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AND TYPE
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01/24/1994
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COLLECTION:
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�A M E R I / A N
1
PSYCh/OLOGICAL
ASSOCIATION
A n i t a B. B r o w n , Ph.D.
Assistant Executive Director
Policy, Training and Research
Practice Directorate
750 First Street, NE
Washington, DC 20002-4242
(2021 336-5878
(202] 336-5797 Fax
AMERICAN
PSYCHOLOGICAL
ASSOCIATION
R a y m o n d D. F o w l e r Ph.D.
Executive Vice President and
Chief Executive Officer
750 First Street, NE
Washington, DC 20002-4242
(202) 336-6080
(2021 336-6069 Fax
AMERICAN
PSYCHOLOGICAL
ASSOCIATION ~
Nina Gail Levitt, Ed.D.
Assistant Director lor Education
Public Policy Office
750 First Street, NE
Washington, DC 20002-4242
(202| 336-6023
(202) 336-6063 Fax
Internet, ngl.apa@email apa.org
Policy
�AMERICAN
PSYCHOLOGICAL
ASSOCIATION
EDUCATION AND TRAINING FOR PSYCHOLOGISTS
IN NATIONAL HEALTH REFORM
The American P s y c h o l o g i c a l A s s o c i a t i o n r e c o g n i z e s
t h e need t o
e s t a b l i s h p r i m a r y c a r e as an e s s e n t i a l focus f o r h e a l t h care
reform.
This
organization
s t r o n g l y supports
the Clinton
A d m i n i s t r a t i o n ' s g o a l f o r u n i v e r s a l h e a l t h c a r e coverage f o r a l l
Americans. To a c h i e v e t h a t end, i t i s necessary t o i n c r e a s e t h e
p o o l o f p r i m a r y c a r e p r o v i d e r s t o meet t h e needs o f 72 m i l l i o n
Americans l i v i n g i n r u r a l and i n n e r c i t y areas w i t h i n s u f f i c i e n t o r
no adequate h e a l t h s e r v i c e s a v a i l a b l e . P s y c h o l o g i s t s have and w i l l
continue t o p l a y a c r i t i c a l r o l e i n t h e d e l i v e r y o f these h e a l t h
care s e r v i c e s .
ROLE OF PSYCHOLOGISTS IN HEALTH CARE
Most p e o p l e r e c o g n i z e t h e r o l e t h a t p s y c h o l o g i s t s p l a y i n t h e
design
and d e l i v e r y o f mental h e a l t h and substance abuse
i n t e r v e n t i o n s , as w e l l as t h e r e s e a r c h conducted by p s y c h o l o g i s t s
who d e v e l o p and e v a l u a t e these s e r v i c e s . However, p s y c h o l o g i s t s
r o l e s i n h e a l t h c a r e d e l i v e r y a r e n o t s o l e l y c o n f i n e d t o mental
h e a l t h c a r e . Over t h e l a s t 45 y e a r s , p s y c h o l o g y has s t e a d i l y
increased
i t s activity
i n the f i e l d
of health
care.
R e p r e s e n t a t i v e s o f o r g a n i z e d m e d i c i n e and b e h a v i o r a l s c i e n t i s t s
have t e s t i f i e d i n Congress t h a t more than h a l f o f a l l v i s i t s t o
p h y s i c i a n s a r e f o r c o n d i t i o n s w i t h no known p h y s i c a l b a s i s .
This
f i g u r e i s even h i g h e r when s t r e s s - r e l a t e d i l l n e s s e s a r e i n c l u d e d
(Cummings and VandenBos, 1981) . Many o f t h e c o m p l a i n t s brought t o
a m e d i c a l d o c t o r a r e a c t u a l l y p h y s i c a l symptoms caused by
p s y c h o l o g i c a l problems. Psychology has responded t o t h e s e problems
and m e n t a l d i s o r d e r s by i m p r o v i n g h e a l t h care i n many ways.
Focusing on b e h a v i o r a l and e m o t i o n a l aspects o f m e d i c a l d i s o r d e r s ,
p s y c h o l o g i s t s p l a y an i n t e g r a l r o l e t h a t i s a b s o l u t e l y c r i t i c a l t o
t h e d e s i g n and success o f an i n t e g r a t e d h e a l t h c a r e system.
S e r v i c e s p r o v i d e d by p s y c h o l o g i s t s i n h e a l t h care systems h e l p
patients t o :
o
o
o
o
o
cope w i t h i l l n e s s and s t r e s s f u l m e d i c a l p r o c e d u r e s ;
l e a r n how t o handle s t r e s s t h a t may be causing
otherwise n e g a t i v e l y impacting t h e i r diseases;
adhere t o m e d i c a l regimens;
manage p a i n ;
r e g u l a t e p s y c h o p h y s i o l o g i c a l symptoms.
1
750 First Street, NE
Washington, DC 20002-4242
(202) 336-5500
(202) 336-6123 TDD
or
�P s y c h o l o g i s t s a l s o work t o p r e v e n t disease t h r o u g h b e h a v i o r change,
as i n smoking c e s s a t i o n and weight management.
P s y c h o l o g i s t s , w o r k i n g t o g e t h e r w i t h p e d i a t r i c i a n s i n p r i m a r y care,
provide:
o
o
o
psychodiagnostic
assessment
services
required
to
a c c u r a t e l y diagnose l e a r n i n g d i s a b i l i t i e s ;
c o n s u l t a t i o n s r e g a r d i n g c h i l d b e h a v i o r and developmental
issues;
i d e n t i f i c a t i o n o f h i g h r i s k s i t u a t i o n s and t h e d e s i g n of
a p p r o p r i a t e i n t e r v e n t i o n s (one study has demonstrated a
63%
r e d u c t i o n i n u t i l i z a t i o n of p e d i a t r i c
medical
services a f t e r psychological i n t e r v e n t i o n w i t h parents.
Other p s y c h o l o g i s t s p r o v i d e n e u r o p s y c h o l o g i c a l
evaluations to
assess c o g n i t i v e and b e h a v i o r a l c a p a c i t i e s o f a p a t i e n t a f t e r
s t r o k e o r b r a i n tumor.
I n sum, i n t e r v e n t i o n s developed and p r o v i d e d by p s y c h o l o g i s t s have
proven e f f e c t i v e i n t h e management of many d i f f e r e n t h e a l t h
problems and diseases t o o numerous t o mention.
PSYCHOLOGISTS OFFER HEALTH CARE THAT I S COST EFFECTIVE
Studies
examining
medical
utilization
before
and
after
p s y c h o l o g i c a l t r e a t m e n t have shown t h a t c l i e n t s w i t h l a r g e medical
e x p e n d i t u r e s p r i o r t o t r e a t m e n t are t h e most l i k e l y t o show medical
s e r v i c e r e d u c t i o n s f o l l o w i n g t r e a t m e n t . A t h r e e - y e a r study of over
10,000 Aetna b e n e f i c i a r i e s showed t h a t a f t e r t h e i n i t i a t i o n of
mental h e a l t h t r e a t m e n t , c l i e n t medical c o s t s dropped c o n t i n u o u s l y
over t h e next 36 months.
The h e a l t h c o s t s of one mental h e a l t h
i n t e r v e n t i o n group f e l l from $242 per person i n t h e y e a r p r i o r t o
t r e a t m e n t t o $162 two y e a r s post t r e a t m e n t . Furthermore, s e v e r a l
s t u d i e s suggest t h a t c o s t o f f s e t s i n c r e a s e over t i m e .
P s y c h o l o g i c a l support groups have helped p a t i e n t s and f a m i l i e s d e a l
w i t h cancer, a r t h r i t i s , d i s a b i l i t y and bereavement. I n a d d i t i o n t o
decreases
i n subjective distress,
controlled
studies
have
demonstrated h e a l t h b e n e f i t s i n terms of reduced m o r t a l i t y and
morbidity,
e s p e c i a l l y f o r post-mastectomy and
heart
attack
patients.
W i t h r e s p e c t t o s u r g i c a l p a t i e n t s , an a n a l y s i s of 191
studies revealed that b r i e f p r e s u r g i c a l psychological i n t e r v e n t i o n
has
been
continuously
associated
with
fewer p o s t s u r g i c a l
c o m p l i c a t i o n s , l e s s m e d i c a t i o n usage and an average of 1.5 fewer
h o s p i t a l days. (Devine, 1992).
Numerous f o l l o w - u p s t u d i e s have
demonstrated not o n l y s i g n i f i c a n t improvement i n symptoms and
q u a l i t y o f l i f e w i t h t h e p s y c h o l o g i c a l i n t e r v e n t i o n s developed f o r
health
care
problems,
but
also
reductions
in
subsequent
h o s p i t a l i z a t i o n s , medical o f f i c e v i s i t s , m e d i c a t i o n usage and
v i s i t s t o t h e emergency room.
�The r e c e n t Hawaii M e d i c a i d P r o j e c t funded by t h e H e a l t h Care
Financing A d m i n i s t r a t i o n provides f u r t h e r confirmation o f t h i s
phenomenon.
The study, i n v o l v i n g e c o n o m i c a l l y
disadvantaged,
l a r g e l y m i n o r i t y i n d i v i d u a l s , t r a c k e d h e a l t h care c o s t s over a
three-year period.
I t found t h a t m e d i c a l c o s t s i n c r e a s e d by 15%
( i n c o n s t a n t d o l l a r s ) f o r M e d i c a i d e n r o l l e e s who never used mental
h e a l t h t r e a t m e n t s e r v i c e s . R e l a t i v e t o t h i s b a s e l i n e , t a r g e t e d and
focused m e n t a l h e a l t h t r e a t m e n t reduced m e d i c a l c o s t s by 2 5% t o 3 6%
depending on t h e comparison group. Thus, t h e c o s t s o f p r o v i d i n g
mental h e a l t h t r e a t m e n t were r e c o v e r e d i n terms o f m e d i c a l cost
r e d u c t i o n s w i t h i n 5-13 months.
PSYCHOLOGISTS ARE ACCESSIBLE FOR HEALTH CARE
Psychologists'
services
i n c l u d e assessment, c o n s u l t a t i o n and
t r e a t m e n t i n b o t h p r i m a r y and s p e c i a l t y care s e r v i c e s e t t i n g s ,
where they f u n c t i o n as members o f m u l t i d i s c i p l i n a r y teams.
I n a d d i t i o n , p s y c h o l o g i s t s a r e t h e o n l y d o c t o r a l l e v e l nonp h y s i c i a n h e a l t h care p r o v i d e r i n many s e t t i n g s . I n 622 c o u n t i e s ,
most o f t h e s e i n areas w i t h a h i g h percentage o f r u r a l r e s i d e n t s o r
r e s i d e n t s over 65 y e a r s o f age, t h e r e a r e p s y c h o l o g i s t s b u t no
p s y c h i a t r i s t s t o c o n s u l t w i t h and p r o v i d e t r e a t m e n t f o r b e h a v i o r a l
and e m o t i o n a l problems. The p s y c h o l o g i s t ' s a b i l i t y t o c o l l a b o r a t e
w i t h t h e p h y s i c i a n p r o v i d e r who has no s p e c i a l i z e d t r a i n i n g i n
b e h a v i o r a l h e a l t h enhances a l l aspects o f h e a l t h care d e l i v e r y .
Psychologists p r a c t i c e i n h o s p i t a l s , health c l i n i c s , r e h a b i l i t a t i o n
c e n t e r s , Veteran's A d m i n i s t r a t i o n f a c i l i t i e s , schools and p u b l i c
i n s t i t u t i o n s and o f f i c e - b a s e d i n d i v i d u a l and group p r a c t i c e .
The major s p e c i a l t i e s t h a t have c o n t r i b u t e d i n the past t o h e a l t h
care p r a c t i c e are c l i n i c a l , c o u n s e l i n g , and school psychology. New
areas such as b e h a v i o r a l medicine, h e a l t h psychology and c l i n i c a l
neuropsychology a r e now emerging. P r o f e s s i o n a l p s y c h o l o g i s t s , i n
terms
of
treatment
approaches,
numbers,
accessibility,
effectiveness
and competence,
constitute
an
increasingly
i n d i s p e n s a b l e component o f American h e a l t h care d e l i v e r y .
EDUCATION AND TRAINING FOR PSYCHOLOGISTS I S A GOOD INVESTMENT BUT
I S ENDANGERED UNDER NATIONAL HEALTH REFORM IN ITS CURRENT FORM
The C l i n i c a l T r a i n i n g Program i n t h e Center f o r Mental H e a l t h
S e r v i c e s ( i n t h e Department o f H e a l t h and Human Services) has been
a h i g h l y s u c c e s s f u l program which t r a i n s s t u d e n t s , p r i m a r i l y
m i n o r i t i e s , i n psychology, p s y c h i a t r y , p s y c h i a t r i c n u r s i n g and
s o c i a l work.
Of 6,072 t r a i n e e s who have r e c e i v e d s u p p o r t s i n c e
1981, 93% have p a i d back t h e i r l o a n s .
The t r a i n e e s completed
93,000 months o f payback s e r v i c e m o s t l y i n community based s e t t i n g s
(public or non-profit) .
A t o t a l o f 80% c o n t i n u e t o work i n
community s e t t i n g s a f t e r f u l f i l l i n g the s e r v i c e o b l i g a t i o n . (CMHS,
1993) .
�The f u n d i n g f o r t h e program has gone from a h i g h of more t h a n $90
m i l l i o n i n t h e 70's t o $2.5 m i l l i o n f o r FY94.
The m a j o r i t y of
s t u d e n t s i n t h i s program t r a i n e d i n t h e f i e l d of psychology.
Psychology s t u d e n t s , e s p e c i a l l y m i n o r i t i e s have l i m i t e d access t o
f i n a n c i a l a s s i s t a n c e . Psychology s t u d e n t s have f a r fewer resources
for
f u n d i n g a t t h e i r d i s p o s a l i n comparison w i t h p s y c h i a t r y
s t u d e n t s , who have numerous f e d e r a l s t i p e n d s and programs a v a i l a b l e
under T i t l e V I I o f t h e P u b l i c H e a l t h S e r v i c e Act and Medicare.
The
number o f y e a r s of study are a p p r o x i m a t e l y t h e same and a l t h o u g h
t u i t i o n i s h i g h e r f o r p s y c h i a t r y s t u d e n t s they have access t o
h i g h e r s a l a r y and t u i t i o n o f f s e t s . Psychology s t u d e n t s are t r a i n e d
i n o n l y a h a n d f u l o f programs where Medicare d o l l a r s are a v a i l a b l e .
Students o f p s y c h i a t r i c n u r s i n g a l s o have access t o numerous
f e d e r a l s t u d e n t n u r s i n g and programs i n T i t l e s V I I and V I I I of t h e
P u b l i c H e a l t h S e r v i c e A c t . S o c i a l work s t u d e n t s , l i k e psychology
s t u d e n t s , have l i m i t e d access t o f i n a n c i a l a s s i s t a n c e ; however, i t
i s not necessary t o have a d o c t o r a t e t o be a l i c e n s e d s o c i a l worker
as i t i s f o r psychology. I n f a c t -- two t o t h r e e y e a r s o f graduate
study and a t h e s i s f o r an Masters i s r e q u i r e d i n o r d e r t o s i t f o r
t h e e x a m i n a t i o n t o become a l i c e n s e d c l i n i c a l s o c i a l worker.
There i s an o v e r a l l shortage of p s y c h o l o g i s t s and o t h e r mental
h e a l t h p r o f e s s i o n a l s . There are c u r r e n t l y 578,000 mental h e a l t h
p r o v i d e r s s e r v i n g 50 m i l l i o n a d u l t s and 7.5 m i l l i o n c h i l d r e n w i t h
mental i l l n e s s e s . Only 20% of a l l those w i t h mental i l l n e s s e s are
b e i n g t r e a t e d (CMHS, 1993).
Many o f t h e 578,000 mental h e a l t h
p r o v i d e r s are not c o n s i d e r e d adequately t r a i n e d by t h e i r l i c e n s i n g
bodies.
Of l o n g s t a n d i n g concern t o psychology and o t h e r s c i e n t i f i c f i e l d s
has been t h e t r a d i t i o n a l l y low l e v e l o f p a r t i c i p a t i o n by m i n o r i t i e s
( N a t i o n a l Science Foundation 1991).
A l t h o u g h t h e r e has been
p r o g r e s s i n i n c r e a s i n g t h e number of m i n o r i t i e s , much more must be
done.
I n 1985 t h e r e were 2,000 A f r i c a n American p s y c h o l o g i s t s
compared t o a p o p u l a t i o n of 30 m i l l i o n A f r i c a n Americans, 805 Asian
Americans p s y c h o l o g i s t s i n a p o p u l a t i o n of 3.7 m i l l i o n Asian
Americans, and 180 N a t i v e American p s y c h o l o g i s t s i n a p o p u l a t i o n of
2 m i l l i o n N a t i v e Americans.
I n 1986 t h e r e were 1,500
Hispanic
American p s y c h o l o g i s t s out o f 16.9 m i l l i o n H i s p a n i c Americans. I n
1991, 10.6% o f those r e c e i v i n g Ph.D.s i n psychology were e t h n i c
minorities.
A f t e r a r i s e i n t h e l a t e 70s, t h i s percentage has
remained c o n s t a n t f o r s e v e r a l y e a r s .
Research shows t h a t e t h n i c m i n o r i t i e s are b e t t e r served
by
p s y c h o l o g i s t s o f t h e i r own e t h n i c group. The shortage of m i n o r i t y
p s y c h o l o g i s t s must be taken q u i t e s e r i o u s l y i n l i g h t o f changing
demographics.
By 2025 one h a l f of a l l American c h i l d r e n w i l l be
m i n o r i t i e s and by 2050 one h a l f of a l l Americans w i l l
be
minorities.
E f f o r t s are underway t o more a g g r e s s i v e l y r e c r u i t and r e t a i n e t h n i c
4
�m i n o r i t i e s i n graduate programs o f psychology.
A l l minorities
appear t o be b e t t e r r e p r e s e n t e d among psychology
baccalaureates
than d o c t o r a t e s ( N a t i o n a l Research C o u n c i l 1986) . T h i s s i t u a t i o n
i n d i c a t e s t h a t t h e r e i s a p o o l t o be tapped f o r graduate e d u c a t i o n
but m i n o r i t y s t u d e n t s f i n d advanced study not so a c c e s s i b l e .
The
most s i g n i f i c a n t d e t e r r e n t i s t h e p r o s p e c t o f i n c u r r i n g a d d i t i o n a l
f i n a n c i a l debt.
As f i n a n c i a l a i d has become i n c r e a s i n g l y more
d i f f i c u l t t o o b t a i n , psychology s t u d e n t s are r e l y i n g more and more
on p e r s o n a l resources and l i m i t e d u n i v e r s i t y funds, w i t h debts o f
at l e a s t 50% r e p o r t e d i n 1991.
The median debt f o r psychology
s t u d e n t s i s $15,000 and t h e mean debt i s $20,404) . (APA o f f i c e of
Demographic Employment & E d u c a t i o n a l Research, 1993.)
There a r e F e d e r a l programs t o r e c r u i t m i n o r i t y p s y c h o l o g i s t s . For
example, such a program e x i s t s i n Texas where one out o f every
t h r e e s t u d e n t s are H i s p a n i c .
To meet t h e needs o f H i s p a n i c
s t u d e n t s w i t h a p o t e n t i a l handicapping c o n d i t i o n , Texas A & M
U n i v e r s i t y ' s School o f Psychology has s u c c e s s f u l l y a t t r a c t e d
H i s p a n i c s t u d e n t s t o t h e i r program. T h e i r success i s based on an
a c t i v e r e c r u i t m e n t s t r a t e g y , a d m i n i s t r a t i o n and f a c u l t y s u p p o r t , a
q u a l i t y t r a i n i n g program and a v a i l a b i l i t y o f s t u d e n t f i n a n c i a l a i d .
Student f e l l o w s h i p s have been p r o v i d e d t h r o u g h t h e U.S. Department
of Education's o f f i c e o f S p e c i a l Education a t $7200 per year f o r up
to four years.
While t h e f e l l o w s h i p o n l y p a r t i a l l y o f f s e t s t h e
f i n a n c i a l l o s s , i t p r o v i d e s an i m p o r t a n t i n c e n t i v e f o r t h e s t u d e n t .
In a d d i t i o n t o p r o v i d i n g p s y c h o l o g i c a l services t o Hispanic
s t u d e n t s w i t h s p e c i a l needs, t h i s program has added t o t h e
knowledge base on how t o assess H i s p a n i c c h i l d r e n which leads t o
a p p r o p r i a t e e d u c a t i o n a l placements e a r l y on.
In addition, i t
promotes e a r l y i n t e r v e n t i o n and r e s u l t s i n c o s t containment.
THE FEDERAL ROLE IN ENSURING THAT ALL AMERICANS HAVE ACCESS TO
QUALITY PSYCHOLOGICAL SERVICES TO MEET THEIR BEHAVIORAL HEALTH
NEEDS
A l t h o u g h psychology i s d e f i n e d as a h e a l t h p r o f e s s i o n , i t i s
i m p o r t a n t t o i n c l u d e t h e d e f i n i t i o n o f h e a l t h p r o f e s s i o n as i t i s
d e f i n e d i n S e c t i o n 1582 (c) i n each p r o v i s i o n t h a t p r o v i d e s f o r
n o n - p h y s i c i a n p r o v i d e r s ( o t h e r than n u r s i n g ) . I t i s i m p e r a t i v e
t h a t psychology be i n c l u d e d i n a l l t h e T i t l e V I I programs f o r loans
and s c h o l a r s h i p s as r e f e r e n c e d i n t h e A c t .
I n t h e p r o v i s i o n s on
school h e a l t h and p u b l i c h e a l t h ( h e a l t h p r o m o t i o n and disease
p r e v e n t i o n ) , i t i s i m p o r t a n t t o mention t h a t p s y c h o l o g i s t s can
p r o v i d e e s s e n t i a l s e r v i c e s t o achieve t h e o b j e c t i v e s as s t a t e d .
The f i e l d o f psychology has demonstrated i t s r o l e i n t h e h e a l t h
care system. The q u a l i t y and q u a n t i t y o f p s y c h o l o g i s t s a v a i l a b l e
t o meet t h e b e h a v i o r a l needs o f consumers i n t h e h e a l t h care
d e l i v e r y system w i l l depend on access by psychology s t u d e n t s , and
i n p a r t i c u l a r e t h n i c m i n o r i t i e s , t o f e d e r a l f i n a n c i a l a i d programs.
�Attached are the f o l l o w i n g :
1.
A bibliography
services.
of medical cost
offsets for
psychological
2.
A graph of the changing United States demographics.
3.
A graph of the projected United States ethnic
population
compared t o the number of ethnic
psychologists.
4.
A f a c t sheet on the successful C l i n i c a l T r a i n i n g Program i n
the Center f o r Mental Health Services (HHS).
minority
minority
�^^=p=^
.-.MERiCAN
ASSOCIATION
The APA Practice Directorate
August 4, 1992
MEDICAL COST OFFSET
I. DEFINING MEDICAL COST OFFSET: POLICY IMPLICATIONS
A. Definition ot Medical Cost OfTset
For tne purposes ot this analysis, medical cost offset is defined as follows: an offset occurs if
memcai ucilizauon decreases as a result of mental heanh intervention. A Total Offset occurs
•vnen general health care savings exceed the cost of the mental health treatment effectively
resulting in the treatment paying for itself.
-Fiedler. J.L.. and Wight. J.B. ' 19891. The medical offset effect and puoiic health
poiicv: Mental health inaustry m transition. New York: Praeger.
B. Mental health patients typically overutilize medical services.
1. Many visits to primary care physicians are actually mental health related.
Researchers have estimated that between 50 and 70 percent of a physician's normal caseload
consists of pauents whose medical ailments are significantly related to psychological factors
(VanaenBos. 1988). If mental health care were available to these pauents. it could reduce
medical utilizauon and generate significant cost savings.
A group of psychologists and physicians conducted a nationwide survey to determine mental
disorder prevalence tn the primary care system. The survey included 350 physicians classified
by the American Medical Associauon as office-based family practitioners. According to
physician reports, nearly 25% of all pauents seen by the primary care physicians had disabling
_ psychiatric disorders. Anxiety and depression were among the six most common conditions seen
in family practice.
--Orleans, C.T., George, L.K.. Houpt, J.L. et al. (1985). How primary care physicians
treat psychiatric disorders: A nauonai survey of family practitioners. Amencan Journal of
Psychiatry. 142. 52-57.
A total of 1,072 primary care pauents at a small clinic in Wisconsin were screened for mental
disorders using the General Health Questionnaire, an interview-format psychological test. Based
on the tests, authors reponed that 25% of the pauents had a mental disorder at one or both of two
diagnostic interviews.
--Kessler, L.G.. Cleary, P.G., & Burke. J.D. (1985). Psychiatric disorders in primary
care. Archives of General Psychiatry, 42, 583-587.
~:0 Firs? irreet. NE
VnsninaTon. DC IC002-4242
2021336-5500
�A study ot 235 patients with conditions requinng long-term meaicai care were studied at a large,
urban university hospital. Patients had been attenaing the clinic for 6 montns. and had seen the
.^ame primary care physician at least 3 times. Psycnological profiles derived from General Health
Questionnaires indicated that 149 (63%1 of these primary care patients had scores suggesting
psycniatnc disturbance.
-Brody, D.S. i 1980). Physician recognition or behavioral, psychological, and social
aspects of medical care. Archives of Internal Medicine. 140. 1286-1289.
s
Standard prevalence estimates of primary care pauents with diagnosable mental disorders range
from 15% to 40%.
-Jencks, S.F. (19851. Recognition of mental distress and diagnosis of mental disorders
in primary care. JAMA. 253. 1903-1907.
2. Patients with mental illness are heavy users of medical services.
Patients diagnosed with mental illness are typically heavy users of medical services. If mental
health services were made available to these patients, medical utilization would decrease resulting
in potentially large savings to health care programs.
Research based at the Columbia Medical Plan, a prepaid Maryland group practice divided
approximately 20,000 enrollees into.three groups: mentally ill who received treatment, mentally
ill who did not receive treatment, and a comparison group who had no diagnosable mental
disorders. Stadstics showed that in all three study years, the comparison group utilized less
medical services than individuals with mental disorders. During a one year period, untreated
mentally ill increased their medical utilization by 61%, while the comparison group averaged only
a 9% increase. The treated group was similar to the comparison population, averaging only an
11 % average increase.
-Hankin. J.R.. Kessler. L.G.. Goldberg, I.D.. et al. (1983). A longitudinal study of offset
in the use of nonpsychiatric services following specialized mental health care. Medical Care, 21,
1099-1110.
A study performed at the Columbia Medical Plan involved nearly 3,300 subjects who had
expenenced at least one psychiatric episode less than a year prior to the study. Researchers
discovered a proportional relationship between the number of psychiatnc visits, and the number
~ of medical visits, implying that persons most in need of intensive mental health services use
inordinate amounts of medical resources.
-Kessler, L.G., Steinwachs. D.M., and Hankin, J.R. (1982). Episodes of psychiatric care
and medical utilization. Medical Care, 20, 1209-1221.
Concluding a systematic review of the scientific literature regarding mental health in primary care
settings, one researcher calculated primary care utilization differences. He reponed that pauents
with diagnosable mental disorders average twice as many visits to their primary care physicians
as those without a mental disorder.
-Bonis, J.F., Olendzki. M.C., et al. (1985). The offset effect of mental health treatment
on ambulatory medical care utilizauon and charges. Archives of General Psychiatry, 42,573-580.
�Other researchers have proposed that mentally distressed persons are pnme candidates for
unnecessary surgical procedures, lab tests, and hospitalization. Instead of ameliorating
psychological problems, these needless and expensive procedures may deteriorate the patient's
psychological condition causing a decrease in overall health.
-Inman. L. (1981). The cost-effectiveness of psychotherapy. Paper preparea for the
1981-82 NCPA Insurance Committee.
A recent six year analysis of the Hawaii Medicaid population, funded by a S5.5 million
government grant, included 16,000 Medicaid recipients and nearly 30.000 federal employees.
By tracking medical records, researchers were able to show that pauents seeking mental health
treatment during the study period were much higher utilizers of the medical system, with physical
health care costs 200 to 250 percent higher than those not seeking mental health intervention.
-Cummings, N.A., Dorken. H., Pallak. M.S. et al. (1990). The impact of psychological
intervention on healthcare utilization and costs. Biodyne Institute, April 1990.
I I . MEDICAL COST OFFSET
A. Those who overuse medical services provide the best vehicle for realizing offsets
Studies examining medical utilization before and after psychological treatment have shown that
clients with large medical expenditures prior tojreatment are the most likely to show medical
service" reductions following treatment.
-Jones, K. ed. (1979). Repon of a conference on the impact of alcohol, drug abuse, and
mental health treatment on medical care utilization. Medical Care. 17, Supplement, 1-82.
This study used subjects drawn from a California HMO. Each subject was placed into one of
four treatment groups involving: a) one psychotherapy session, b) short term therapy lasting an
average of 6 sessions, c) longer term psychotherapy, or d) no psychological intervention
(companson group). Cummings and Follette found that there were significant medical utilization
declines in all three psychotherapy groups, and that these results remained constant over the next
five years following psychotherapy. The control group, in contrast, did not exhibit such offset
effects.
-Cummings, N.A., & Follette, W.T. (1968). Psychiatric services and medical utilizauon
in a prepaid health plan setung. Part II. Medical Care, 6, 31-41.
Offset analysts studied medical and psychological histories of nearly 300 veterans from 19851987. Those that received psychotherapy were compared to controls for psychological condidon
and medical utilization following an index period. Results revealed that psychiatric patients
whose pre-treatment medical utilization was excessive showed a dramatic reduction in subsequent
use of medical services after receiving abbreviated mental health treatment. These pauents
dropped from an average of 5.5 annual outpatient medical visits in 1985 to an average of 3.5
visits in 1987. Control groups, who received no psychotherapy, actually increased outpatient
medical utilization. Subjects in all groups whose initial medical utilizauon levels were low or
average maintained appropriate use of these services.
-Massad, P., West, A., and Friedman, M. (1990). Relationship between utilizauon of
mental health and medical services in a VA hospital. Amer. Journal of Psvchiatrv, 147, 465-469.
�B. Elderly pauents receiving mental health care can realize significant offset
In a comprehensive analysis of 58 studies examining the offset effect (i.e.. a 'meta-analysis'),
Mumiord et al. found while testing in three different settings and using three different subject
ooois that the age group showing the most sizable offsets following psychotherapy are persons
over age 55. The most notable effects were revealed in a study comparing elderly patients who
received psychological interventions to eiderly patients wno were hospitalized for the same
reasons, but did not receive mental health care. Elderiv who received mental health care
averaged 12 fewer hospital days than the comparison group, which averaged 42 days. Since
those 65 years and older constituted about 11% of the population in 1980. but consumed a
disproportionate 29% of all health expenditures (Mumford. 1984), this age group is a potenuaily
rich source of offset savings.
In other studies, which included elderly subjects, even modest psychological interventions were
ihown to reduce hospital stays approximately 1.5 days below the control group's average 8.7
days. 35% of all offset studies reviewed demonstrated medical utilization decreases following
psychotherapy. The average decrease for inpatient utilization was 73.4%. and for outpatient
services was 22.6%. Reports were extremely consistent across nearly 60 examinations of offset.
-Mumford, E. et al. (1984). A new look at evidence about reduced cost of medical
utilization following mental health treatment. Amencan Journal of Psvchiatrv, 141, 1145-58.
C. Amount of offset can depend on the severity of illness
1. Those with less severe mental illnesses can realize significant offsets.
Offset studies reveal evidence that less severe mental disorder diagnoses, the conditions most
amenable to psychotherapy, also demonstrate the greatest offset effects. Numerous sources
provide suppon for this claim.
The Columbia Medical Plan, rendering medical and psychiatric services to predominantly white,
educated, middle class enrollees. provided the site for this offset study. The study group
originally included nearly 1200 enrollees whose utilizauon rates were studied for one year prior
to the first psychiatnc visit. After psychiatnc treatment was implemented, subjects were studied
for two more years to determine changes in utilization patterns. The total sample of psychiatric
care recipients decreased their medical utilization an average 11.1% dunng the six months
following treatment. Significant offset effects were still present up to two years after completion
of the psychiatnc intervention. Results were even more striking for patients with less disabling
diagnoses who received high intensity therapies.
-Kessler, L.G., Steinwachs, D.M., and Hankin. J.R. (1982). Episodes of psychiatric care
and medical utilization. Medical Care, 20, 1209-1221.
�Borus corroborated these findings in a forty-nine month study of 8.100 enrollees at an ambulatory
medical clinic in Boston. He found that while patients who received psychotherapy for a nonchronic condition decreased their nonpsychiatric services utilization by 7.2 percent, similarly
diagnosed patients who did not receive mental health intervention increased their utilizauon by
9.5 percent. The cumulative difference between these groups was a substantial 16.7 percent—and
lasted for the next 24 months of observation.
-Borus. J.F., Olendzki. M.C.. et al. (1985). The onset effect of mental health treatment
on ambulatory medical care utilizauon and charges. Archives of General Psvchiatrv. 42.573-580.
2. Those with serious physical illnesses can also realize offsets.
Patients with more severe physical disorders can realize significant reductions in medical
utilization if provided with mental health care. A study of the Georgia Medicaid population (see
Sec. Ill) showed that patients who used inpatient services during a ten quaner penod spent
SI 1.391. Outpatients spent a comparatively small S2.574 during the same penod. Thus, pauents
undergoing surgery or other traumatic inpatient procedures have the highest potential to realize
offset effects.
-Fiedler, J.L., and Wight, J.B. (.1989). The medical offset effect and public health
policy: Mental health industry in transition. New York: Praeger.
Other studies have shown that pauents with functional limitauons, including physical handicaps
and debilitaung physical ailments, show high potential for offset. The Rand Corporation
designed a study involving nearly 4,500 subjects from six geographically diverse sites.
Researchers assigned families to one of 14 fee-for-service insurance plans which ranged in mental
health coverage from free psychiatnc care to almost no coverage. Each enrolle was tested for
psychological and physical well-being using a battery of standard tests. The authors found that
in every category of mental health status (low, medium, or high functioning; those who had
functional limitauons (defined as physically caused impairment in ability to carry out the
activities of daily living) used 50% to 100% more mental health services than those without such
limitauons. The study concluded that those with functional limitations due to poor health are
high users of both medical and mental services. The high-pnce of these subjects' health care
makes them excellent candidates for offset.
-Ware, J.E., Manning, W.G., Duan. N., et al. (1984). Health status and the use of
outpatient mental health services. American Psychologist. 39, 1090-1100.
SEE ALSO SEC. I I E
�3. Those with serious mental illnesses can realize an offset in terms of slowing
their consumption of expensive medical services.
Borus (see Sec. II C 1) showed that patients diagnosed with severe mental ailments who do not
receive psychological treatment increase their medical utilization at significantly faster rates than
those chronic patients who do receive treatment. These results indicate that uniess the severeiy
mentally ill enter the mental health system, they are likely to become voracious users of already
limited medical resources. Borus and other offset analysts suggest that in the absence of
appropnate psychiatnc care, the cost to insurers and to the primary care system is astronomical.
--Bonis, J.F., Olendzki. M.C.. et al. (19851. The offset effect of mental health treatment
on ambulatory medical care utilization and charges. Archives of General Psvchiatrv, 42. 573-580.
O. Recipients of psychotropic medications show less likelihood of offset
Very few studies to date have examined the impact of psychotropic medications in cost offset.
Results from at least one repon indicate that although patients who receive psychotropic
medications are some or the heaviest medical health system pamcipants (which would typically
indicate a high probability of offset), they are less likely to show offsets than similarly diagnosed
persons not receiving psychotropic medications (Jones. 1979-. Kessler. 19821. Although
conclusions may be premature at this juncture, these results could have profound policy
implications. Since a very limited-number of-specialists are able to write psychotropic drug
prescriptions, insurers wishing to maximize offset effects may wish to consider this issue
carefully.
E. Making outpatient mental health care available can offset the cost of expensive
inpatient care.
'...individuals suffering from mental illness who also have severe enough physical health
problems to be admitted inpatient for treatment provide the greatest vehicle for saving physical
health treatment dollars via the otfset effect." fp 971
-Fiedler, J.L.. and Wight, J.B. (19891. The medical offset effect and public health
policy: Mental health industry in transition. New York: Praeger.
A study performed by Schlesinger et al. shows that outpatient mental health treatment is
remarkably successful in reducing inpatient costs. Subjects included nearly 2000 people
diagnosed with one of four chronic diseases (diabetes, ischemic hean disease, hypenension. and
airflow limitation disease). Over 700 patients received varying lengths of psychotherapy, while
the remainder served as a control sample. Researchers studied all groups for a three year penod,
tracking medical expenditures and mental health status. Results showed that three years later
most intervention groups had medical costs that were between S284 and S309 lower than
companson groups. Offsets remained stable during the entire three year study penod. 25% of
the group receiving mental health realized a total offset, indicating that their treatments were
essentially cost-free.
-Schlesinger, H.J., Mumford. E.. Gene, V. et al. (19831. Menial health treatment and
medical care utilization in a fee-for-service system: Outpatient mental health treatment following
the onset of a chronic illness. Amencan Journal of Public Health. 73. 422-29.
�Positive results such as these take on even more significance when considering the prevalence
ot the tour chronic diseases studied. 40% ot the American population suffers from diabetes,
ischemic hean disease, hypenension. or airway-respiratory conditions Given the conect
psychological intervention, a huge number could limit their medical expenditures while
simultaneously improving their mental health status-at vinually no cost.
-Cummings, N.A., Dorken. H.. Pallak, M.S. et al. (1990"). The impact of psychological
intervention on healthcare utilization and costs. Biodyne Institute. Apni 1990.
F. SPECIAL CASES: NICOTINE AND CHEMICAL DEPENDENCY
1. Smoking
Every year thousands die or are hospitalized as a direct result of their smoking. The economic
costs are conservatively estimated to range between S336 and $601 a year per smoker-billions
of dollars annually absorbed by insurers and the health care system.
-Shipley, R.H., Orleans. C.T.. Wilbur. C.S., et al. (1988). Effect of the Johnson &
Johnson Live for Life Program on employee smoking. Preventive Medicine, 17, 25-34.
In the last two decades smoking cessation techniques developed by psychologists have helped
millions cease this self-destructive habit. Scientists calculate that 70 percent of all smokers "
would stop smoking if introduced to rapid smoking or similar psychological treatments, and 40
percent or more would remain abstinent for at least 6 months to a year.
-Yates, B.T. (1984). How psychology can improve effectiveness and reduce costs of
health services. Psychotherapy. 21, 439-451.
**APA is currently invesugating exact cost savings generated by smoking cessation.
2. Alcoholism and Drug Dependency
Expens project that alcohol costs society 85.8 billion dollars in terms of reduced producuvity,
mortality, treatment, and non-health related costs (ADAMHA, 1985). Others estimate that
alcohol accounts for SI of every $5 spent on hospital care (Yates, 1984).
- Psychologists and other mental health specialists are finding ways to prevent alcohol from
ravaging the nation's health. Jones and Vischi reviewed the role of substance abuse treatment
in medical cost offset. The review assessed 13 studies germane to alcohol/drug abuse
intervenuons. The authors found that as much as 85% of medical expenditures could be reduced
through treatment. The average reduction in medical utilizauon generated by mental health
treatments was a sizable 20%. When the scope was broadened to include sick days and accident
benefits paid to employees, the median reduction doubled to 40%. In 1988 dollars this median
reduction represents 35.2 billion dollars, nearly one-third the cost of the entire Medicare program.
The review led researchers to conclude that strong evidence exists associating alcoholism
treatment with subsequent reductions in medical utilization.
-Jones, K. ed. (1979). Repon of a conference on the impact of alcohol, drug abuse, and
mental health treatment on medical care utilization. Medical Care, 17, Supplement, 1-82.
�Scientists have tound that failure to receive treatment for alcohol and substance abuse diagnoses
can result in a very rapid escaiation of individual medical costs. Cummings very recently
concluded a study of Medicaid recipients in Hawaii ('See Sec I B 2). After a review of medical
records, he found that patients diagnosed as chemically deoendent who did not use mental health
services increased their medical costs by 91% dunne the study period, compared to actual
decreases in medical costs by treatment recipients. Some types of intervention produced net
decreases of approximately S514 per person in the first twelve months after treatment.
-Cummings, N.A. (1990V Psychologists: An essential component to cost-effective,
innovative care. Paper presented to the American College of Healthcare Executives. Feb, 1990.
Research also documents the fact that substance abuse treatment can occur inexpensively and
effectively in outpatient settings. A recent study compared the outcomes of subjects who spent
their entire rehabilitation as inpatients and similar subjects who commuted to treatment daily
(saving an average of S 1,500 per patient). The authors found vinually no differences in
outcomes between the two settings, with the exception of cost savings in the outpatient group.
-McCrady, B.S. (1986). Cost effectiveness of alcoholism treatment in panial hospital
versus inpatient settings after brief inpatient treatment: 12 month outcomes. Journal of
Consulting and Clinical Psychology. 54, 708-13.
I I I . SAVINGS IN TERMS OF DOLLARS
A three year study of over 10,000 Aetna beneficiaries showed that after the initiation of mental
health treatment, client medical costs dropped continuously over the next 36 months. The health
costs of one mental health intervention group fell from S242 the year prior to treatment to $162
two years post-treatment. Other subject groups demonstrated similarly dramauc offset effects,
leading the researchers to conclude that a decrease in total health care costs can be expected
following mental health interventions even when the cost of the intervention is included.
-Holder, H.D.. and Blose, J.O. (1987). Changes in health care costs and utilization
associated with mental health treatment. Hospital and Community Psvchiatrv. 38. 1070-75.
In his review of the offset literature. John Shemo. M.D.. a specialist on cost offset, found several
studies which suggest that cost offsets increase over time. One of the most imponant reasons
this occurs, is that the treatment recipients continue to decrease their medical utilization, while
_ usually not requiring any additional mental health services.
-Shemo, J. (1985-86). Cost effectiveness of providing mental health services: The
offset effect. International Journal of Psvchiatrv in Medicine, 15, 19-30.
�A study of the enure Georgia Medicaid population revealed substantial offset savings resulting
from mental health treatments. Patients receiving inpatient physical health treatment in addition
to their mental health treatment realized a cumulative savings of nearly SI.500 over a two and
a half year penod. The cost of the mental health intervention was entirely paid ford.e totally
offset) by these savings. The result is psychologically and physically healthier patients at
essentially no charge.
While not reaching total offset, patients without physical ailments requiring inpatient treatment
who received mental health care still showed significant savings. This group, which contained
both severe and less severe diagnoses, had medical health charges that were lower than
companson samples by $296 to $392 during the study period.
--Fiedler, J.L., and Wight, J.B. (1989). The medical offset effect and public health
policy: Mental health industry in transition. New York: Praeger.
Other total offsets were reported in Schlesinger's study of patients with chronic physical
diagnoses (See Sec II E). By the third year after mental health intervention, the average cost of
patients who did not receive psychotherapy was $950. while the average cost of mental health
patients was only $579. a nearly 40% reduction in cost. Even when the cost of psychiatnc care
was included in the mental health group's total health care bill, the sum was still substanually
less than the untreated group. Treated patients were not only psychologically healthier, but spent
5% less than companson pauents.
-Schlesinger, H.J., Mumford. E., Gene, V. et .al.- (1983). - Mental health treatment and
medical care utilization in a fee-for-service system: Outpatient mental health treatment following
the onset of a chronic illness. American Journal of Public Health, 73, 422-29.
Analysis of Blue Cross \ Blue Shield Federal Employee Program records, which contain data on
over 6.7 million federal employees, showed that while receiving mental health treatment, persons
with mental diagnoses had higher medical utilization than a companson sample. However, after
completion of treatment, the mental health group had inpauent charges that were indistinguishable
from the companson group, and four years later, their expenses were lower. This study provides
evidence that psychotherapy not only stabilizes medical utilizauon. but the effects are long lasung
and may even increase over time.
-Mumford, E. et al. (1984). A new look at evidence about reduced cost of medical
utilization following mental health treatment. American Journal of Psvchiatrv. 141, 1145-58.
_ Durand Jacobs, a psychologist at a veterans hospital penormed two studies which yielded
impressive reductions in inpauent and outpatient physical health utilizauon resulting from
psychological therapies. The first showed that with simple biofeedback training, which reduces
debilitaung pain and tension, patients decreased inpatient utilization by 72% and outpatient
utilization by 63% on pre-to-post treatment comparisons. A second study involving vocational
rehabilitation showed that successful clients were able to reduce their aggregate number of
hospital days from 1133 pretreatment to 212 post-treatment. Similarly, outpatient clinic visits
declined by 41%.
-Jacobs, D.F. (1987). Cost-effectiveness of specialized psychological programs for
reducing hospital stays and outpatient visits. Journal of Clinical Psychology. 43, 729-35.
�IV. MENTAL HEALTH CARE UTILIZATION IS STABLE AND PREDICTABLE
Insurance companies are tearful that generous mental health coverage will result in adverse
selection and excessive use of services. Decades of research, however, have shown that mental
health costs are a small percentage of total health care expenditures, and that utilization of mental
health services is predictable and stable, regaraiess of a poiicy's generosity.
The Rand Corporation designed a study involving nearly 4,500 subjects from six geographically
diverse sues. Researchers assigned families to one of 14 fee-for-service insurance plans which
ranged in mental health coverage from free psychiatric care to almost no coverage. In the study,
both the probability of receiving mental health care and the intensity of care were directly related
to amount of psychological distress. This finding indicates that those who need psychological
services most are the ones most likely to seek it-regardless of cost. Enrollees were very unlikely
to use mental health services inappropriately, even with the most plentiful coverage.
-Ware. J.E.. Manning, W.G.. Duan. N., et al. (1984). Health status and the use of
outpatient mental health services. Amencan Psychologist, 39, 1090-1100.
Other data attesting to the stability of the mental health care system comes from the Blue Cross
\ Blue Shield federal employees plan. These statistics show that after a slight initial increase in
costs following the introduction of a broad mental health care package, psychiatnc service
utilization.at Blue Cross \ Blue Shield did nouvary more than .5 percent in over 11 years.
-Shanstein, S.S., Muszynski. S.. and Amett. G.M. (1984). Dispelling myths about
mental health benefits. Business and Health. Oct. 1984. 7-11.
�Total U.S. PoMation, by Ethnic Group: 1 982-2080
In Millions
Population
250
200
150
100
1982 1985 1990 1995 2000 2010 2020 2030 2040 2050 2060 2070 2080
Ethnic Group
White, Non-Hispanic
e
Other
�ATTACHMENT
30 r
i
i
^
Present and Projected U. S. Population
-fl
Psychology Doctoral Enrollments
-Q
Psychology Doctorate Recipients
-JL Psychology Faculty (Grad. Depts.)
25
-
A-
- A APA Members with PhD
o
-(-»
C
C/J
20
a
o
fi
15
03
ca
-*•>
10
fi
o
1970
^80
1990
^ears of Time
Martha Bernal Ph.D.
2000
�Fact Sheet:
The Mental Health C l i n i c a l Training Program's
Paybacjc Service Requirement
The c l i n i c a l training program administered from 1948 until 1992
by the National Institute of Mental Health (NIMH) and now by the
Center for Mental Health Services (CMHS), was modified in 1981 to
require an obligation to pay back one month of service by working
in an approved setting with a priority population (e.g.,
seriously mentally i l l adults) for each month of Federal
financial support as a c l i n i c a l trainee. The purpose of this
requirement was to insure that c l i n i c a l trainees who receive
Federal financial support provide services to underserved
mentally i l l populations in public f a c i l i t i e s . C H has reviewed
MS
several aspects of the effectiveness of the payback service
requirement.
Major findings of this review include:
o
Of 6,072 trainees who received support since 1981 and
completed training in psychology, psychiatry, psychiatric
nursing, and social work, 5,654 trainees, or 93^ percent, have
completed or are engaged in the payback service obligation. Of
the remaining 7 percent, 2 percent are currently providing
information about payback status; 3 percent had the obligation
waived" due to death or-total d i s a b i l i t y ; and 2 percent are _ .
engaged in monetary payback.
o
The former trainees have completed over 93,000 months
of payback service, or over 7,700 years of service. Two-thirds
of t h i s payback service was done in inpatient hospital settings
or in community-based outpatient settings.
o
One-fourth of these trainees worked with children and
adolescents, one-sixth with minorities with mental disorders, and
another one-sixth with seriously mentally i l l adults.
o
Since 1981, curriculum modifications in these training
programs have become progressively more oriented toward training
professionals to provide services to the priority populations.
o
Based on responses from a sample of trainees who have
completed their payback service obligation, about 49 percent of
the trainees continue to work in public mental health settings,
and an additional 31 percent continue to work in private
nonprofit mental health settings, for a total of_80 percent who
are continuing to work in the public or private nonprofit
sectors.
The average Federal investment per trainee has been $11,000.
Requiring trainees to work in public or private nonprofit
settings has frequently resulted in their continuing employment
in such agencies.
For further information, please contact the CMHS Human Resource
Planning and. .Development Branch (301-443-5850).
�Total U.S. Population, by Ethnic Group, 1982-2080
Percent of Total Population
Percentage
100°/
80%
60%
407c
o
20 /c
1982 1985 1990 1995 2000 2010 2020 2030 2040 2050 2060 2 0 7 0 2080
Ethnic Group
" I " White, Non-Hispanic "
H
Other
�MENTAL HEALTH NEEDS OF
RACIAL/ETHNIC MINORITY AMERICANS
T
, he tables attached provide demographic and epidemiological evidence of
the increased significance of ethnic minorities as a demographic force in the United
States and as a segment of the population that continues to be inadequately served by
the mental health system. At the time of the 1990 census, racial minorities constituted
about 20% of the population, with individuals of hispanic origin (of any race) accounting
for 9 of the population (see Table 1). Compared to their representation in the
%
populations, some racial/ethnic groups appear to over utilize mental health services
available (cf african americans) whereas other groups (hispanic, asian/pacific islanders)
appear to under utilize mental health services. Racial and ethnic minorities, however,
tend to be overrepresented in the lower socioeconomic groups. This is important to
recognize since data from the National Institute of Mental Health (NIMH) Epidemiologic
Catchment Area Program suggests that socioeconomic status (among other variables),
and not race per se, is most highly predictive of psychological disorders. In addition,
data from the NIMH study summarized in Table 2 indicates that the prevalence of
psychological disorders is higher across most categories for black and hispanic than for
nonblack/nonhispanic individuals.
�TABLE 1
U.S. DEMOGRAPHIC DISTRIBUTION AND CORRESPONDING
MENTAL HEALTH UTILIZATION (1990)
Race/Ethnicity
African American
% of
Racial/Ethnic
Group Below
Poverty Level'
Inpatient
12.1
28.2
21.5
21.4
.8
30.8
.6
.9
% of
Population
1
2
Mental Health Utilization
Outpatient
Hispanic (of any race)
Native American
Asian/Pacific Islander
'U.S. Census, 1990
2
Nntional Inslitute of Menial Health, Utilization Statistics (1990)
�TABLE 2
O N E MONTH PREVALENCE RATES OF SELECTED PSYCHOLOGICAL DISORDERS
1 2
BASED ON DIS/DSM III CATEGORIZATIONS
Race/Ethnicity
Any DIS
Disorder
Any Disorder
Except Cog.
Imp., Subst. Use,
& Antisocial
Substance Use
Disorder
Antisocial
Personality
Severe
Cognitive
Impairment
20.3
14.7
4.5
0.4
3.3
Non Black/Non Hispaii
Black
'The rates are given in percentages.
2
National Institute of Mental Health, Division of Epidemiology and Services Research
�Fact Sheet:
1
The Mental Health C l i n i c a l Training Program s
Payback Service Requirement
The c l i n i c a l training program administered from 1948 u n t i l 1992
by the National Institute of Mental Health (NIMH) and now by the
Center for Mental Health Services (CMHS), was modified in 1981 to
require an obligation to pay back one month of service by working
in an approved setting with a p r i o r i t y population (e.g.,
seriously mentally i l l adults) for each month of Federal
financial support as a c l i n i c a l trainee. The purpose of this
requirement was to insure that c l i n i c a l trainees who receive
Federal financial support provide services to underserved
mentally i l l populations in public f a c i l i t i e s . C H has reviewed
MS
several aspects of the effectiveness of the payback service
requirement.
Major findings of this review include:
o
Of 6,072 trainees who received support since 1981 and
completed training in psychology, psychiatry, psychiatric
nursing, and social work, 5,654 trainees, or 93 percent, have
completed or are engaged in the payback service obligation. Of
the remaining 7 percent, 2 percent are currently providing
information about payback status; 3 percent had the obligation
waived due to death or total d i s a b i l i t y ; and 2 percent are
engaged in monetary payback.
o
The former trainees have completed over 93,000 months
of payback service, or over 7,700 years of service. Two-thirds
of t h i s payback service was done in 'inpatient hospital settings
or in community-based outpatient settings.
o
One-fourth of these trainees worked with children and
adolescents, one-sixth with minorities with mental disorders, and
another one-sixth with seriously mentally i l l adults.
o
Since 1981, curriculum modifications in these training
programs have become progressively more oriented toward training
professionals to provide services to the priority populations.
o
Based on responses from a sample of trainees who have
completed their payback service obligation, about 49 percent of
the trainees continue to work in public mental health settings,
and an additional 31 percent continue to work in private
nonprofit mental health settings, for a total of_80 percent who
are continuing to work in the public or private nonprofit
sectors.
The average Federal investment per trainee has been $11,000.
Requiring trainees to work in public or private nonprofit
settings has frequently resulted in their continuing employment
in such agencies.
For further information, please contact the C H Human Resource
MS
Planning and. Development Branch (301-443-5850).
�MEMORANDUM
TO:
Dr. Marty Sieg-Ross
O f f i c e of Senator Nancy Kassebaum
302 Russell O f f i c e B u i l d i n g
FROM:
Nina G a i l L e v i t t , Ed.D.
A s s i s t a n t D i r e c t o r f o r Education P o l i c y
American Psychological A s s o c i a t i o n
DATE:
J u l y 16, 1993
SUBJECT:
I n f o r m a t i o n Requested on Debt O b l i g a t i o n of
Minority/Disadvantaged Psychology Students
The f o l l o w i n g t a b l e s w i l l provide you w i t h i n f o r m a t i o n on the debt
o b l i g a t i o n o f e t h n i c minorities/disadvantaged students i n d o c t o r a l
programs o f psychology.
Table 7 i n d i c a t e s an increased r e l i a n c e on personal sources and
u n i v e r s i t y sources w i t h a decreased r e l i a n c e on Federal funds
i n c l u d i n g student assistance programs.
Table 8 i n d i c a t e s t h a t debt i s r e p o r t e d higher f o r h e a l t h service
p r o v i d e r s b u t a l l psychology f i e l d s are r e p o r t i n g percentages of
debt o f a t l e a s t 50%.
Table 9 i n d i c a t e s t h a t almost 1/5 o f a l l the students i n 1991 upon
r e c e i p t o f the d o c t o r a l degress had over $30,000 i n debt. 243 out
of 1446 had a debt between $20 and $30,000.
The A d d i t i o n a l Debt Table i l l u s t r a t e s t h a t $15,000 i s the median
d o l l a r f i g u r e and the $2 0,484 i s the mean (average).
There i s as
you can t e l l l o t s o f v a r i a t i o n .
I f you need any more i n f o r m a t i o n please don't h e s i t a t e t o contact
me a t 202-336-6023.
�1 ^LAJLUMJJ /ULJ-u--'
,
v
.
-
i
A
-\
Table 7
'-,
•
••
/
Sources of Financial Support for Doctoral Training Reported by
1991 Doctorate Recipients In Psychology
—All sources
N
X
Sources of Support
Own/Family Resources
Own earnings
Spouse's earnings
Famlly contrI but Ions
Other personal sources
Subtotal
b
N
%
1834
908
844
175
2024
85.2%
42.2%
39.2%
8.1%
94.0%
370
251
128
35
784
1142
i ty* 102
'
339
53.0%
4.7%
15.7%
8.3%
56.9%
217
10
6
6
239
1107
850
495
238
1542
51.4%
39.5%
23.0%
11.1%
71.6%
199
143
60
41
443
20.6%
163
28
22
14
26
9
14
9
32
48
50
10
7.6%
1 .3%
1.0%
.7%
1.2%
.4%
.7%
.4%
1.5%
2.2%
2.3%
.5%
24
8
12
3
1
2
5
1
2
4
26
5
1.1%
.4%
.6%
.1%
.0%
.1%
.2%
.0%
.1%
.2%
1 .2%
.2%
5
Student Loans
Guaranteed Student Loan
H.E.A.L.
National Direct Student Loan
Other loan
Subtotal
Primary source
3^
University-Related Sources
Teaching Assistantshlp
Research Assistantshlp
Fe11owshIp
Other University source
Subtotal"
9.2%
6.6%
2.8%
1 .9%
Federal Sources
NIMH Tralneeshlp
NIH Tralneeshlp
NSF Fellowshlp
NSF Research Assistantshlp
NIH Research Assistantshlp
Other HHS sources
G*P0P
Other Dept of Educ
VA (Gl Bl11 e t c . )
Other US federal
Canadian Provincial/Federal Fellow
Other federal
Subtotal
15
Other sources
No sources s p e c i f i e d
Total
375
17.4%
93
160
7.4%
27
1.3%
23
1.1%
567
26.4%
2153
100.0%
2153
100.0%
Source: 1991 Doctorate Employment Survey, Office of Demographic, Employment,
and Educational Research, APA Education Directorate.
Respondents were given the opportunity to Indicate all sources of financial
support, and many indicated more than one source. Therefore, the percentages
in this column total to more than 100.0%.
b
These entries Indicate the number and percentage of respondents who Indicated
1±L.
�Table 8
Debt Related to Undergraduate and/or Graduate Education On Receipt of
Doctoral Degree: 1991 Doctorate Recipients In Psychology
Education-Related Debt Reported
Yes
Not specified
No
Total
SubfIeld
N
Row %
1 ,442
66.8
696
23
7
162
14
70
Biological,
Comparat1ve.
Physiological,
Psychopharmaco1ogy
Cogn1t1ve
Developmental
Educatlonal
Exper(mental
Genera 1
I/O
Neurosclences
PersonalIty
Psychometrles
Quantitative
Socla 1
Other In psychology
Other not psychology
Not specified
CI In leal
CI in leal Neuropsychol
Commun1ty
Counse11ng
Health
School
Row %
Row %
N
688
31.9
28
1 .3
73.4
71 .9
87.5
60.7
70.0
69.3
240
9
1
102
6
31
25.3
28.1
12.5
38.2
30.0
30.7
12
0
0
3
0
0
1.3
.0
.0
1.1
.0
.0
948
32
8
267
20
101
19
45
59
35
37
12
60
11
7
4
6
63
55
16
65.5
65.2
63.4
44.9
63.8
52.2
65.2
52.4
77.8
57.1
50.0
64.9
61 .1
51 .6
10
24
34
42
21
10
32
10
2
3
6
34
35
15
34.5
34.8
36.6
53.8
36.2
43.5
34.8
47.6
22.2
42.9
50.0
35.1
38.9
48.4
0
0
0
1
0
1
0
0
0
0
0
0
0
0
.0
.0
- .0
1 .3
.0
4.3
.0
.0
.0
.0
.0
.0
.0
.0
29
69
93
78
58
23
92
21
9
7
12
97
90
31
41
56.2
21
28.8
11
15.1
73
N
Source: 1991 Doctorate Employment Survey, Office of Demographic,
Employment, and Educational Research, APA Education Directorate.
2,158
�1
Table 9
Level of Education-Related Debt Owed On Receipt of Doctoral Degree:
1991 Doctorate Recipients in Psychology Who Reported Any Debt
Level of Cumulative Debt at Graduation
$5K or less
N
N»
Clinical
Clinical Neuropsychology
Community
CounselIng
Health
School
Blo/Physlol/
Compar/Psychopharmacotogy
Cognitive
Developmental
Educatlonal
Exper(mental
General
I/O
Neurosclences
PersonalIty
PsychometrIcs
Quantitative
Social
Other In psych
Other not psych
Not specified
X
$6-ieK
N
$11-15K
X
$16-26*:
$21-3eK
N
N
N
X
X
X
Total
$31-40K
$41-50K
N
N
$51- 75K
More than
$75. 828—
N
X
254 17.6
286 19.8
213 14.7
173 12.e
243 16.8
126 8.7
77 5.3
52 3.6
22
1.5
1446
89 12.8
95 13.6
91 13.1
72 18.3
147 21.1
81 11.6
62 8.9
42 6.8
18 2.6
697
4
1
32
1
15
17.4
14.3
19.3
7.1
21.7
4
4
35
6
18
1 4.3
.8
8
38 18.1
8
.8
13 18.8
3 13.8
8
.8
3 1.8
8
.8
8
.8
1 4.3
8
.8
1
.6
8
.0
8
.8
23
7
166
14
69
6
12
16
7
14
2
11
3
2
31.6
27.3
16.9
18.9
37.8
15.4
18.6
27.3
28.6
4 21.1
14 31.8
21 35.6
.8
.8
.8
.8
.8
7.7
1.7
.8
.8
.8
.8
1.6
1.8
.8
.8
8
.8
1 2.3
.8
8
.8
8
.8
8
.8
8
.8
8
.8
8
e .8
e .8
e .8
.8
8
1 1.8
8
.8
8
.8
19
44
59
37
37
13
59
11
7
4
6
63
55
16
40
2 se.e
2
15
16
2
8
33.3
23.8
29.1
12.5
26.8
17.4
57.1
21.1
42.9
26.1
? 2,,
43
8
3
13
4
2
8
21.6
23.1
22.6
36.4
28.6
.0
e .
e
17
16
_6
7
27.8
29.1
37.5
17.5
5
6
19
7
5
2
14
1
2
8
26.3
13.6
16.9
18.9
13.5
15.4
23.7
9.1
28.6
.8
3 se.e
19
3
3
7
15.9
5.5
18.8
17.5
1
26
5
9
.8
14.3
15.7
35.7
13.8
6 26.1
8
.8
23 13.9
8
.8
9 13.8
2
1
15
2
4
8.7
14.3
9.8
14.3
5.8
2 8.7
8
.8
.6
1
8
.8
1 1.4
3
6
7
6
3
3
5
1
6
15.8
13.6
11.9
16.2
8.1
23.1
8.5
9.1
.9
1 5.3
5 11.4
16 16.9
5 13.5
4 18.8
1 7.7
16 16.9
1 9.1
6
.8
8
.8
.8
1.7
5.4
5.4
7.7
6.8
.8
14.3
.8
.8
3.2
3.6
6.3
12.5
8
e
e .
e
e .
e
9
7
3
7
14.3
12.7
18.8
17.5
2 se.e
1
8
6
1
3
18.7
12.7
18.9
6.3
7.5
e
1
2
2
1
4
e
i
e
e
2
2
1
5
e
e
i
i
e
i
i
.8
.8
.0
2.7
2.7
.8
1.7
9.1
e
e
8
.8
1 1.6
3 5.5
8
.8
3 7.5
1
1
8
8
8
8
1
1
8
8
Source: 1991 Doctorate Employment Survey, Office of Demographic, Employment, and Educational Research, APA Education
Directorate.
^
�pG^Pt*
\S>WL^<n OAJ^^Y-
Additional Debt Table (todiscuss in text)
Average Education-Related Debt Owed On Receipt of Doctora1 Degree:
1991 Doctorate Recipients In Psychology Who Reported Any Debt
Level of Educational Debt
SubfIeld
Med 1 an
Mean
Std Dev
N
1,446
$15,000
$20,484
17,741
Health Service Provider
fields:
CIInlcal
CI 1n1ca1 Neuropsycho1ogy
Commun1ty
Counse11ng
Health
School
$21,000
$30,000
$10,000
$13,000
$12,000
$13,000
$25,729
$28,130
$15,000
$16,771
$14,929
$14,435
20,307
22,566
11,902
13,476
11,276
10,278
697 /
23
7
166
14
69
Research and Other fields:
Biological, Comparative,
Physiological,
Psychopharmaco1ogy
Cogn1t1ve
Developmental
Educatlonal
ExperImental
General
I/O
Neurosclences
PersonalIty
Psychometrles
Quant 1 tatIve
Social
Other In psychology
Other not psych
$10,000
$9,000
$10,000
$13,000
$9,000
$15,000
$13,000
$10,000
$7,000
$14,500
$14,500
$10,000
$10,000
$10,500
$10,316
$13,955
$13,017
$16,297
$12,622
$18,231
$16,458
$14,000
$10,429
$15,000
$13,000
$14,254
$15,909
$13,125
6,709
18,741
8,242
10,811
10,905
14,125
12,842
13,697
10,845
13,976
7,720
11,369
15,848
8,500
19
44
59
37
37
13*
59
11
7
4
6
63
55
16
$15,000
$18,550
13,638
40
N-
Not specified
Source: 1991 Doctorate Employment Survey, O f f i c e of Demographic,
Employment, and Educational Research, APA Education Directorate.
�DRAFT
December
1993
The American Psychological Association Advocacy I n i t i a t i v e
on T i t l e I I of S.1757, Health Security Act
GOAL: To ensure t h a t psychology i s included i n the p r o v i s i o n s of
T i t l e I I I of S.1757, Health Security Act.
RATIONALE: Q u a l i t y t r a i n i n g leads t o q u a l i t y s e r v i c e . I n order t o
e s t a b l i s h an adequate pool of q u a l i f i e d psychologists,
in
p a r t i c u l a r ethnic and r a c i a l m i n o r i t y , f o r the p r o v i s i o n of h e a l t h
care services i n p u b l i c s e t t i n g s t o underserved populations i t i s
necessary t o provide q u a l i t y education and t r a i n i n g o p p o r t u n i t i e s
f o r students of psychology.
OBJECTIVES: To make the f o l l o w i n g changes i n the p r o v i s i o n s
T i t l e I I I of the Act:
of
1. Section 3071 Programs of Health & Human Services
A. To (c) T r a i n i n g of Underrepresented M i n o r i t i e s and
Disadvantaged Persons- add "psychology"
Purpose: There i s a severe shortage of ethnic and r a c i a l m i n o r i t y
psychologists who are needed t o provide behavioral h e a l t h services
t o other ethnic and r a c i a l m i n o r i t i e s .
B. A f t e r (d) Nurse t r a i n i n g add a p r o v i s i o n : (e) Other Health
Professions t h a t describes a program to t r a i n the other needed
p r o f e s s i o n a l s i n a h e a l t h care system i n c l u d i n g psychology.
Examples of h e a l t h professions would be provided and the Secretary
would determine p r i o r i t i e s based on established need.
Purpose: There i s a shortage of psychologists a v a i l a b l e t o work i n
p u b l i c s e t t i n g s ( i . e . community h e a l t h centers) w i t h underserved
populations; nevertheless, psychology students have l i m i t e d access
t o a f f o r d a b l e f e d e r a l f i n a n c i a l a i d programs which would allow them
t o undertake seven years of graduate study t o become licensed
psychologists.
�2. Section 3101 Federal Formula Payments t o Academic Health Centers
A. To (b) Payments f o r Costs A t t r i b u t a b l e t o Academic Nature
of I n s t i t u t i o n s - a d d (4) the a d d i t i o n a l costs f o r t r a i n i n g other
h e a l t h professions that work i n academic h e a l t h centers
Purpose: Many psychologists have h i s t o r i c a l l y been t r a i n e d i n
h o s p i t a l s e t t i n g s along w i t h physicians and have received funding
through Medicare i n d i r e c t funds. They have been an i n t e g r a l p a r t of
h e a l t h care teams i n h o s p i t a l s and have i n f a c t been on the f a c u l t y
of many of the medical schools associated w i t h these teaching
facilities.
B. To (c) D e f i n i t i o n s - add (5) other h e a l t h professions which
includes psychology
Purpose: Unless s p e c i f i e d , psychology has not been p a r t i c i p a t i n g i n
the various education and t r a i n i n g programs under T i t l e V I I of the
Public Health Service Act; i n f a c t , even when included and
p r i o r i t i e s have had t o be e s t a b l i s h e d , pyschology has not been
funded.
3. Section 3312 Grants t o States f o r Core Health
to
Functions
A. To (b) Core Functions of Public Health Programs- add
(7) psychologists a f t e r l a b o r a t o r y technicians
Purpose: Psychologists play a c r i t i c a l r o l e i n the promotion of
h e a l t h and the prevention of disease.
Psychotherapy has been
instrumental i n reducing s t r e s s , a n x i e t y , and other psychosomatic
f a c t o r s which lead t o medical disorders such as heart c o n d i t i o n s
and cancer. Psychologists have been a c t i v e l y involved i n educating
the p u b l i c concerning the use of tobacco, alcohol and drugs and
about sexual a c t i v i t i e s t h a t increase the r i s k of AIDS.
4. Section 3331 Grants f o r National I n i t i a t i v e s Regarding Health
Promotion and Disease Prevention I n i t i a t i v e s
A.
This s e c t i o n requires r e p o r t language t o e x p l a i n the
c r i t i c a l r o l e psychologists play i n h e a l t h promotion and disease
prevention.
Purpose: I t i s e s s e n t i a l t h a t psychologists are not l e f t out of the
equation when i t comes t o p r o v i d i n g p u b l i c h e a l t h services t o the
most needy and vulnerable populations. Psychologists provide the
necessary services t o deal w i t h v i o l e n c e , abuse, chronic
unemployment, homelessness, chronic i l l n e s s e s ...
�5. Section 3421 Grants and Contracts
[Health] Plans and [ P r a c t i c e ] Networks
f o r the
Development
of
A. To
(c) Q u a l i t y community Practice Networks- add a
d e f i n i t i o n of "health care p r o v i d e r " t h a t includes psychologist
to (g) d e f i n i t i o n s
Purpose: I f h e a l t h care p r o v i d e r i s not described t o include
psychologist, the h e a l t h plans nor the p r a c t i c e networks would
n e c e s s a r i l y involve a p r o f e s s i o n a l t h a t deals w i t h behavioral
h e a l t h issues.
B. To (d) Relevant Categories of E n t i t i e s - add a d e f i n i t i o n
of "health p r o f e s s i o n a l " t h a t includes psychologist t o (g)
definitions
Purpose: I f h e a l t h p r o f e s s i o n a l does not include psychologist as an
example psychologists might not be a v a i l a b l e t o i n d i v i d u a l s who are
members of a medically underserved population i n c l u d i n g American
Indians who g r e a t l y need such services due t o the high incidence of
s u i c i d e , alcoholism, and abuse.
6. Section 3471 A u t h o r i z a t i o n s of Appropriations
Health Service Corps]
[ f o r the National
A. This s e c t i o n requires r e p o r t language t o e x p l a i n the need
t o t r a i n psychologists i n order t o provide the c r i t i c a l mental
h e a l t h services i n underserved areas
Purpose: Eventhough psychology i s defined as a "primary h e a l t h
s e r v i c e " Sec.331(a)(1)(D) of the Public Health Service Act f o r the
purposes of t h a t Act, psychologists are not a c t i v e l y p a r t i c i p a t i n g
i n the programs. I t i s necessary f o r the Congress to make a
statement about the need f o r psychologists i n h e a l t h p r o f e s s i o n a l
shortage areas i n order t o provide e s s e n t i a l behavioral h e a l t h
services.
7. Section 3521 P i l o t Programs [Mental Health; Substance Abuse]
A. Add a f t e r (b)(5) Certain Considerationsof providers f o r these services
(6) on t r a i n i n g
Purpose: This s e c t i o n i s based on the services programs of the
Substance Abuse and Mental Health Services A d m i n i s t r a t i o n of HHS
but there i s no mention of t r a i n i n g . Q u a l i t y s e r v i c e r e s u l t s from
q u a l i l t y t r a i n i n g . There should at l e a s t be p i l o t programs on the
t r a i n i n g of these h e a l t h care providers.
�8. Section 3602 D e f i n i t i o n s [Comprehensive School Health Education
Program]
A.
Add a f t e r (a) (9) Comprehensive School Health Education
Program- (10) on the p r o v i d e r s of school h e a l t h education and
include psychologists
Purpose: School psychologists play a c r u c i a l r o l e i n d e a l i n g w i t h
h e a l t h r i s k behaviors, personal h e a l t h and f a m i l y l i f e , a l c o h o l ,
substance abuse and tobacco and the other p r i o r i t i e s addressed i n
t h i s s u b t i t l e f o r c h i l d r e n and youth i n school (and i n the
community) . I f p s y c h o l o g i s t s are not mentioned i t i s p o s s i b l e t h a t
t h e i r r o l e w i l l be overlooked i n planning school h e a l t h education
i n i t i a t i v e s since the connection between behavioral aspects of
h e a l t h and o v e r a l l h e a l t h of an i n d i v i d u a l i s not as w e l l known as
i t should be.
�D R A F T
December 1993
The American P s y c h o l o g i c a l A s s o c i a t i o n Advocacy I n i t i a t i v e
on T i t l e I l L o f S.1757, Health S e c u r i t y Act
GOAL; To ensure t h a t psychology i s i n c l u d e d i n t h e p r o v i s i o n s o f
T i t l e I I I o f S.1757, H e a l t h S e c u r i t y A c t .
RATIONALE: Q u a l i t y t r a i n i n g leads t o q u a l i t y s e r v i c e . I n o r d e r t o
e s t a b l i s h an adequate p o o l
of q u a l i f i e d psychologists, i n
p a r t i c u l a r e t h n i c and r a c i a l m i n o r i t y , f o r t h e p r o v i s i o n o f h e a l t h
care s e r v i c e s i n p u b l i c s e t t i n g s t o underserved p o p u l a t i o n s i t i s
necessary t o p r o v i d e q u a l i t y e d u c a t i o n and t r a i n i n g o p p o r t u n i t i e s
f o r s t u d e n t s o f psychology.
OBJECTIVES? To make t h e f o l l o w i n g changes i n t h e p r o v i s i o n s o f
T i t l e I I I of the Act:
1. S e c t i o n 3071 Programs o f H e a l t h & Human S e r v i c e s
A. To (c) T r a i n i n g o f Underrepresented M i n o r i t i e s and
Disadvantaged Persons- add "psychology"
Purpose: There i s a severe s h o r t a g e o f e t h n i c and r a c i a l m i n o r i t y
p s y c h o l o g i s t s who a r e needed t o p r o v i d e b e h a v i o r a l h e a l t h s e r v i c e s
t o o t h e r e t h n i c and r a c i a l m i n o r i t i e s .
B. A f t e r (d) Nurse t r a i n i n g add a p r o v i s i o n : (e) Other H e a l t h
P r o f e s s i o n s t h a t d e s c r i b e s a program t o t r a i n t h e o t h e r needed
p r o f e s s i o n a l s i n a h e a l t h care system i n c l u d i n g psychology.
Examples o f h e a l t h p r o f e s s i o n s would be p r o v i d e d and t h e S e c r e t a r y
would d e t e r m i n e p r i o r i t i e s based on e s t a b l i s h e d need.
Purpose: There i s a s h o r t a g e o f p s y c h o l o g i s t s a v a i l a b l e t o work i n
p u b l i c s e t t i n g s ( i . e . community h e a l t h c e n t e r s ) w i t h underserved
p o p u l a t i o n s ; n e v e r t h e l e s s , psychology s t u d e n t s have l i m i t e d access
t o a f f o r d a b l e f e d e r a l f i n a n c i a l a i d programs which would a l l o w them
t o u n d e r t a k e seven y e a r s o f graduate study t o become l i c e n s e d
psychologists.
�2. Section 3101 Federal Formula Payments t o Academic Health Centers
A. To (b) Payments f o r Costs A t t r i b u t a b l e t o Academic Nature
of I n s t i t u t i o n s - a d d (4) the a d d i t i o n a l costs f o r t r a i n i n g other
h e a l t h professions t h a t work i n academic h e a l t h centers
Purpose: Many psychologists have h i s t o r i c a l l y been t r a i n e d i n
h o s p i t a l s e t t i n g s along w i t h physicians and have received funding
through Medicare i n d i r e c t funds. They have been an i n t e g r a l p a r t of
h e a l t h care teams i n h o s p i t a l s and have i n f a c t been on the f a c u l t y
of many of the medical schools associated w i t h these teaching
facilities.
B. To (c) D e f i n i t i o n s - add (5) other h e a l t h professions which
includes psychology
Purpose: Unless s p e c i f i e d , psychology has not been p a r t i c i p a t i n g i n
the various education and t r a i n i n g programs under T i t l e V I I of the
Public Health Service Act; i n f a c t , even when included and
p r i o r i t i e s have had t o be established, pyschology has not been
funded.
3. Section 3312 Grants t o States f o r Core Health
to
Functions
A. To (b) Core Functions of Public Health Programs- add
(7) psychologists a f t e r l a b o r a t o r y technicians
Purpose: Psychologists play a c r i t i c a l r o l e i n the promotion of
h e a l t h and the prevention of disease.
Psychotherapy has been
instrumental i n reducing s t r e s s , anxiety, and other psychosomatic
f a c t o r s which lead t o medical disorders such as heart conditions
and cancer. Psychologists have been a c t i v e l y involved i n educating
the p u b l i c concerning the use of tobacco, alcohol and drugs and
about sexual a c t i v i t i e s t h a t increase the r i s k of AIDS.
4. Section 3331 Grants f o r National I n i t i a t i v e s Regarding Health
Promotion and Disease Prevention I n i t i a t i v e s
A.
This s e c t i o n requires report language t o e x p l a i n the
c r i t i c a l r o l e psychologists play i n h e a l t h promotion and disease
prevention.
Purpose: I t i s e s s e n t i a l that psychologists are not l e f t out of the
equation when i t comes t o p r o v i d i n g p u b l i c h e a l t h services t o the
most needy and vulnerable populations. Psychologists provide the
necessary services t o deal w i t h violence, abuse, chronic
unemployment, homelessness, chronic i l l n e s s e s ...
�5. Section 3421 Grants and Contracts
[Health] Plans and [ P r a c t i c e ] Networks
f o r the
Development
of
A. To
(c) Q u a l i t y community Practice Networks- add a
d e f i n i t i o n of "health care provider" t h a t includes psychologist
to (g) d e f i n i t i o n s
Purpose: I f h e a l t h care provider i s not described t o include
psychologist, the h e a l t h plans nor the p r a c t i c e networks would
necessarily involve a p r o f e s s i o n a l t h a t deals w i t h behavioral
h e a l t h issues.
B. To (d) Relevant Categories of E n t i t i e s - add a d e f i n i t i o n
of "health p r o f e s s i o n a l " t h a t includes psychologist t o (g)
definitions
Purpose: I f h e a l t h p r o f e s s i o n a l does not include psychologist as an
example psychologists might not be a v a i l a b l e t o i n d i v i d u a l s who are
members of a medically underserved population i n c l u d i n g American
Indians who g r e a t l y need such services due t o the high incidence of
s u i c i d e , alcoholism, and abuse.
6. Section 3471 Authorizations of Appropriations
Health Service Corps]
[ f o r the National
A. This section requires report language t o explain the need
to t r a i n psychologists i n order t o provide the c r i t i c a l mental
h e a l t h services i n underserved areas
Purpose: Eventhough psychology i s defined as a "primary h e a l t h
service" Sec.331(a) (1) (D) of the Public Health Service Act f o r the
purposes of t h a t Act, psychologists are not a c t i v e l y p a r t i c i p a t i n g
i n the programs. I t i s necessary f o r the Congress t o make a
statement about the need f o r psychologists i n h e a l t h p r o f e s s i o n a l
shortage areas i n order t o provide e s s e n t i a l behavioral h e a l t h
services.
7. Section 3521 P i l o t Programs [Mental Health; Substance Abuse]
A. Add a f t e r (b)(5) Certain Considerationsof providers f o r these services
(6) on t r a i n i n g
Purpose: This section i s based on the services programs of the
Substance Abuse and Mental Health Services A d m i n i s t r a t i o n of HHS
but there i s no mention of t r a i n i n g . Q u a l i t y service r e s u l t s from
q u a l i l t y t r a i n i n g . There should at l e a s t be p i l o t programs on the
t r a i n i n g of these h e a l t h care providers.
�8. Section 3602 D e f i n i t i o n s [Comprehensive School Health Education
Program]
A.
Add a f t e r (a) (9) Comprehensive School Health Education
Program- (10) on the providers of school h e a l t h education and
include psychologists
Purpose: School psychologists play a c r u c i a l r o l e i n dealing w i t h
h e a l t h r i s k behaviors, personal h e a l t h and family l i f e , a l c o h o l ,
substance abuse and tobacco and the other p r i o r i t i e s addressed i n
t h i s s u b t i t l e f o r c h i l d r e n and youth i n school (and i n the
community). I f psychologists are not mentioned i t i s possible that
t h e i r r o l e w i l l be overlooked i n planning school h e a l t h education
i n i t i a t i v e s since the connection between behavioral aspects of
h e a l t h and o v e r a l l h e a l t h of an i n d i v i d u a l i s not as w e l l known as
i t should be.
�iStal U.S. Population, by Ethnic Group, 1 9 8 2 - ^ ) 8 0 *
Percent of Total Population
Percentage
100%
80%
60%
40%
20%
0%
1982 1985 1990 1995 2000 2010 2020 2030 2040 2050 2060 2070 2080
Ethnic Group
�MENTAL HEALTH NEEDS OF
RACIAL/ETHNIC MINORITY AMERICANS
T
he tables attached provide demographic and epidemiological evidence of
the increased significance of ethnic minorities as a demographic force in the United
States and as a segment of the population that continues to be inadequately served by
the mental health system. At the time of the 1990 census, racial minorities constituted
about 20% of the population, with individuals of hispanic origin (of any race) accounting
for 9% of the population (see Table 1). Compared to their representation in the
populations, some racial/ethnic groups appear to over utilize mental health services
available (cf african americans) whereas other groups (hispanic, asian/pacific islanders)
appear to under utilize mental health services. Racial and ethnic minorities, however,
tend to be overrepresented in the lower socioeconomic groups. This is important to
recognize since data from the National Institute of Mental Health (NIMH) Epidemiologic
Catchment Area Program suggests that socioeconomic status (among other variables),
and not race per se, is most highly predictive of psychological disorders.
In addition,
data from the NIMH study summarized in Table 2 indicates that the prevalence of
psychological disorders is higher across most categories for black and hispanic than for
nonblack/nonhispanic individuals.
�TABLE 1
U.S. DEMOGRAPHIC DISTRIBUTION A N D CORRESPONDING
MENTAL HEALTH UTILIZATION (1990)
Race/Ethnicity
African American
% of
Population
1
% of
Racial/Ethnic
Group Below
Poverty Level
Mental Health Utilization
1
Inpatient
2
Outpatient
12.1
28.2
21.5
21.4
.8
30.8
.6
.9
Hispanic (of any race)
Native American
Asian/Pacific Islander
'U.S. Census, 1990
2
Nntionnl Inslitute of Mental Health, Ulilization Statistics (1990)
�TABLE 2
ONE MONTH PREVALENCE RATES OF SELECTED PSYCHOLOGICAL DISORDERS
1 2
BASED ON DIS/DSM III CATEGORIZATIONS
Race/Ethnicity
Any DIS
Disorder
Any Disorder
Except Cog.
Imp., Subst. Use,
& Antisocial
20.3
14.7
Substance Use
Disorder
i^l^StiSiillillSIIliil
Non Black/Non Hispanic
Black
Antisocial
Personality
4.5
iliili^lSlll!ISii^i:S;|
'The rates are given in percentages.
2
Severe
Cognitive
Impairment
National Institute of Mental Health, Division of Epidemiology and Services Research
0.4
3.3
�Fact Sheet:
The Mental Health C l i n i c a l Training Program's
Payback Service Requirement
The c l i n i c a l t r a i n i n g program administered from 1948 u n t i l 1992
by the National I n s t i t u t e of Mental Health (NIMH) and now by the
Center f o r Mental Health Services (CMHS), was modified i n 1981 to
r e q u i r e an o b l i g a t i o n t o pay back one month of service by working
i n an approved s e t t i n g w i t h a p r i o r i t y population (e.g.,
s e r i o u s l y mentally i l l adults) f o r each month of Federal
f i n a n c i a l support as a c l i n i c a l t r a i n e e . The purpose of t h i s
requirement was t o insure t h a t c l i n i c a l trainees who receive
Federal f i n a n c i a l support provide services to underserved
mentally i l l populations i n p u b l i c f a c i l i t i e s . C H has reviewed
MS
several aspects of the effectiveness of the payback service
requirement.
Major f i n d i n g s of t h i s review include:
o
Of 6,072 trainees who received support since 1981 and
completed t r a i n i n g i n psychology, psychiatry, p s y c h i a t r i c
nursing, and s o c i a l work, 5,654 trainees, or ^3 percent, have
completed or are engaged i n the payback service o b l i g a t i o n . Of
the remaining 7 percent, 2 percent are c u r r e n t l y providing
information about payback s t a t u s ; 3 percent had the o b l i g a t i o n
waived due t o death or t o t a l d i s a b i l i t y ; and 2 percent are
engaged i n monetary payback.
o
The former trainees have completed over 93,000 months
of payback service, or over 7,700 years of service. Two-thirds
of t h i s payback service was done i n i n p a t i e n t h o s p i t a l s e t t i n g s
or i n community-based o u t p a t i e n t s e t t i n g s .
o
One-fourth of these trainees worked w i t h c h i l d r e n and
adolescents, one-sixth w i t h m i n o r i t i e s w i t h mental disorders, and
another one-sixth w i t h s e r i o u s l y mentally i l l adults.
o
Since 1981, curriculum modifications i n these t r a i n i n g
programs have become progressively more oriented toward t r a i n i n g
professionals to provide services t o the p r i o r i t y populations.
o
Based on responses from a sample of trainees who have
completed t h e i r payback service o b l i g a t i o n , about 49 percent of
the t r a i n e e s continue t o work i n public mental health s e t t i n g s ,
and an a d d i t i o n a l 31 percent continue to work i n p r i v a t e
n o n p r o f i t mental health s e t t i n g s , f o r a t o t a l of J30 percent who
are continuing to work i n the public or p r i v a t e n o n p r o f i t
sectors.
The average Federal investment per trainee has been $11,000.
Requiring trainees to work i n public or p r i v a t e n o n p r o f i t
s e t t i n g s has frequently r e s u l t e d i n t h e i r continuing employment
i n such agencies.
For f u r t h e r information, please contact the C H Human Resource
MS
Planning and Development Branch (301-443-5850).
�Clinton Presidential Records
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�The D.O. Curriculum
The first two years of the osteopathic medical curriculum focus on basic sciences such
as anatomy and physiology, often enhanced
by early exposure to clinical work. The third
and fourth years emphasize the clinical work
and much of the teaching takes place in
community hospitals, major medical centers
and doctors' offices.
During these clinical years, students study
areas such as general practice, internal
medicine, obstetrics/gynecology, surgery and
pediatrics. Students rotate through urban,
suburban and rural settings, experiencing all
areas of medicine.
Osteopathic principles and practices are
integrated throughout the four-year curriculum. Students learn to use osteopathic
techniques for diagnosis and treatment of
disease, as well as for disease prevention.
The curriculum emphasizes the relationship
of body systems and holistic patient care.
For More Information
y l D.O., or doctor of
For more information about osteopathic
medicine contact the American Osteopathic
Association, 142 East Ontario Street,
Chicago, IL 60611 (800-621-1773).
Ask for the brochures "What is a D.O.?"
and "Osteopathic Medicine."
For more information about admission to a
college of osteopathic medicine, contact the
American Association of Colleges of
Osteopathic Medicine, 6110 Executive
Boulevard, Suite 405, Rockville, M D 20852
(301-468-0990).
osteopathic medicine, is
a complete physician,
m
licensed to prescribe
medication, perform
surgery, and utilize
Financial assistance is offered through several state osteopathic medical associations, the
National Osteopathic Foundation, the U.S.
Public Health Service, the Armed Forces
and the Auxiliary to the AOA.
manipulative therapy.
Osteopathic medicine emphasizes the
relationship among the
Postdoctoral Training & Licensure
body's nerves, muscles,
Following graduation, D.O.s must complete
an approved 12-month internship. Interns
rotate through major hospital depanments
iternal medicine, general practice and
Jany D.O.s then choose to take a
program in a specialty area, requir: y^rs.of-additional^training.
1 for the ftill practice of
ery in ead^ofithe 50
rmihes^Ke'tests and
.physicians in that
e tests are given
Iminister
fully trained and
bones and organs. The
osteopathic philosophy
rt
of treating the whole
OH
person is applied to the
prevention, diagnosis^
142 E. Ontario St., Chicago, II 60611
312/280-5800
800/621-1773
and treatment of illness,
W5
O
disease and injury.
�Osteopathic Medical Education
Osteopathic physicians serve as family doctors to millions of people throughout the
United States. They first train in general
practice and many receive additional training in specialty areas such as psychiatry,
pediatrics, obstetrics, surgery, ophthalmology or cardiology.
dmission
ered for admission to one of 15
medical schools, applicants typite four years of undergraduate
inating in a bachelor's degree,
athic medical schools also
year each of English, biological
sics, general chemistry and
istry. Some schools have other
uch as genetics, mathematics
these are listed in the catalogs
each osteopathic medical
the end of this brochure.
d take the Medical College
(MCAT) during their junior
he MCAT examines knowlm areas such as biology, math,
nd problem-solving. A pre-med
an assist applicants in scheduling
paring for this examination.
future D.O.s major in sciences, such as
or chemistry, in their undergraduate
;. However, applicants may major in any
long as they meet the minimum course
ade requirements, and demonstrate their
ial for successfully completing an osteomedical curriculum.
Prospective osteopathic medical students
must also exhibit a genuine concern for people. Osteopathic medicine is a peopleoriented profession that demands dedicated
and empathetic individuals. Osteopathic
colleges require a personal interview to
assess the applicant's communication skills
and learn more about why that person
wants to become an osteopathic physician.
The applicant may wish to spend some time
with a D.O. or do volunteer work in healthcare before applying
Continuing Medical Education
Continuing Medical Education, as the term
implies, is a lifetime commitment to learning by osteopathic physicians in full
recognition of the fact that the study of
medicine does not end with graduation from
medical school. The American Osteopathic
Association requires its members to complete
a specified number of continuing medical
education credits during each three-year
in orcler^toJfnliintain membership.
Osteopathic Medical Colleges
555 31st Street
Downers Grove, ' linois 60515
(708) 971-6080
Southeastern University of
Health Sciences
College of Osteopathic
Medicine
1750-60 N.E. 168th Street
North Miami Beach, Florida
33162
(305) 949-4000
College of Osteopathic
Medicine of the Pacific
College Plaza
Pomona, California 91766
(714) 623-6116
Texas College of
Osteopathic Medicine
3500 Camp Bowie Boulevard
Fort Worth, Texas 76107
(817) 735-2000
Kirksville College of
Osteopathic Medicine
800 West Jefferson
Kirksville, Missouri 63501
(816) 626-2121
University of Health Sciences,
College of Osteopathic Medicine
2105 Independence Boulevard
Kansas City, Missouri 64124
(816) 283-2000
Michigan State University
College of Osteopathic
Medicine
East Fee Hall
East Lansing, Michigan 48824
(517) 355-961 1
University of Medicine &
Dentistry of New Jersey, School
of Osteopathic Medicine
40 East Laurel Road
Stratford, New Jersey 08084
(609) 346-6990
New York CoUege of
Osteopathic Medicine
New York Institute of
Technology
Box 170
Old Westbury
Long Island, New York ] 1 568
(516) 626-6947
University of New England,
College of Osteopathic
Medicine
1 1 Hills Beach Road
Biddeford, Maine 04005
(207) 283-0171
Chicago College of
Osteopathic Medicine
5200 South Ellis Avenue
Chicago, Illinois 6061 5
(312) 947-3000
Ohio University College of
Osteopathic Medicine
Grosvenor Hall
Athens, Ohio 45701
(614) 593-1800
University of Osteopathic
Medicine and Health Sciences
College of Osteopathic
Medicine and Surgery
3200 Grand Avenue
Des Moines, Iowa 50312
(515) 271-1400
CoUege of Osteopathic Medicine
of Oklahoma State University
1111 West 17th Street
Tulsa, Oklahoma 74107
(918) 582-1972
West Virginia School of
Osteopathic Medicine
400 North Lee Street
Lewisburg, West Virginia 24901
(304) 645-6270
Philadelphia College of
Osteopathic Medicine
4150 City Avenue
Philadelphia, Pennsylvania 19131
(215) 871-1000
�I f you're like most people, you've been going
D.O.s bring something extra to medicine:
o
• Osteopathic medical schools emphasize
training students to be primary care
physicians.
• D.O.s practice a "whole person" approach
to medicine. Instead of just treating specific symptoms or illnesses, they regard
your body as an integrated whole.
• Osteopathic physicians focus on preventive healthcare.
to a doctor ever since
you were born, and perhaps were not aware
whether you were seeing
a D.O. (Osteopathic
Physician) or an M.D.
(Allopathic Physician).^
• D.O.s receive extra training in the musculoskeletal system—your body's
interconnected system of nerves, muscles
and bones that make up two-thirds of its
body mass. This training provides
osteopathic physicians with a better understanding of the ways that an in jury or
illness in one part of your body can affect
another. It gives D.O.s a therapeutic and
diagnostic advantage over those who do
not receive additional specialized training.
You may not even be
aware that there are
these two types of com-
<
plete physicians in the
5/5
United States.
The fact is, both
• Osteopathic manipulative treatment
(OMT) is incorporated in the training and
practice of osteopathic physicians. With
OMT, osteopathic physicians use their
hands to diagnose injur)' and illness and to
encourage your body's natural tendency
toward good health. By combining all
other medical procedures with OMT,
D.O^ToffeAheir patients the most comprehensive care available in medicine today.
D.O.s and M.D.s are
complete physicians.
They are both licensed
to perform surgery and
prescribe medication in
all 50 states. Is there
142 E. Ontario St., Chicago, II 60611
312/280-5800
800/621-1773
any difference betwee^^
these two kinds of doctors? Yes. And no.
AMERICAN OSTEOPATHIC ASSOCIATION
O I'WI American Osti.ii|wrliic Associarion
�WhatlsAD.O.?
D.O.s and M.D.s are alike in many ways:
"•-Applicants to both D.O. and M.D.
colleges typically have a four- year undergraduate degreg-wjth an emphasis on
science courses.
• Both D.O.s and M.D.s complete four
years of basic medical education
, _Aher medical school^both Ejt^s and
K-M.D.s can-chebse^td practice'in a specialtffiedicine^^such as psyc&iatty,
leryja^phstefric? — after compli:ting .
>g^am^Jvipieallytwotto six \
ars o£add tional training
N
Both D.O.s and M.D.s must pass comparable state licensing examinations.
:VD.O.s and M.D.s both practice in fully
accredited and licensed hospitals and
^medical centers.
Q-.s comprise a separate, yet equal branch
erican medical care. Together, D
t.D.s enhance the state of care availn-America.
oWe&er, it's the ways that D.O.s and j
'.D.Skire different that can bring an extra
."dimension to your family's healthcare.
100 Years of Unique Care
Osteopathic medicine is a unique form of
American medical care that was developed
in 1874 by Andrew Taylor Still, M.D. Dr.
Still was dissatisfied with the effectiveness of
19th Century medicine. He believed that
many of the medications of his day were
useless or even harmful. Dr. Still was one of
the first in his time to study the attributes of
good health so that he could better understand the process of disease.
In response Dr. Still founded a philosophy of
medicine based on ideas that date back to
Hippocrates, the Father of Medicine. The
philosophy focuses on the unity of all body
parts. He identified the musculoskeletal
system as a key element of health. He recognized the body's ability to heal itself and
stressed preventive medicine, eating properly
and keeping fit.
Dr. Still pioneered the concept of "wellness"
100 years ago. In today's terms, personal
health risks — such as smoking, high blood
pressure, excessive cholesterol levels, stress
and other lifestyle factors — are evaluated for
each individual. In coordination with appropriate medical treatment, the osteopathic
physician acts as a teacher to help patients
take more responsibility for their own
wellbeing and change unhealthy patterns.
Sports medicine is also a natural diitgS^hWv
of osteopathic practice, b ecauseof 1 t s l c ^ t e ^
on the musculoskeletal system, osteo~patRre-~:fi£
manipulative treatment, di^,|exe-.Fcw^^aj
fitness. Many professional spoEis^anfi;^^
cians, Olympic physicians a'licUp.ers
sports medicine physicians areiD|
21st Century, Frontier Medicine
Just as Dr. Still pioneered osteopathic
medicine on the Missouri frontier in 1874,
today osteopathic physicians serve as modern day medical pioneers.
They continue the tradition of bringing
healthcare to areas of greatest need:
• Over half of all osteopathic physicians
practice in primary care areas, such as
pediatrics, general practice obstetrics/gynecology and internal medicine.
• Many D.O.s fill a critical need for family
doctors by practicing in small towns and
rural areas.
Today osteopathic physicians continue to be
on the cutting edge of modern medicine.
D.O.s are able to combine today's awesome
medical technology with the tools of their
ears, to listen caringly to their patients; their
eyes, to see their patients as whole persons;
and their hands, to diagnose and treat injury
and illness.
Additional information may be found in the
American Osteopathic Association's •
brochures "Osteppathic_Medicine" and
"Osteopathic Medical Education:"-
�You are more than just
D.O.s are complete physicians. That means
they are fully trained and licensed to prescribe medication and to perform surgery.
D.O.s and allopathic physicians (M.D.s) are
the only two types of complete physicians.
o ^
the sum of your body
o t
parts. That's why
D.O.s practice in all branches of medicine
and surgery, from psychiatry to obstetrics;
from geriatrics to emergency medicine.
However, D.O.s are trained to be doctors
first, and specialists second. The majority
are family-oriented, primary care physicians.
Many D.O.s practice in small towns and
rural areas, where they often care for entire
families and whole communities.
doctors of osteopathic
medicine (D.O.s)
^
w
practice a "whole person"
o ^
• By the year 2000, it is expected that
45,000 osteopathic physicians will be in
practice in the U.S.
13
approach to medicine.
Instead of just treating
• Over half of all D.O.s practice in the
primary care areas of general practice,
internal medicine, obstetrics/gynecology
and pediatrics.
specific symptoms,
• D.O.s represent 5.5% of the total U.S.
physician population and 10% of all U.S.
military physicians.
osteopathic physicians
• ,Each yeatv\100 million patient visits are
,made to D.O.s.
concentrate on treating
you as a w hole.
id
15
• Strong concentrations^otD.O.s are found
Jersey, Ohio, Pennsylvania^and Texas.
in Florida, Michigan, Missouri, New
142 E. Ontario St., Chicago, II 60611
312/280-5800
800/621-1773
MANZmrj®*OTTEDMT1H10CAmnaATDOSJ
�so
Osteopachic physicians understand how all
the body's systems are interconnected and
how each one affects the others. They focus
special attention on the musculoskeletal system, which reflects and influences the
condition of all other body systems.
This system of bones and muscles makes up
about two-thirds of the body's mass, and a
routine part of the osteopathic patient
examination is a careful evaluation of these
important structures. D.O.s know that the
body's structure plays a critical role in its
ability to function. They can use their eyes
and hands to identify structural problems
and to support the body's natural tendency
toward health and self-healing.
To become an osteopathic physician an individual must be a graduate of one of 1 5
osteopathic medical schools. Each school is
accredited by the Bureau of Professional
Education of the American Osteopathic
Association. This accreditation is recognized
by the U.S. Department of Education and
the Council on Postsecondary Education.
Typically, applicants to osteopathic colleges
have a four-year undergraduate degree, and
complete specific science courses. Applicants
must take the Medical College Admissions
Test (MCAT). Osteopathic medical schools
also require a personal interview to assess the
student's interpersonal communication skills.
Osteopathic physicians also use their ears —
to listen to you and your health concerns.
Doctors of osteopathic medicine help
patients develop attitudes and lifestyles that
don't just fight illness, but help prevent it,
too. Millions of Americans prefer this concerned and compassionate care, and have
made D.O.s their doctors for life.
The osteopathic curriculum involves four
years of academic study. As a reflection of
the osteopathic philosophy, the curriculum
emphasizes preventive medicine and holistic
patient care. Medical students learn to use
osteopathic principles and techniques for
diagnosis and treatment of disease throughout the curriculum.
After completing osteopathic medical college, D.O.s serve a one-year internship,
gaining hands-on experience in internal
medicine, obstetrics/gynecology, family
practice, pediatrics and surgery. This experience ensures that osteopathic physicians are
first trained as primary care physicians —
even if they plan to pursue a specialty. The
internship provides every D.O. with the
perspective to see and treat every patient as a
whole person.
Many D.O.s then choose to take a residency
program in a specialty area, such as internal
medicine, surgery, pediatrics, radiology or
pathology. A residency typically requires
from two to six years of additional training.
All physicians (both D.O.s and M.D.s) must
pass a state medical board examination in
order to obtain a license and enter practice.
Each state board sets its own requirements
and then issues the license for the physician
to practice in that state.
Additional information may be found in the
American Osteopathic Association's brochures
"What is a D.O.?" and "Osteopathic Medical
Education."
�312-280:5810
800-621-1773
3 1 2 - 2 8 0 5 8 9 3 (FAX)
:
c
J
R O B E R T E. DHABA, PH.D.
EXECUTIVE
DIRECTOR
AMERICAN OSTEOPATHIC ASSOCIATION
142 E A S T O N T A R I O
C
j
E D W A R D A. L O N I E W S K I ,
^—<
C H I C A G O 60611
D.O.
PAST PRESIDENT
AMERICAN OSTEOPATHIC ASSOCIATION
26040
DOW
REDFORD.
Ml
PHONE
48239
313-592-8636
�American Osteopathic Association
Statement on Health Care Reform
(Approved by AOA Board of Trustees - 3/93)
(Endorsed by AOA House of Delegates - 7/93)
Executive Summary
The AOA supports health care reform which includes the following provisions.
I.
A global budget for health care expenditures.
II.
The establishment of a uniform basic package of
benefits, which includes coverage of preventive care.
III.
A system based on managed competition, defined as an
integrated system of financing and delivering health care
through several types of health plans. Central to
managed competition is the establishment of an
intermediary which acts as a bargaining agent between
purchasers of health care and competing health plans.
Any managed competition system must provide for the
inclusion of osteopathic providers. The AOA only
supports health care reform that mandates the inclusion
of osteopathic physicians and their distinctive services in
health plans.
IV.
Insurance market reforms mandating that insurers must
accept all applicants, regardless of pre-existing
conditions, and establishing premiums according to
community rating.
V.
Tort reform such as caps on awards, limits on joint and
several liability, establishment of alternative dispute
resolution system and the use of practice guidelines as
an educational tool.
VI.
Recognition of the importance of primary care
physicians as gatekeepers in the managed competition
model. The osteopathic profession historically has
provided, and continues to produce, a majority of
primary care physicians. Over 60 percent of the
osteopathic profession practices in primary care fields.
�AOA STATEMENT ON HEALTH CARE REFORM
The nation is facing a crisis of great proportions as health care costs increase while access
to care declines. Many areas of the nation are without an adequate supply of physicians and
providers despite policies to provide incentives to practice in these areas.
Further,
physicians are growing ever more frustrated with the U.S. insurance system with its
duplicative and complicated coverage policies. Finally, our litigious society has contributed
to changes in practice patterns causing many physicians to practice "defensive medicine" to
ensure their care can meet a legal challenge. The net effect of these factors demands the
development of an effective comprehensive health care policy. The American Osteopathic
Association (AOA), which represents nearly 35,000 doctors of osteopathic medicine (D.O.s)
believes the following proposals will go far to appropriately reform the nation's health care
delivery system.
GLOBAL BUDGET
The osteopathic profession recognizes the need to establish a national health policy and
system which reduces cost-shifting among the public and private payors, and controls the
rising health care portion of the GDP. To achieve these goals, the AOA supports a global
budget for health care expenditures.
A global budget, as its name implies, would simply set an upper limit on both private and
�public health care spending. The AOA believes that without such a framework under which
to reform the health care delivery system, other health care reforms would be rendered
ineffective. In other words, unless there are funds available, the necessary flexibility to
achieve complete and effective reform will not exist.
It must be noted that the AOA is not a stranger to the "budget limit" concept. In 1989, the
AOA distanced itself from the rigid orthodoxy of many other medical associations and
supported the proposal of then-Department of Health and Human Services Secretary Louis
B. Sullivan to apply an expenditure target to Medicare Part B costs. In embracing a target
or limit concept then and now, the AOA hopes to avoid further stop-gap cost containment
efforts such as another physician fee freeze or limiting charges, which would indeed result
in rationing of health care services. Although the AOA is obviously committed to physicians
being appropriately compensated for their services, the osteopathic community has an
abiding concern about the quality and availability of health care services to all Americans.
The AOA recognizes that targets are strong medicine but believe that such a concept is
prescribed in the context of a fiscal crisis and written in consonance with the osteopathic
physician's perspective that the health and welfare of the patient is paramount.
UNIFORM BASIC BENEFITS
The AOA believes that once a target is established, a uniform basic package of benefits,
which includes coverage of preventive care must and can be developed and made available
�to all Americans. As a profession which was born based on the belief that the body has the
intrinsic ability to heal itself, the AOA wholeheartedly supports a greater reliance on
preventive and primary care. Since its inception in 1892, the osteopathic profession has
lauded the benefits of prevention including adequate nutrition, sleep and appropriate
exercise and other methods that assist the body in its healing process. While primary and
preventive care will not solve all the problems of the American patient, greater access to
primary care, preventive methods and health education will greatly improve the overall
health of Americans without imposing the corresponding cost associated with acute care
services.
Along with support from the federal, state and local levels to provide a baseline of care to
all Americans, however, must come a commitment from the providers themselves. The
osteopathic profession is proud of its commitment to the underserved which was recently
illustrated in the Care-A-Van program. Under this initiative, two medical screening vans - better known as "Care-A-Vans" traversed the contiguous United States, providing baseline
health screening to the underserved. After 200 cities, 20,000 patients and 50,000 miles, the
two Care-A-Vans arrived in Washington, D.C. in early October 1992 and offered area
residents, employees and visitors free health screening.
The AOA is continuing this
initiative through its "Share the Care" plan, under which members are encouraged to donate
health care to the medically underserved. It is this commitment by the providers of health
care coupled with that of the payors which will go far to address the distribution and
consequently the health care access problem.
�MANAGED COMPETITION
Once a uniform basic benefits package is developed, a method on how best to deliver these
benefits must be determined. The AOA believes that a model which provides enough
competition to promote efficient health care without sacrificing quality health care is the
best method to meeting the competing objectives of reducing costs while preserving quality.
To that end, the Association supports a system based on managed competition, which is
defined as an integrated system of financing and delivering health care through several types
of health plans. Central to managed competition is the establishment of an intermediary
which acts as a bargaining agent between purchasers of health care and competing plans.
It is believed that this model will prohibit insurers distorting prices, allow consumers to
better assess their benefits and ensure the appropriate role of the provider.
Also integral to the managed competition concept is the need for primary care physicians
to act as gatekeepers. The osteopathic profession is able to assist in meeting this need as
it has historically provided, and continues to produce, a majority of primary care physicians.
In fact, over 60 percent of the osteopathic profession practices in primary care fields.
The profession believes that the American people should be able to receive their health care
from the professional of their choice. Hence, any managed competition system must provide
for the inclusion and active participation of osteopathic providers. The AOA only supports
health care reform that mandates the inclusion of osteopathic physicians and their distinctive
�services in health plans. Each year, 100 million patient visits are made to D.O.s. These
patients are seeking the services of an osteopathic physician because they believe in the
profession's unique approach to health care - that of treating the patient as a whole, not
just the diseased part.
INSURANCE MARKET REFORM
A system based on managed competition, however will not work unless certain insurance
practices are reformed. Growing numbers of the uninsured include the average employed
American who can no longer meet the payments for health care coverage due to the
skyrocketing cost of coverage. Further, many Americans must remain in unfulfilling jobs
simply to retain their health care coverage pre-existing conditions. To combat these
problems, the AOA believes that insurers must establish premiums according to community
rating which would set premiums on the same terms for all groups in a particular area. In
addition, insurers must be required to accept all applicants, regardless of pre-existing
conditions.
TORT REFORM
Due to the profession's emphasis on primary care, many osteopathic physicians provide the
care from birth through old age in small communities across America. Many D.O.s,
however, have been forced to cease delivering obstetrical care and other high risk
�procedures because of the high professional liability insurance premium costs associated with
delivering such care. The AOA believes that relief from this untenable situation can be
found in tort reform, such as caps on awards, limits on joint and several liability,
establishment of alternative dispute resolution (ADR) systems and the use of practice
guidelines as an educational tool. In considering the establishment of ADR systems,
however, one must realize that because of the increased access to the legal system which
ADRs could bring, malpractice costs could potentially increase. Close scrutiny of such
systems would be necessary to assess their value.
The profession strongly believes in the value of practice guidelines and is excited about their
development. Such guidelines, however, do not establish the exclusive method of treatment.
Rather, practice guidelines attempt to provide overall guidance on the best treatment plan they should be used as a guide and not a mandate.
CONCLUSION
There is no doubt that the nation is facing a crisis of great proportions as health care costs
spiral while access to care declines. The profession believes that reform of the current
delivery system is necessary and should include a global budget for health expenditures, a
delivery system based on managed competition which includes D.O.s, a uniform basic
package of benefits, which includes coverage of preventive care, and reforms of the
insurance market and tort law.
�IV
103D CONGRESS
1ST SESSION
H. C N R S 173
O . E.
Expressing the sense of the Congress that the unique and vital health care
services provided by osteopathic physicians must be included in any
health care benefits package developed as part of health care system
reform.
IN THE HOUSE OF REPRESENTATIVES
NOVEMBER 4, 1993
Mr. BARCIA of Michigan (for himself Mr. BILIRAKIS, Mr. BROWN of Ohio, Mr.
KILDEE, Mr. SKELTON, Mr. STRICKLANT), Mr. TOWNS, and Mr. WYDEN)
introduced the following concurrent resolution; which was referred to the
Committee on Energy and Commerce
CONCURRENT RESOLUTION
Expressing the sense of the Congress that the unique and
vital health care services provided by osteopathic physicians must be included in any health care benefits package developed as part of health care system reform.
Whereas there exist two distinct branches of medicine in the
United States—osteopathic physicians, denoted by the
initials D.O., and allopathic physicians, denoted by the
initials M.D.;
Whereas osteopathic physicians comprise 5.5 per centum
(thirty five thousand) of all complete physicians in the
United States;
�2
Whereas each year over one hundred million patient visits are
made to osteopathic physicians;
Whereas the unique focus of osteopathic medicine, with its
guiding principle of treating the whole person, has rooted
the profession in a philosophy which emphasizes primary
care and prevention;
Whereas for more than one hundred years, the osteopathic
profession has trained more than 50 per centum of its
physicians in primary care areas;
Whereas policy makers agree that the number of primary
care physicians must be increased if appropriate health
care is to be made available to all Americans;
Whereas osteopathic medical education has a unique internship requiring a rotation in internal medicine, OB/GYN,
family practice and surgery, ensuring that osteopathic
physicians are first trained as primary care physicians,
regardless of whether one chooses to specialize;
Whereas, osteopathic physicians provide complete medical
care in all specialties with over half of the physicians currently practicing in primary care;
Whereas, osteopathic physicians comprise 15 per centum of
all physicians practicing in communities of ten thousand
or less, and 18 per centum of all physicians serving communities of two thousand five hundred or less;
Whereas osteopathic physicians serve approximately one out
of every seven Medicare and one out of every four Medicaid recipients in the United States;
Whereas osteopathic physicians comprise 10 per centum of all
physicians serving in the military; and
HCON 173 I H
�3
Whereas, despite their valuable contributions to the nation's
health care, osteopathic physicians continue to experience
discrimination from some health care institutions and
managed care entities: Now, therefore, be it
1
Resolved by the House of Representatives (the Senate
2 concurring), That it is the sense of the Congress that any
3 legislation enacted to reform the health care delivery sys4 tern of the United States should include the services of5 fered by all of the Nation's osteopathic physicians. Specifi6 cally, such legislation should:
7
(1) Ensure that any American included in the
8
health care coverage systems supported by the Unit-
9
ed States Government have the opportunity, without
10
restriction, to secure the services of an osteopathic
11
physician.
12
(2) Encourage and advance practices and prin-
13
ciples utilized by the osteopathic profession which
14
are proven to produce high numbers of physicians
15
trained in all areas of primary care.
o
HCON 173 I H
�CONGRESSIONAL
RECORD—Exievsiom
OSTEOPATHIC
PHYSICIAN'S
SHOULD
BE
INCLUDED
IN
H E A L T H CARE R E F O R M
H N JAMES A. BARCIA
O.
OF" MICH7GAJ-I
IN THE HOUSE OF R E P R E S E N T A T I V E S
Thursday, November 4, 1993
Mr. BARCIA of Michigan. Mr. Speaker. I rise
today to introduce The Osteopathic Medicine
Awareness and Appreciation Act, a House
concurrent resolution recognizing the contribotwns of osteopathic medicine to health care in
America.
Many Americans may be unaware o! the
(act that there are two paths to becoming a
complete physician: the allopathic route, denoted by the tnrtials M.D., and the osteopathic
route, designated by the initials D.O. Osteopathic physicians are complete physicians,
tulty trained and licensed to prescribe medication, perform surgery, and all other services
within a physician's scope of practice.
In addition to these shared elements between D.O.'s and M.D.'s, osteopathic physn
dans are dedicated to a holistic philosophy of
health care, and receive extra training in the
musculoskeletal system, the body's interconnected system of nerves, muscles, and
bones that make up two-thirds of its mass.
This training provides osteopathic physicians
»vith a better understanding of the ways thai
an injury or illness tn one part of the body can
aflect another. It gives D.O.'s a therapeutic
and diagnostic advantage over those vwho d o
not receive additional specialized training. In
addition to the traditional art of medicine, an
imegral component of osteopathic medicine is
the utilization of osteopathic manipulative
treatrnerrt (OMT). a procedure through which
D.O.'s use their hands to diagnose injury and
illness and to encourage the body's natural
tendency toward good health. By combinirtg
traditional medical practices with OMT. D.O.'s
offer their patients the most comprehensive
care available in medicine today.
For more than a century, osteopathic physicians have been filling a unique and vital
niche in the delivery of health care in America.
Desprte the fact that osteopathic physicians
constitute only 5.5 percent—about 35.000 osteopathic physicians—of the Nation's physician-ftianpower, they are often the only physicians In rural areas, as well as those which
traditionally have difficulties in attracting and
retaining physicians. Osteopathic physicians in
fact comprise more than 15 percent of ail physicians practicing in communities with populations of less than 10,000 people and 18 percent of at) physicians serving communities of
2,500.
of Remarks
November
4,
In addition, osteopathic ptiysirians serve approwmatety one out ot every seven Medicare
and 25 percent of aU Medicaid recipients in
the United States. Osteopathic physoans also
comprise 10 percent of all physicians serving
in the milrtary. In ali, over 100 million patient
visits are made to osteopathic physicians annually.
Further, the unique focus o< osteopathic
medicine, with its guiding principle of treating
the wixtie person, has rooted the profession in
a philosophy which emphasizes pnmary care
and prevention, and has contributed to making
the profession one of today's fastest growing
segments of the medical professions.
Mr. Speaker, one point on which virtually all
experts on health system reform agree is the
disproportionately high percentage of recent
medical school graduates choosing to specialize in areas other than primary care, and their
distribution nationally. Because of this fact, a
significant and critical demand for primary care
physicians has developed—a trend which will
not easily be reversed For more than 100
years, the osteopathic profession has trained
rnore than 50 percent of its physicians hi primary care areas. Today, over 50 percent of
osteopathic physicians practice kn primary care
area<>, such as pecfiatiics, general practice obstetrics/gynecology {OB/GYN], and internal
medicine. While osteopathic physicians may
choose to specialize, arid are represented in
all specialty areas, the osteopathic internship
requires a unique rotation in internal medicine,
0 8 / G Y N , family practice and surgery. This
unique educational requirement ensures that
osteopathic physicians are first trained as primary care physicians.
Despite these significant contributions to
American health care, many Americans rem a n unaware that there are two types of fufl
physicians in the United States, D.O.'s, and
M.D.'s. I am deeply concerned that in the
wake of comprehensive health system reform—which may include the establishment of
minimum benefits packages, health networks,
and other managed care systems—the services of D.O.'s may be unintentionally excluded, causing the eventual demise of an important treatment option for many Americans.
That Is why I am introducing this measure,
which I strongly urge my colleagues to support ft Is my hope that this resolution will provide a significant step toward ensuring that the
vital services provided by osteopathic physicians remain available to any American seeking them. In addition, the osteopathic profession is doing something right in the battle to
develop high numbers of primary care physicians: it is my hope that the Congress witl
seek the counsel of the osteopathic profession, and learn from the century-old example
that ft has set when we address this critical
problem.
1993
�n
Calendar N . 295
o
103D CONGRESS
1ST SESSION
S.1668
To amend the Social Security Act and related Acts to make miscellaneous
and technical amendments, and for other purposes.
IN THE SENATE OF THE UNITED STATES
17 (legislative day, NOVEMBER 2), 1993
Mr. MOYNIHAN, from the Committee on Finance, reported the following
original bill; which was read twice and placed on the calendar
NOVEMBER
A BILL
To amend the Social Security Act and related Acts to make
miscellaneous and technical amendments, and for other
purposes.
1
Be it enacted by the Senate and House of Representa-
2 tives of the United States of America in Congress assembled,
3
4
SECTION 1. SHORT TITLE.
This Act may be cited as the "Social Security Act
5 Amendments of 1993".
6
7
SEC. 2. REFERENCES I N ACT; TABLE OF CONTENTS.
(a) AMENDMENTS TO SOCIAL SECURITY ACT.—Ex-
8 cept as otherwise specifically provided, whenever in this
�210
1
(5) in subsection (f), by adding at the end the
2
following new sentence: "Such sums as may be avail-
3
able under the limitation set forth in this paragraph
4
for fiscal year 1993 shall be available until ex-
5
pended.".
6
SEC. 260. CORRECTION RELATING TO SECTION 4751 (AD-
7
8
VANCED DIRECTIVES).
Section 1903(m)(l)(A) (42 U.S.C. 1396b(m)(l)(A)),
9 as amended by section 4751(b)(1) of OBRA-1990, is
10 amended—
11
12
(1)
by striking "1902(w)" and
inserting.
"1902(w) and"; and
13
(2)
14
"1902(w)".
15
striking "1902(a)"
and
inserting
SEC. 261. CORRECTIONS RELATING TO SECTION 4752 (PHY-
16
17
by
SICIANS'SERVICES).
(a) Paragraph (59) of section 1902(a) (42 U.S.C.
18 1396a(a)) as added by section 4752(c)(1)(C) of OBRA)
19 1990 and as redesignated by section 13623(a)(6) of
20 OBRA-1993, is amended by striking "subsection (v)" and
21 inserting "subsection (x)".
22
(b) Section 1903(i)(12) (42 U.S.C. 1396b(i)(12)), as
23 inserted by section 4752(e) of OBRA-1990 and as redes24 ignated by section
25 amended—
13631(c)(3)
of OBRA-1993, is
�211
1
2
(1) by amending clause (i) of subparagraph (A)
to read as follows:
3
"(i) is certified in famity practice or
4
pediatrics by the medical specialty board
5
recognized by the American Board of Med-
6
ical Specialties for family practice or pedi-
7
atrics or is certified in general practice or
8
pediatrics by the medical specialty board
9
recognized by the American Osteopathic
10
11
12
Association,";
(2) by amending clause (i) of subparagraph (B)
to read as follows:
13
"(i) is certified in family practice or
14
obstetrics by the medical specialty board
15
recognized by the American Board of Med-
16
ical Specialties for family practice or ob-
17
stetrics or is certified in general practice or
18
obstetrics by the Medical Specialty Board
19
recognized by the American Osteopathic
20
Association,"; and
21
(3) in subparagraphs (A) and (B)—
22
23
(A) b}' striking "or" at the end of clause
(V);
24
25
(B) by redesignating clause (vi) as clause
(vii); and
•S 1668 PCS
�212
1
(C) by inserting after clause (v) the follow-
2
ing new clause:
3
"(vi) delivers such services in the
4
emergency department of a hospital par-
5
ticipating in the State plan approved under
6
this title, or".
7
SEC. 262. CORRECTIONS RELATING
8
9
TO SECTION 4801
(NURSING HOME REFORM).
(a)
Section
1919(b)(3)(C)(i)(I)
(42
U.S.C.
10 1396r(b)(3)(C)(i)(I)), as amended by section 4801(e)(3)
11 of OBRA-1990, is amended by striking "not to exceed"
12 before "14 da3's".
13
(b)
Section
1919(b)(5)(D)
(42
U.S.C.
14 1396r(b)(5)(D)), as amended by section 4801(a)(4) of
15 OBRA-1990, is amended by striking the comma before
16 "or a new competency evaluation program.".
17
(c)
Section
1919(b)(5)(G)
(42
U.S.C.
18 1396r(b)(5)(G)) is amended by striking "or licensed or
19 certified social worker" and inserting "licensed or certified
20 social worker, registered respiratoiy therapist, or certified
21 respiratoiy therapy technician".
22
(d)
Section
1919(f)(2)(B)(i)
(42
U.S.C.
23 1396r(f)(2)(B)(i)) is amended by striking "facilities," and
24 inserting "facilities (subject to clause (iii)),".
•S 1668 PCS
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. memo
SUBJECT/TITLE
DATE
Addresses (Partial); Phone No.'s (Partial); DOB's (Partial); SSN's
(Partial) (2 pages)
01/24/1994
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Simone Reuschemeyer
OA/Box Number:
3625
FOLDER TITLE:
Physician Group [binder] [2]
2006-0885-F
jm922
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA|
b(3) Release would violate a Federal statute 1(b)(3) of the F01A|
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes |(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation nf
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells |(b)(9) of the FOIA|
National Security Classified Information |(a)(l) of the PRA|
Relating to the appointment to Federal office 1(a)(2) of the PRA|
Release would violate a Federal statute 1(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�JflN-25-1994
• J O * ! *«> S T A M T .
14:07 F O R E O T O RSSN - U O
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/
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15152227257
P.02
or 2 0 2 - 5 4 4 - 5 0 6 0
: American Osteopathic Association
B E T S Y W. BECKVOTM, DIRECTOR
•
: GOVSRNMCKT RELATIONS
MFMORANDtlM
: j
1
TQ:
:
.
;
' L^.Sbaniiah^;Director, National Health PoUcy Cc^incil
:
:;: ;;.:;v^\SFK0M::.- :: f B d ^ ^cfcwith, AOA Direcfbr, Government Relations
: :
i^v:>: ;-$l^
•
.
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;
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^ Vl''-/:; ;
;
.: i(lV
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: Laitre'nce Bo^char^ IXCX, AOA President:.; •;;
I>:0.;AOA Piesident-EIeci
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�JfiN-25-1994 14 = 08
(4)
F O A E O T O ASSN - U O
RM MR SE
/
TO
15152227257
Barbara Ross-Lee, D.O.
(5> : : Ro^rt Draba, PhD
Executivfe Director
Americaa Osteopaithic Association
(6) • Elizabeth W. Beckwith
DiEector, Government Relations
As always, thanksforyour assistance. I look forward:to seepgiyon soon.
Sincerely, ';
Betsy W. Beckiviifi
Director, Govetmiment Relations
P.03
�^
JflN-25-1994
14 = 06
FROM RMER OSTEO RSSN - Ld/Q
TO
1515222725?
P.01
AMERICAN OSTEOPATHIC ASSOCIATION
Fax Transmittal Form
DATE:
TO:
ORGANIZATION:
FAX #: (Sib ) & '? 3 "
FROM:
DEPARTMENT:
GOVERNMENT RELATIONS
TOTAL NUMBER OF PAGES INCLUDING THIS COVER LETTER:
IF TOTAL # OF PAGES ARE NOT RECEIVED, PLEASE CALL: (202) 544-5060
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
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"3 "
l 5
-
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
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William J. Clinton Presidential Library & Museum
Identifier
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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Physicians Group [binder] [2]
Creator
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White House Health Care Task Force
Health Care Task Force
Simone Rueschemeyer
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 34
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092987" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
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Reproduction-Reference
Date Created
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3/16/2015
Source
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42-t-12092987-20060885F-Seg3-034-007-2015
12092987