-explain outcomes, and identifying treatment approaches, including treatment of comorbidities.

He noted that pain-related complaints are extremely common in the general population and  that the presence of pain influences recovery in neuropsychological conditions. He covered
psychosocial factors that influence recovery.

Dr. Bianchini also reviewed how psychometric testing is a valuable component of a consultation to assist the physician in making a more effective treatment plan and that it is useful in the assessment of mental conditions, pain conditions, cognitive functioning, treatment planning, vocational planning & evaluation of treatment effectiveness.

Psychosocial treatment is recommended as an important component in the total management of the patient with chronic pain, he told attendees, and treatments should be implemented as soon as the problem is identified, he explained. Psychosocial treatment may enhance the patient’s ability to participate in pain treatment rehabilitation, manage stress, and increase their problem-solving & self- management skills.

He described the scope of the problem and that pain complaints result in millions of
physician office visits per year and as many as 150 million lost work days. He noted that
the lifetime incidence of low back pain is 11 to 84% and lifetime incidence of neck pain
is 10 to 15%. Back pain is the most common reason for filing a workers compensation claim
and 30-50% of all Workers Compensation claims involve back pain. However, objective
physical findings do not fully explain the breadth and magnitude of disability seen in
many patients with back pain, he noted.

Scott Roye, MA, graduate student at Louisiana State University, presented a research poster, “Associations of Normative and Maladaptive Personality Traits with Self-Reported  Executive
Functioning.” Co-authors are Peter Castagna, MA, from Louisiana State University, and Matthew Calamia, PhD, Assistant Professor and also from Louisiana State University.

In his abstract, Rove noted, “Executive functioning (EF) is a collection of higher order processes designed to facilitate goal-oriented performance. Although commonly studied using performance-based tasks, self-report measures are also useful in assessment given their association with functional impairment. The relationship between self- reports of personality and EF is limited by the use of global EF scores and primarily measures of normative, rather than maladaptive, traits.”

In his study, Roye sought to better understand the relationships between
individual, self-reported EF domains and personality traits among a non-clinical
sample of young adults. Findings replicate prior work emphasizing the relationship of
neuroticism and conscientious/disinhibition to self-reported executive functioning and
extend previous research, Rove wrote.

Alyssa De Vito, MA, also a graduate student at Louisiana State University, presented “Apathy Symptom Severity and Progression Across Empirically-Derived Mild Cognitive Impairment Subtypes.” Her co-author is Matthew Calamia, PhD, Louisiana State University. De Vito examined apathy severity at baseline and its progression over time in empirically derived mild cognitive impairment (MCI) subtypes, she noted.

Using clinical and neuropsychological criteria, amnestic MCI individuals were identified as having more severe apathy symptoms than cognitively normal participants at baseline. However, only clinical criteria identified dysexecutive individuals as having more severe apathy symptoms compared to cognitively normal controls at baseline.

The study demonstrates that apathy severity and progression differ across MCI subtypes. Identification of individuals who may be at risk of developing more severe symptoms is important given apathy’s association with functional impairment, even after controlling for cognitive impairment.

Andrea Smith, an undergraduate senior at Louisiana State University, presented, “White Noise Effects on Cognitive Performance in Those with ADHD: The Moderating Role of Internalizing
Symptoms.” Co-authors are Scott Roye, MA, and Dr. Calamia.

According to her abstract, prior research suggests that white noise played concurrently with a cognitive task may facilitate cognitive performance in those with ADHD, for example, by reduced need to seek out other stimulation. However, much of this work has been done only with children. Additionally, studies of white noise and ADHD have not examined the role of comorbid depressive and anxiety symptoms, which are known to effect cognitive performance in those with ADHD. Smith aimed to address this gap in the literature.

The results indicate that the effects of white noise may uniquely influence cognition among individuals with ADHD, depending upon the presence and severity of their internalizing symptoms, Smith’s review said.

Psychologists to be Compensated for “Thinking” CMS Publishes New Psychological and Neuropsychological Testing Codes

The 2019 Medicare Physician Fee Schedule Final Rule was published at the Federal Register this week, and includes major changes in how psychological testing codes will be handled, changes
that Dr. Tony Puente, Past-President of the American Psychological Association, says are “…the biggest paradigm shift since the development of testing.” Puente presented at the annual  conference of the National Association of Neuropsychology last month held in New Orleans.

Dr. Kim Van Geffen, Director and Chair of Professional Affairs for the Louisiana Psychological
Association, explained that these changes are important for psychologists to understand.  “Beginning on January 1, 2019,” she said, “psychologists who bill insurance companies will be required to use a new set of CPT codes for billing psychological and neuropsychological testing,”
Van Geffen said.

“These codes, which were developed with input from the American Psychological Association,  ill greatly change the way assessments are billed,” Van Geffen said. “The new codes will include base codes and ‘add on’ codes and will distinguish technical work, such as administration and
scoring of tests, from professional work, such as integration and interpretation of evaluation data, clinical decision making and treatment planning. Both types of services will be billed with different codes.”

The CMS final rule updates payment policies, payment rates, and other provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after Jan. 1, 2019, noted CMS. In addition to policies affecting the calculation of payment rates, this final rule finalizes a number of documentation, coding, and payment changes to reduce administrative burden and
improve payment accuracy for office/outpatient evaluation and management (E/M) visits over
several years, according to the announcement.

CMS officials also said that through an interim final rule with comment period, CMS is implementing a provision from the Substance Use-Disorder Prevention that Promotes Opioid
Recovery and Treatment (SUPPORT) for Patients and Communities Act that expands access to telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019. CMS will accept comments on the interim final rule until December 31, 2018.

All releases about the Rule can be reviewed as CMS.gov.

In a series of recent announcements over the last months, Doug Walter, JD, Associate Executive Director for Government Relations, American Psychological Association Practice Organization, alerted psychologists that the Centers for Medicare and Medicaid Services (CMS) released its proposed changes on the 2019 Fee Schedule.

CMS had targeted the codes for revisions and asked the American Medical Association’s CTP® and RUC (Relative Value Update) Committees to restructure and revalue the testing codes. Doug
Walter, JD, Associate Executive Director for Government Relations, American Psychological Association Practice Organization, alerted psychologists to the proposed changes.

CMS had targeted the services because the claims had exceeded $10 million, up to $42 million in 2016, according to Puente. CMS considered the services to be overvalued and targeted them for revision and review.

Walter said APA’s Practice Organization staff had met repeatedly with CMS throughout the year to ask the agency not to make substantial cuts in testing service payments. “We are gratified that CMS listened, and rejected the significant reductions in payments that had been under consideration…” They prevented  4% cuts that would have come when psychologists collect their own test data, APA officials said.

Van Geffen will be conducting on-line training for LPA members and other psychologists in the next few weeks, she said. “These new testing codes represent significant changes in the way in
which psychologists code their testing services. Dr. Tony Puente, former APA President, refers to them as a ‘paradigm shift.'”

“Under the current Medicare regulations,” Van Geffen said, “psychologists are viewed as ‘technicians’ which means that our services are not financially valued for the cognitive work
which we do as a part of our assessments. The new codes represent a move toward
psychologists being paid for cognitive work.”

Although the codes will be somewhat complicated to learn initially, they will ultimately be a
valuable change in the reimbursement landscape,” Dr. Van Geffen explained.

In the most recent announcement, Walter wrote, “Based on a close examination of the proposal we project that the Medicare payment for a six-hour battery of psychological tests would increase 6.3%. The Medicare payment for a neuropsychological test conducted with the assistance of a technician would increase 6.8%, while the payment for a neuropsychological test
conducted by a neuropsychologist her/himself would decrease by just over 3%. The reimbursement rate for a one-hour neuropsychological status exam would increase almost 2%, with reimbursements for a two-hour exam declining 5.3%

Stress Solutions

by Susan Andrews, PhD

APA Study:
Discrimination Leads to Stress

APA has done a survey every year on stress in America. In recent years the Harris Poll survey has focused on discrimination because it is a growing cause of stress. The news has reported numerous clashes between police and black people and Hispanic people. Sadly, there has also been examples of violence based on racial and religious discrimination.

According to an APA study based on a survey of 3,361 adults, more than half of U.S. adults say they have experienced discrimination at the workplace, from police or in other situations. Discrimination was linked to high stress levels and to poor health in those who reported discrimination as compared to the people in the survey who reported not experiencing
discrimination.

The survey respondents reported that their discrimination induced stress has risen over last year. The discrimination has taken the form of poor service, threats, lack of courtesy, lack of
respect shown, among other examples. More than 75% of black people said they experience day-to-day discrimination. Almost one-third of both black and Hispanic adults told the survey that they have become hypervigilant about their appearance in the hope of being treated more fairly.

What the survey does not say is that this type of discrimination-induced stress is chronic stress. Stress that one has little relief from means that the negative effects on one’s health are stronger. Negative effects include excessive fatigue, higher blood pressure readings, reduced immune system protection, among others.

Discrimination-induced stress begs the question of how to reduce such stress. It is pervasive, and its reduction depends upon a major change in people’s beliefs and attitudes. Obviously changes in beliefs and attitudes cannot be legislated. Psychology failed to change even minor beliefs and attitudes about eating organ meat (such as liver) during WW2, such that the more desirable meat could be sent to our troops.

And, when we have no answers or ideas of how to change a situation, it is hard to figure out how to end a column on a more positive note.

 

The Sisters Brothers

by Alvin G. Burstein

Varieties of Western tales, film and story, abound. There is the mysterious stranger who arrives to right wrongs like Shane or The Lone Ranger; there are the stories of a gunslinger, sometimes aging, sometimes retired, like The Unforgiven and The Long Ride; there are ironic spoofs like Cat Ballou and Destry Rides Again. The Sisters Brothers is somehow different, hard to place.

Given that it is in no sense a biopic, its title is an unsubtle indication of a focus on gender, and perhaps especially, Oedipal relationships.

As it unfolds, it goes to lengths to de-sanitize our view of the West in the 1850s; people are unshaven, clothing worn and stained. It abounds with fire fights that make the spaghetti westerns seem tame. There are gross-out elements, swallowed spiders, incinerated live stock,
gratuitous killing. And with all of this, tenderness and sometimes uproarious humor.

Eli and Charles Sisters are hit men in the employ of a shadowy San Francisco gang boss, The  Commodore. He has given them an assignment. They are to find, torture and kill another employee of The Commodore who has gone rogue with a valuable secret that the torture is to
extort. The brothers, improbably, call the assignment a “mission”—in what the director seems to mean as a nod to Ethan Hawk and his colleagues. The brothers will be able to identify the rogue, understandably on the run, because he will be fingered by another employee of The
Commodore’s hirelings traveling with the intended victim.

As the plot twists and turns, the brothers, the rogue and the finger man become allies in an effort to use the secret to generate wealth that will permit them all to escape The Commodore and to found a utopian community in—of all places, Dallas.

Employing the secret has unforeseen, gruesome consequences, and triggers attacks by other minions of The Commodore. What with one thing and another the rogue and the finger man die and Charlie, the younger brother, loses an arm. The brothers decide that they will have to return to San Francisco and kill The Commodore. They get there to find him already dead.

So where’s the humor? It pops up in unexpected moments like the brothers’ encounter with toothpaste and indoor plumbing.

And the tenderness? In the course of things, we see the bond between the two brothers, and Eli’s unflagging devotion and commitment to protect Charlie. That commitment is grounded
in Charlie’s having killed their abusive father and in Eli’ s guilt about having failed to forestall that.

The Sisters Brothers‘ focus on parricide is unmistakable, and from a Freudian point of view, of interest. Two “fathers” are killed, the abusive parent of the protagonists and The Commodore. Although The Commodore is dead when the brothers arrive, Eli punches the corpse “to make sure”—and to atone for the passivity that forced Charlie’s hand. When the two brothers arrive at the family home and rejoin their widowed mother, the audience is left with a question. Will
they be equals, or given Charlie’s symbolic castration—loss of his gun hand—will Eli become the new patriarch. Your guess?

 

LSBEP Sends Blistering Critique to Psych Boards in US & Canada. ASPPB Rescinds Decision to Make EPPP-2 Mandatory

On August 17, President of the Association of State and Provincial Psychology Boards (ASPPB), Sharon Lightfoot, PhD, announced that the ASPPB Board of Directors voted to rescind their 2017 decision, a decision which would have essentially mandated a second exam for those seeking a license in psychology.

“Based on your input this summer and our own priority-setting,” wrote Lightfoot, “the ASPPB Board of Directors on Sunday August 12, passed a motion to rescind our decision of August 2017 and announced to you in October that made the Enhanced EPPP (including both knowledge and skills portions) as the single licensure exam offered by the ASPPB.”

“We will continue toward launch of the Enhanced EPPP in 2020,” Lightfoot said, “and make it available to states and provinces interested in serving as early adopters. We are lifting the requirement for use of the Enhanced EPPP and are lifting the deadline for implementation.”

Lightfoot’s announcement came after a blistering critique of ASPPB’s methods, sent July 20 on behalf of the Louisiana State Board of Examiners of Psychologists (LSBEP) and signed by Executive Director Jaime Monic. The letter listed numerous criticisms and was addressed to the ASPPB Board of Directors, ASPPB members, and copied to the administrators at state psychology boards across the US and Canada.

“LSBEP does not believe that data exists demonstrating that psychologists are not already held to high standards of competence,” wrote Monic. “The data that exists in terms of complaints and disciplinary actions toward psychologists also does not support the theory that competency problems abound in the field of psychology. In fact, ASPPB’s own data regarding complaint patterns notes that ‘Incompetence’ is not even among the top 10 reasons psychologists were disciplined in 2016 (the most recent year of date reported). Moreover, reported disciplinary action (for any reason) has steadily decreased since 2013.”

“Nationwide, ASPPB reported that only 12 licenses were revoked in both 2015 and 2016,” Monic said. “These numbers are exceedingly low and do not suggests that public safety is in question. Therefore, LSBEP is not convinced that another exam is justified by the current data. Prior to instituting additional barriers to the process of licensure by the LSBEP, clear rationale must be presented for their necessity.”

The letter also noted that there is a strong anti-regulatory climate in the country and that Board members are concerned that additional barriers to practice would draw the attention of Louisiana legislators. They also criticized the idea put forth by the ASPPB that additional testing for psychologists would bring the professional psychology in line with medical training, saying that these two professions are inherently different.

Monic, on behalf of the Board, also pointed out concerns with validity and test construction. “Psychology has long held itself as the profession with the most expertise surrounding test design and construction. We are uniquely qualified to create and implement assessments. We are trained that tests are not used prior to establishing validity and reliability. Changing statutes and rules preemptively before we know that the test is necessary and valid is not prudent and would prevent us from choosing another, perhaps better, exam from another vendor.”

The authors also criticized ASPPB’s role and reminded them that they are not a regulating body and have no jurisdiction in Louisiana, and that the decision is “…an overstep.”

“We are concerned that ASPPB has lost sight of their original mission, which from this board’s understanding was limited to facilitating communication between various member jurisdictions,” Monic and the LSBEP pointed out, and that mandatory decisions on EPPP-2 do not fit this role but rather the role of a vendor providing a product.

The expansion of the current licensing exam, called the EPPP2, has been a source of controversy in Louisiana and for some other state boards.

In 2016, ASPPB CEO, Dr. Stephen DeMers, told the state boards that the ASPPB Board of Directors approved the development and implementation of a second examination to assess competency-based skills. Through 2016 and 2017 the new “skills” test was promoted as a voluntary addition to the Examination for Professional Practice in Psychology (EPPP).

Through 2016 and 2017 objections to the EPPP-2 mounted, mostly from student and early career psychologist organizations. In Louisiana, Dr. Amy Henke, then a Director on the Executive Council of the Louisiana Psychological Association (LPA) and Co-Chair of the LPA Early Career Psychologists Committee, put forth a Resolution to oppose the EPPP-2 for Louisiana. The Resolution passed unanimously.

However, then, in a surprise move, the ASPPB Board voted to make the new test mandatory. In late 2017 Dr. DeMers announced that the EPPP-2 was no longer going to be voluntary and that the price would increase from $600 to $1200 for the two sections.

Issues of need and statistical validity have been concerns for Dr. Henke, the state psychology board, and the state psychological association. She took up the banner for the young doctoral graduates, who will bear the financial and emotional burdens of the proposed new test. Other LPA members began looking closely at the scientific need for the new test and also the methodology.

“There is no evidence that the public is facing some sort of previously unheard of crisis in terms of safety from currently practicing psychologists,” said Henke, who currently serves on the LSBEP.

This past April Dr. DeMers met with LSBEP members and representatives of LPA and others about the objections. After the meeting, Dr. Kim VanGeffen, LPA Past-President and current Chair of the Professional Affairs Committee for LPA, said, “Dr. DeMers acknowledged that, currently, there is not really any research on the validity of the EPPP-2.

“The EPPP2 committee believes that this exam has face validity and content validity,” VanGeffen said. “They are satisfied that these types of validity are acceptable for the EPPP2. There do not seem to be any plans to obtain predictive validity nor does the EPPP2 committee believe that establishing this type of validity is necessary,” she said.

Dr. Marc Zimmermann, past LSBEP board member and Chair of the LPA Medical Psychology Committee, also attended DeMers’ meeting. “I think the idea of measuring a professional’s skills before turning him/her lose on the public is a good idea. I do not think this attempt hits the mark,” Zimmermann said. “When the Board does oral examinations we come closer to this by allowing the
person to provide reasoning for their projected behaviors.”

“He [Dr. DeMers] stated that there is no predictive validity,” said Zimmermann. “He also threw in that none of the national tests had predictive validity. He reported that content validity was the accepted standard because a test with predictive validity could not be constructed.”

“He said several times that they were just a vendor, but they have put themselves in the position of being the only vendor,” said Dr. Zimmermann, and it impressed him that, “… DeMers had the
temerity to try to sell us something that does not meet the standard that psychological tests being published are expected to have.”

In Dr. Lightfoot’s announcement, she wrote, “our goal is to provide the best possible resource to you to evaluate your candidates. All jurisdictions will continue to receive detailed information about the nature, content, validity, and utility of the Enhanced EPPP as that information becomes available during 2020 and beyond.” The ASPPB is a private, nonprofit, 501(c) tax-exempt corporation located in Tyrone, Georgia. The company states its mission is to “Facilitate communication among member jurisdictions about licensure, certification, and mobility of professional psychologists.”

ASPPB’s main income producing product is the national exam for psychologists, which brings in about $5,000,000 in gross sales each year. They have a few other products, such as the Psychology Interjurisdictional Compact (PSYPACT), a service to coordinate psychologists working across state lines. In 2016 they listed assets of $8,954,240.

The “members” are about 65 representatives from regulatory boards from across the United States and Canada. The boards pay dues to be a member of ASPPB.

While many members are government officials, ASPPB does not follow open meetings laws. Deliberations and decisions are private. “If you are not a member or staff of an ASPPB Member Psychology Regulatory Board or an individual member, you are not eligible to access this section of our website,” they write. Their conferences are also members only.

The company it also owns the intellectual property rights to the EPPP and the data generated by the testing program, which they appear to have acquired in or around 2013 from PES.
ASPPB officials said that the change was “mutually beneficial because ASPPB can now provide a simplified agreement that is more specific to the needs of psychology licensure boards. In addition, the renewal of contracts is expected to be more efficient…” And, “Finally, as voting members of ASPPB, each jurisdiction exercises more oversight of this important examination service by contracting directly with ASPPB for examination services.”

Over the last two years, Henke and others have also pointed to multiple hurdles that candidatesalready must clear, including two years of supervision, a written exam, oral exam, background check, and jurisprudence exam. Additionally, the law allows the board to require additional physical and psychological assessments whenever needed, Henke has pointed out.
However, Dr. Emil Rodolfa, involved with test development at ASPPB, has said he questions if these standards are enough, saying that supervisors have “… difficulty providing accurate evaluations of their supervisees to others who may have to evaluate the supervisee’s competency.”

Dr. Henke has said, “I am particularly concerned about ASPPB Rescinds Decision Continued regulatory boards encroaching ownership of training standards. The goal of a regulatory board, in my personal opinion, is to provide the least restrictive amount of guidelines possible in order to protect the safety of the public.”

Dr. Rodolfa disagrees and said, “Licensing boards have a mandate to ensure that the professionals they license are competent. Competence is comprised of the integrated use of knowledge, skills, attitudes and values.”

[Editors Note: The Times has reported on this topic over a number of years. See reports in past issues, Vol 7, No. 6, No. 5, No. 8, and No. 9, and Vol. 8, No. 12, and Vol. 9, No. 5, available on our website.]

Mission Impossible –Fallout

by Alvin G. Burstein

There are two levels on which to enjoy this film. The first is its predictable employment of the features that characterize the whole series of movie adaptations of its television predecessor: the pounding musical theme, the amazing face masks, the fanciful technology, metal crunching car and motorcycle races, bloody hand-to-hand combat, acrophobic dangling, and the familiar mantra, “Your mission, should you choose to accept it….”.

The edge of some of the physical violence is carefully modulated with a dollop of camp. After a fight, the shirt is hardly rumpled, and the suit can merit entrance into a fancy soiree. The risks being run can be enjoyed even more safely than a real roller coaster ride.

The plot, too, is familiar. The Mission Impossible Force must deal with a conspiracy that threatens the civilized word. The degree of threat is such that IMF itself can violate rules, but must not be caught in the act. If it is, “The Secretary will deny all knowledge of….”.

All this is gratifying to IMF buffs. But this episode has another, subtler element. That is the tension between personal obligations and love for the individual and heroic struggles in the service of society as a whole.

In this film the threat to society is posed by a conspiracy peopled by a group called “The Apostles.” The group believes that social perfection can ensue only from the total destruction of society as we know it. A Leninist point of view, but arguably also a jab at religious zealotry. The Apostles have stolen nuclear material and plan world-wide nuclear and epidemic chaos.

In a hint of the personal/institutional tension that the film will explore, it opens with a scene of Ethan Hunt’s—he is the leader of the IMF team—marriage ceremony. The officiant’s invocation devolves into a recitation of the risks the marriage will involve for Julia, his bride, and Hunt begins franticly to protest. He is having a nightmare, and wakes from his restless sleep to receive a package that will begin the IMF war with the Apostles. IMF/Ethan Hunt buffs will recall the backstory of the couple’s painful decision to divorce, for Julia to “walk away,” leaving Ethan unfettered in his role as the IMF leader.

IMF’s pursuit of the Apostles will bring Hunt into the usual encounters with femmes fatales, and Julia will reappear in a way that I won’t spoil by describing. In addition, the issue of individual caring vs. what would aptly be titled “missions” repeatedly arises as the plot unfolds. In an echo of the basis for his divorce, Hunt muffs an opportunity to recover the
stolen nuclear material in order to save the life of one of his colleagues. The decision earns him predictable operational criticism. Hunt, and his IMF team, are contrasted with the Apostle’s by the former’s valuing of individuals at the cost of risking mission failures, and the latter’s unflinching pursuit of their “greater” good.

Many viewers probably won’t care much about that conflict, and will be happy with the film’s pyrotechnics. But it is a complicated and interesting element of the story—and it makes sense of the film’s title.

Getting Involved Can Reduce the Stress Caused by Today’s Politics

by Susan Andrews, PhD

One psychologist, Dr. Tammy Savoie, has taken those words to heart. Dr. Savoie decided to run for office because of the same stress that 63 percent of Americans reported last December in an APA poll. The stress – simply put – is concern about the division of neighbors and families over partisan bickering and an ineffective Congress, concern about the future of our country.

“Americans Are Freaking Out” was the headline conclusion of the 2017 Stress in America poll conducted for the APA by Harris. As I reported last year, nearly two-thirds of the people who responded to the Harris poll said that this is the lowest point in US history – and it is keeping a lot of them up at night. The poll, which was the 11th annual Stress in America survey done by the APA, was conducted online between August 2 and August 31 and included 3,440 respondents, aged 18 and over.

Those who are being kept up at night reported that they are worried about health care, the economy and an overall feeling of division and conflict between them and their neighbors. More Democrats (73 percent) than Republicans (56 percent) agreed that this was their top concern. Nonetheless, the sentiment was this is the lowest point in our nation’s history spanned generations, which includes World War II, Vietnam, and 9/11.

As we approach the mid-term elections, that stress has been building for many of us. Actually, many of us have complained for years about the qualifications of the politicians who are supposed to represent us. We complain but most of us will tell you that in truth they have not gotten involved, even with the local School Board elections. Sure, the most frequent answer: “Sorry, I am just too busy to volunteer.”

And, forget putting your hat into the Ring. That really would take too much time. This year is different, and as one who never volunteered before but complained a lot, I have been volunteering for Dr. Tammy Savoie’s campaign for two reasons:

1. She is a Clinical Psychologist, trained at Emory U., served for 23 years in the Air Force and retired in 2016 as a Lieutenant Colonel. Dr. Savoie was born and raised in the New Orleans area. As a Clinical Psychologist in the Air Force, she is naturally concerned about our veterans. As a Clinical Psychologist, Dr. Savoie understands the importance of a good education, proper child care, and good health care. Further, most people who choose a career as a Clinical Psychologist care about people and want to help them. More psychologists need to get involved actively in politics. We need people trained in critical thinking and objectivity; and Dare I Say It, more women.

2. I have been so stressed with concern about the future of our country that when I saw a woman with recognized credentials, not a professional politician, that I decided to put my time and energy where my mouth was. And, it has worked. Win, Lose, or Draw, I feel better knowing that I got involved. I hope we can have many more qualified candidates, like Dr. Tammy Savoie, in the future. I hope you Get Involved!

A Simple Favor

by Alvin G. Burstein

The film’s opening credits are backed with a shifting array of images and pop songs, a neat foretaste of the complicated tale to follow. The story opens on an ongoing charmingly amateurish vlog (video-log). Stephanie Smothers is regaling her audience of mothers with a mélange of homemaking advice. We quickly learn that the vlog is designed, not only to help her viewers, but to enable her to keep her and her child afloat financially after the death of her husband in an auto accident.

As we follow Stephanie picking up her child at school, we come to see her as a Type A fixit problem-solver and perennial volunteer. At the school, she encounters Emily Nelson, the mother of a classmate of Stephanie’s son. Blonde Emily, in a knock-out white vested pants suit, golden pocket watch chain, and spike heels is a striking contrast to the slightly frumpy brunette Stephanie, but they strike up a friendship.

A pattern ensues of after school visits to Emily’s palatial home, where the children play, and the women drink martinis mixed by the hostess. Stephanie is swept into an idolizing and sexually tinged relationship with her new friend.

One day, she gets an urgent call. Emily must leave town to deal with an emergency. Her husband has gone to visit his dying mother. Can Stephanie pick Emily’s son up at school and child-sit him until his mother gets back? A simple favor.

But Emily does not come back that night. Or the next nights. When Stephanie, panicked, manages to contact the husband, he returns, but has no knowledge of where or why his wife might be. They call the police.

The unfolding mystery has a quick-silver quality. Just as a solution appears, it skitters off in a new, surprising direction. I will refrain from spoiling the pleasure of experiencing those twists and turns, and content myself with comments on the film’s style and approach. When Emily is making the first martini, after shaking the gin and vermouth (just a touch), she pours the drink into long stemmed crystal glasses and twists a bit of lemon rind over them. We see the mist of zest evanesce. That image captures the lightness, delicacy, of this movie. The film cocks an eye at the contrast between high and low culture. It smiles at sisterhood and motherhood. It verges on slapstick humor, paradoxically heightening the fun by artfully scant allusions to human misery.

After the tale twists and turns its way to its climax, the audience is presented with an epigraph outlining what has become of those whose lives we have been following. It is an apt, updated version of the Looney Tunes’ “That’s All Folks.”

Gov. Edwards Joined Pres. Trump and Other Governors to Discuss Criminal Justice Reform

On August 9, Gov. Edwards joined President Trump, other state governors, and White House cabinet members in a roundtable discussion about the positive impact that criminal justice reform is having across the nation.

Gov. Edwards explained to the President that the package of bipartisan criminal justice reform legislation that Edwards signed into law in 2017 was working.

“In Louisiana, we’re proud of the work we’ve done,” said the Governor. “It’s been sentencing reform, prison reform, and a real focus on reentry and for the first time in 20 years, I can tell you Louisiana does not have the highest incarceration rate in the nation today.”

“We are reinvesting the savings into our reentry program and also into the victim services. And so we are excited about what we’re doing and looking forward to sharing that with you,” according to the press release.

A report in the Advocate by Elizabeth Crips noted that Trump and others at the meeting spoke about the need to enhance job and skills training programs in prisons, and to focus on how to prepare people to be productive citizens when they get out. “Our first duty is to our citizens, including those who have taken the wrong path but are seeking redemption and a new beginning,” Trump said. “That’s people that have been in prison, and they come out and they’re having a hard time.”

According to Gov. Edwards’ press release, he was the only democratic governor attending. Also attending were Gov. Matt Bevin (R-Kentucky), Gov. Phil Bryant (R-Mississippi), Gov. Nathan Deal (R-Georgia), Gov. Doug Burgum (R-N. Dakota), Atty. General Ken Paxton (R-Texas), Atty. General Pam Bondi (R-Florida), Labor Secretary Alexander Acosta, Energy Secretary Rick Perry, Jared Kushner and other White House staffers.

Gov. Matt Bevin of Kentucky, commented, “The most powerful thing about this… I look at guys like John Bel Edwards in Louisiana, represents a different party than I do in Kentucky in terms of our political affiliation. This is something that we are very much of like-mind on. I think this transcends anything political.”

Energy Sec. Rick Perry said, “I want to share with these governors around here; every one of them is courageous…”

Just after the meeting, Gov. Edwards gave President Trump a letter detailing Louisiana’s efforts, said the release.

The Governor wrote, “For nearly twenty years, Louisiana was known as the nation’s incarceration capital. Our imprisonment rate was nearly double the national average. We were spending roughly $700 million annually on corrections, more than any other line item except education and healthcare, but our communities were not safer for it….”

And, “With the technical support from The Pew Charitable Trusts, we convened a bipartisan task force and spent a year scrutinizing our correctional policies and practices. In June of 2017, I signed into law the most expansive criminal justice reform package in Louisiana’s history…Republicans, Democrats and Independents, as well as the business and religious community, came together to pass these historic reforms.”

The Governor invited the President to tour the State Penitentiary at Angola and see efforts to reform the state’s criminal justice system.

“I believe you will gain a great deal of insight by visiting Louisiana State Penitentiary and I look forward to welcoming you to Louisiana on behalf of the people I serve,” Edwards wrote in the letter given to Trump. “The reentry programming services at LSP (Louisiana State Penitentiary) are key examples of how we plan to utilize the savings from our reforms to better prepare those being released from our prison system. In fact, the first year savings is dedicated specifically to the five parishes that generate nearly 50% of Louisiana’s prison admissions…

Also according to the report by Crisp, Governor Edwards joined other Democratic governors in Colorado recently and discussed divisive politics and ways to unite people. “Folks are just anxious,” the Aspen Daily News quoted Edwards as saying Friday at the Aspen Institute event. “We ought not to vilify anyone. I don’t talk about Trump backers as crazy or racist.”

The justice reform efforts have not been without controversy. Critics point to the two individuals who are now accused of murder and others who have been rearrested. District attorneys are some of the most vocal skeptics, according to various sources.

Some estimate that as many as 22 percent are now back in the justice system, according to the Advocate. The Department of Corrections disputes that figure as inflated. “I’m not sure where the DAs are getting their information from,” said the head of Corrections, James LeBlanc. “Our numbers are not anywhere close to what they are saying.”

Dr. Susan Tucker, clinical psychologist and the Assistant Warden at the Bossier Parish Medium Security Facility, has explained the significance of comprehensive psychological programs in the corrections and justice system.

Tucker developed the Steve Hoyle Intensive Substance Abuse Program which has earned national recognition for excellence. In 2016 the Louisiana Legislature commended Tucker and her team in a House Concurrent Resolution pointing to multi-million dollar cost savings to the state because of shorter incarceration times of those offenders who participated in the psychological programs designed by Tucker.

Dr. Raman Singh, previous Medical Director at Corrections, pointed out the reasons for over-incarceration in Louisiana. Based on a 2016 Louisiana Legislative Auditor’s review Singh said the top reasons were mandatory sentences and habitual offender laws, high rates of local incarceration without treatment programs, and “not addressing issues driving criminal behavior such as substance and mental illness.”

Jails and prisons have a disproportionately high number of persons with mental health issues and people with a serious mental illness. He noted that of the mentally ill in society, greater than 40 percent have been arrested and the majority of these are brought in for minor offenses. Those with mental illness spend two to five times longer in jail.

There is a complex interplay of multiple societal factors stemming from problems in education, stressed family structures, socio-economic challenges and lack of job opportunities. The unemployment rate in the mentally ill adults in Louisiana is 88.3 percent.

And while 16 percent of the DOC prison population has been diagnosed with a serious mental illness, 82 percent are diagnosed with a substance use disorder.

Stabilized funding for higher education. State Budget Finally Stable Says Governor Edwards

This week Gov. Edwards authored a guest column in The Advocate detailing the progress Louisiana has made since overcoming the state’s fiscal challenges.

“… Louisiana is projected to have a $300 million surplus for the fiscal year 2018,” the Governor said. “This surplus is available to us because Louisiana businesses are doing
better, more Louisianans are finding work, and the improving economy has allowed corporate tax receipts to outpace expectations. Since I’ve been governor, the unemployment rate has fallen from a high of 6.2 percent to its current rate of 5 percent. But our good news doesn’t stop there.”

Gov. Edwards said that Louisiana now has long-term budget stability.

“For the first time in years, we have a stable budget structure that does not rely on one-time money or gimmicks, and we have put an end to the annual cuts to higher education that have threatened our children’s future. Republicans, Democrats, and Independents did all of that, and we still reduced the tax burden on the people of Louisiana by nearly $600 million.”

“Within weeks the national credit rating agencies removed Louisiana from the negative watch list. Our universities began the fall semester with nearly every campus’ enrollment at record levels because for the second year in a row, we stabilized funding for higher education and fully funded TOPS and Go Grants.”

“Bipartisanship has served our state well in other areas as well. Louisiana has taken the courageous step of implementing historic bipartisan criminal justice reforms. The reforms have been in place for just over a year, and the early results show that they are working. The state is no longer the incarceration capital of the world, a title we held for decades. In addition, the reforms have saved Louisiana $12.2 million, money that we are reinvesting into public safety and efforts to reduce recidivism. Our reforms were focused on nonviolent, non-sex offenders and were based off efforts in other Southern, conservative states, and we are proud to continue working with the White House and other states hoping to follow Louisiana’s lead.”

In a September 25 press release, the Governor announced that Louisiana was second in the nation for personal income growth in 2nd Quarter of 2018, behind only Texas, based on Bureau of Economic Analysis. Personal income in Louisiana grew at a rate of 5.9 percent, outpacing the national average of 4.2 percent, said the statement.

“Last week, we announced that the state ended the last fiscal year with a surplus. Today, the Bureau of Economic Analysis confirmed our assumptions – Louisiana’s businesses are doing better and people are bringing home more in their paychecks. This is excellent news, and just another sign that Louisiana is moving in the right direction. Our economy is growing, more people are working, and we have a stable budget structure for the first time in many years. While this is all positive news, we still have more work to do, but there is no denying that the momentum we have in Louisiana is real.”

The good news comes as a feature of the nationally based economic boom but also after painful legislative battles for the Governor.

After a total of seven special sessions since 2016, and three special sessions this year, Governor Edwards and legislators finally wrestled the budget into some type of order this past spring,
by the passage of an extra .45 percent sales tax, in down to the wire negotiations that ended last week. The move sidestepped drastic cuts to public health and higher education and provides several years of stability.

The new sales tax, a partial renewal of an expiring one percent sales tax, gave the lawmakers some respite from the yearly battles with the budget. The .45 brings the state sales tax to 4.45.

In the special sessions lawmakers were attempting to deal with the state’s budget crisis when more than $1 billion in taxes would expire on June 30, 2018. The two earlier special sessions floundered after the House repeatedly rejected increased taxes.

The House passed a budget that made dramatic cuts to TOPs, universities and state agencies. That budget was vetoed by the Governor.

Gov. Edwards Resists Attorney General Landry’s Decision on PreExisting Health Coverage Issues

In September the Governor issued a statement, “Attorney General’s Lawsuit threatens health coverage for 849,000 Louisianans with pre-existing conditions.”

The Governor commented that Attorney General Jeff Landry’s unilateral decision to enter the state of Louisiana into a lawsuit that eliminates health care protections for people with pre-existing conditions would deny people coverage.

On September 10, the attorney general appeared on CNN to discuss his effort. During the interview, said the statement, Landry made clear that prior to joining the lawsuit, he did not have a plan in place to ensure insurance companies do not deny coverage for the 849,000 people in Louisiana who could lose health care because they have a pre-existing condition.

“In Louisiana, 849,000 people have a preexisting condition that could lead to an insurance company denying them healthcare if Attorney General Jeff Landry is successful in his latest lawsuit,” said the Governor.

“It’s deeply disturbing that he has committed the state to this effort without consulting anyone and even worse, without having a plan in place to ensure these individuals do not lose their health care. Entering into this lawsuit should not be an impulse decision. It requires thoughtful consideration of the repercussions to the people of Louisiana. After seeing the attorney general’s interview on CNN this morning, it’s clear he did not think this through. Everyone acknowledges the Affordable Care Act (ACA) has flaws, and we should be working together to fix what’s broken. Protecting coverage for people with pre-existing conditions is one area where there is broad, bipartisan support. If successful, this lawsuit would cause chaos within the health care system, and the people of Louisiana would be left to pick up the pieces.”

The attorney general appeared on CNN to discuss the lawsuit. Pressed by a reporter about his plans for the 849,000 people in Louisiana who would lose health care if the court strikes down the pre-existing condition provision, he had no answer, indicating the attorney general had not spoken to anyone for a “Plan B” prior to filing the lawsuit. The interview is available here.

The press release also offered background, including the following:

According to a Kaiser Family Foundation study, approximately 849,000 in Louisiana have a pre-existing condition that could allow an insurance company to deny them health coverage.

A poll conducted by the UNO Survey Research Center in 2014 found that 76 percent of the people of Louisiana supported “requiring health insurance companies to cover anyone, even if they have a pre-existing medical condition.”

NOLA.com|Times Picayune: “The crux of Paxton’s and Landry’s argument is that Congress has repealed the “individual mandate” that required people to carry health insurance or pay a tax penalty, which means that the whole law should be declared unconstitutional. Paxton and Landry argue that the mandate for health insurance companies to cover people with pre-existing conditions cannot work if the individual mandate to carry health insurance will no longer be in place in 2019.

“…But even if he doesn’t succeed at getting Obamacare thrown out, Paxton has asked the court to still strike down the requirement for insurance companies to cover pre-existing medical conditions in the 20 states participating in the lawsuit, including Louisiana.

“…The Texas Attorney General’s office argued both in written briefs and court Wednesday that states — not the federal government — should get to decide whether health insurance companies are
forced to cover people with pre-existing medical conditions.” [NOLA.com|Times Picayune, 9/7/2018]

Stress Solutions

by Susan Andrews, PhD

“The greatest weapon we have against stress is our ability to choose one thought over another.” William James

This reminds me of a saying I once saw on a T-shirt: “Meditation: It IS what you think.” Of course, William James is taking for granted that most people are capable of controlling their minds well enough to actually choose to think about one thing and NOT to think about something else. Obviously, if everyone could do that, the world would be a much more relaxed and stress-free zone. The trouble seems to be coming from 2 possibilities: (1) many people do not realize that stress can be managed by controlling what they are thinking about and (2) too many people in the world today lack the ability to control what they are thinking.

Stress is absolutely a function of what we think. It is our thoughts about what is happening in the moment that actually trigger stress. And, as James points out, humans can choose to think about something that would normally cause them stress whereas nonhumans do not have that choice. For example, mice can be exposed to chronic stress in a laboratory a number of ways, such as by keeping them in a small space for 21 days. Mice, thus treated, show behavioral and brain cell changes in the amygdala associated with anxiety and depression1.

Research indicates that “reappraising” our situation – i.e., changing the way we think – can actually improve our body’s physiological and cognitive reactions to a stressful event. A team of Harvard and UC San Francisco researchers1 tested this theory by simply instructing participants in a reappraisal condition to think about their physiological arousal during a stressful task as “functional and adaptive.” There were two control conditions: attention reorientation and no instructions.

The participants instructed to “reappraise” their physiological arousal by thinking of the arousal as being more adaptive or functional showed measurably better cardiovascular stress responses (in terms of increased cardio efficiency and lower vascular resistance) and decreased attentional bias. Thus, changing our thoughts and thereby our perception can significantly improve the effects of stress on our body.

The suggestion to reappraise how we are looking at a stressful situation so that we think of it as somehow benefiting us or helping us do something better may be a much easier way to help people learn to control what they are thinking. Often when clients are instructed to try to control what they are thinking and NOT to think of the “X” that is upsetting them, they respond by saying they cannot control what they are thinking. Thus, using the suggestion of “reappraising” or reframing how they think about something may be much more successful at getting a stressed client to think differently – and feel less stressed.

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1 T Lau, B Bigio, D Zelli, B S McEwen, C Nasca. Stress-induced structural plasticity of medial amygdala stellate neurons and rapid prevention by a candidate antidepressant. Molecular Psychiatry, 2016.
2Jamieson, J. Nock, M. and Mendes, W. Brief Report: Mind Over Matter: Reappraising Arousal Improves Cardiovascular and Cognitive Responses to Stress. 2012. Journal of Experimental Psychology: General 2012, 141, 3, 417-422.