Chairman Michaud, Ranking Member Miller, and distinguished members of the committee, I am Dr. Randy Phelps, Deputy Executive Director for Professional Practice of the American Psychological Association (“APA”), the largest association of psychologists, with approximately 90,000 full members and 50,000 graduate student members engaged in the study, research, and practice of psychology.  I am a licensed clinical psychologist, a former practitioner, clinical researcher and educator, and for the past 15 years on the APA executive staff, have served as APA’s liaison to professional psychology in the Department of Veterans Affairs (VA).

APA appreciates the opportunity to testify today about human resource challenges within the Veterans Health Administration (VHA) that have a direct impact on the recruitment and retention of doctoral psychologists to provide care to this nation’s heroes. I should note at the outset that VHA is the workplace of choice for many of our members, with about 2,400 psychologists currently in the system.  VA is, in fact, the largest single employer of psychologists in the country. APA supports VA’s recent and aggressive recent efforts to recruit new psychologists, but has concerns about a number of policies and procedures which are negatively affecting both recruitment and retention.

APA’s Contribution to Growing Needs

Professional psychology as a discipline was “born” as a result of the needs of this nation’s returning World War II heroes, and psychologists are acutely aware of the debt we owe to those veterans and to the brave men and women who have followed in their footsteps, as well as to the system of care this country has evolved to minister to their healthcare needs. 

And, APA is acutely aware that there are over 200,000 homeless veterans on America’s streets today; that the risks of Post Traumatic Stress Disorder (PTSD) and traumatic brain injury (TBI) appear to be at unprecedented levels in the population of 1.7 million service members who have been deployed in the War on Terror;  that there has been a resulting influx of veterans from previous theaters of war who are increasingly seeking VA services;  and that the healthcare needs of aging veterans continue to grow. 

To assist with those needs, APA has many initiatives currently underway, including two Presidential Task Forces on the Needs of Military Service Members and Their Families,  and the recently adopted “Blueprint for Change: Achieving Integrated Healthcare for an Aging Population, which is consonant with VA’s groundbreaking work on primary care integration. 

APA’s Committee on Rural Health is addressing ways for psychologists to help extend services to veterans in rural areas where existing VA and Department of Defense (DoD) facilities are simply beyond the reach of patients.  As well, APA’s public interest component works on issues of direct concern to VA, such as homelessness, military sexual trauma, and family violence. In education, we are creating training pipelines for specialty training of psychologists and other mental health professionals regarding soldiers’ pre and post deployment needs,  through both the Center for Deployment Psychology (with the DoD) and in proposing expansion of our Graduate Psychology Education program.  We also have recently provided testimony proposing funding increases over the Administration’s FY ’09 VA Medical and Prosthetic Research Account funding levels. 

Recruitment and the Psychology Workforce Within VHA

As I indicated, VHA is the single largest employer of psychologists in the nation, and has been for many years.  Yet, VA continues to recognize the need to increase its psychology staffing levels in response to ever-increasing needs for services to veterans.   

As a result, VHA has added more than 800 new positions for psychologists since 2005; thereby rapidly increasing the number of psychologists in the system to a current high of approximately 2,400, which now surpassing the previous 1995 high of approximately 1,800 psychologists nationally.  The 2,400 psychologists now employed by VA range from the GS-11 to GS-15 levels. 

The APA applauds VA for these tremendous and serious recent efforts to recruit additional psychologists into the system, and we have actively partnered with VA to promote the news of these openings, have attempted to assist with recruiting neuropsychologists (who are needed in increasing numbers due to TBI), and have worked to promote VA career choices by the newer generations of psychologists.

I need to emphasize, however, that these increased psychology staffing levels are a very recent development over approximately the last year and a half only.  Psychology staff levels were actually significantly BELOW 1995 levels until 2006.   Moreover, the vast majority of new psychologist hires in VHA are younger, lesser experienced psychologists who have come into the system at the GS-11 to GS-13 levels.   

However, the contrast between the VA’s success in recruiting new professionals into the system versus VA’s retention and promotion of those existing VA psychologists with years of experience treating veterans is dramatic.

For example, at the end of 2007, the number of GS-14s in the entire system nationally was no different than it was 12 years prior in 1995 (at 130 GS-14s total). Of additional concern to the APA is that the number of GS-15 psychologists nationally as of the end of 2007 (approximately 50) was actually considerably lower than the number of GS-15s in 1995.

To the system’s credit, VA has also recognized and capitalized on the fact that the best source of recruiting new psychologists has been the Department’s own training systems.   Over the past two years, approximately 75% of all new psychologist hires have been prior VA trainees.  And, VA is rapidly increasing its funding of psychology training.  In the 2008-2009 training year, VA has added approximately 60 new psychology internship positions and 100 new postdoctoral fellowship positions, spending approximately $5 million to do so.  This will bring the total psychology training positions to approximately 620 per year nationwide.

Retention of the Psychology Workforce

Despite positive developments in recruitment, VA’s advancement and retention policies continue to be driven by outdated and overly-rigid personnel and retention systems.   In addition to hiring new staff, the VA needs to retain those existing psychologists who are qualified, possess specialized skills, and who are already acculturated within VHA.  These psychologists are vital to service provision because of both their professional expertise and their knowledge of the system and its resources for veterans. 

1. Lack of Uniform Psychology Leadership Positions

Since 1995, independent mental health discipline services at most facilities have been replaced with interdisciplinary Mental Health Service Lines. As a result, there has been a decrease in the number of discipline chiefs across the system.  The dissolution of discipline specific services has left a clear leadership gap in terms of professional practice accountability, guidance on the proper use of professional skills, and promotion and oversight of profession specific staff and pre-licensure training.  

Psychology remains the only major mental health discipline without an officially designated leader in every medical center, analogous to the Social Work Executive.  While there are a small number of “Chief Psychologists” remaining, the far more prevalent positions of discipline-based professional leadership are those such as “Supervisory Psychologist”, “Lead Psychologist”, or “Psychology Director”.  Notably, these positions are all too frequently unrecognized at the level of additional pay for the additional professional leadership responsibilities they entail.

2. Inequitable Access to Key Leadership Positions

Psychologists are also not represented equitably in all levels of leadership in the VA’s healthcare delivery system.  In 1998, the Under Secretary for Health (USH) attempted to correct this situation with the issuance of VHA Directive 98-018, later reissued in 2004 as VHA Directive 2004-004, which stated that “it is important that the most qualified individuals be selected for leadership positions in mental health programs regardless of their professional discipline.”

Unfortunately, the only requirement within the Directive was that announcements of VA mental health leadership positions not contain language that restricts recruitment to a specific discipline. As a result, this Directive has had little practical impact on the appointment of highly qualified psychologists to VA mental health senior leadership roles, particularly at medical school affiliated VA facilities.

3. Serious Implementation Problems in Hybrid Title 38

Psychologists remain the only doctoral healthcare providers in VA who are not included in Title 38.  In late 2003, the Hybrid Title 38 system was statutorily expanded to provide psychologists (and a wide range of other non-physician disciplines) some of the same personnel and pay considerations as their physician counterparts.  The hybrid model requires Professional Standards Boards to make recommendations on employment, promotion and grade for psychologists, and is still more subjective than a pure Title 38 program; unlike Title 38 where professionals are hired, promoted and retained based solely on their qualifications. 

The implementation of the new Title 38 Hybrid boarding process has been extremely variable and chaotic across the system.  Many Psychologist leaders from facilities throughout the country have reported that their facilities and Veterans Integrated Service Networks (VISN) have denied GS-14 and 15 promotions that have been recommended by the national boarding process. Even more frequent are reports of facilities and VISNs that have delayed or refused to forward boarding packets to the national board and/or have refused to reveal the results of the national board action.

Informational missteps and technical problems have also plagued the national psychology boarding process.   Just last month, VA Central Office (VACO) sent instructions to the field that eliminated the national cap on GS-14 levels for psychologists.  However, these same instructions tied the award of GS-15 psychology positions to the facility’s level of complexity, making many senior psychologist leaders ineligible for grade increases commensurate with the scope and complexity of their actual duties. 

APA was optimistic that the Hybrid Title 38 system would modernize the pay system and foster greater retention of senior psychologists within the VHA system.  Given that five years after its passage, implementation continues to be such a boondoggle, we are now seriously reconsidering our support for the Hybrid system, and considering instead a policy change to bring psychologists fully into the Title 38 system. The basic concept of Title 38 is “rank-in-person” rather than rank in position, basing rank and pay on one’s qualifications brought to the job rather than on some of the duties of the position.  Hybrid 5/38 uses the procedures of Title 38 for recruitment, but not for rank and pay boards, preferring a mixture of Title 5 types of position descriptions, now re-titled in Title 38 language as “functional statements”.  The functional statements are used with Title 5 kinds of considerations, including scope of supervisory or managerial responsibilities, leaving no room for advancement in rank for senior psychology clinicians who are not part of medical staff. 

For example, efforts to make it easier for outstanding research clinicians to advance in rank have been virtually unsuccessful because in many cases it is written into their jobs as clinicians that research is part of their function; they are denied any special advancement for published papers, grants awarded from merit review bodies, etc.  Indeed the bar of publications has been set so high that few of them have been able to advance in rank, again based on the kinds of measures one would have used under Title 5.

Most physicians, under this rank in person concept, used to achieve a base pay equivalent to a GS-15, step 10.  More recent changes to physician pay have resulted in psychiatric physicians being paid a minimum of $91,500 to a maximum of $225,000, with four levels of pay grade, each with a minimum and maximum, incorporating other elements such as “market pay” and “performance pay.”  The result is that the typical psychologist, depending upon locality tops out at about $101,000 after 15-20 years of service (GS-13, step 10), while a senior physician typically may make 30 to 125% higher salary.

Also, physicians have long had an annual bonus for board certification.  Psychologists are now eligible for a one-time step increase, but only if they were to became newly board certified within a narrow window prior to, or since the inception of hybrid Title 5/38.  Senior psychologists who have topped out in their grade (GS-13) are not eligible for anything other than a one-time award.

Additional Factors Affecting Recruitment and Retention of Psychologists

1. Medical Staff (Clinical) Privileges vs. Full Medical Staff Membership

VA is based on a medical model, and doctoral psychologists are excluded from the decision making process by being denied full medical staff privileges in many facilities, particularly those that are not affiliated with medical schools.  Not being a member of the medical staff is to be a second class citizen.  Psychologists are most typically “clinically-privileged” practitioners, i.e., those who are not full members of the medical staff, and who are called “Licensed Independent Practitioners”.  But they have no formal say in hospital policy, and may not sit on the governing body of the medical staff in those facilities where they are not members.

There are a number of important reasons to support psychologists having full medical staff membership throughout the VHA healthcare system. . In recent years there has been a significant increase in the number of psychologists who have assumed leadership roles in important medical center programs. These include many of the new post traumatic stress disorder (PTSD), Recovery, Pain, Substance Abuse programs, and so forth. These psychologists are responsible for the supervision of various disciplines and provide direct clinical care for the medical center. These are certainly responsibilities that are consistent with full membership on the medical staff. In addition, many of the new Home Based Primary Care (HBPC) psychologists are working independently and away from the physical umbrella of the VA medical centers. They are doing important and demanding work in the veteran’s homes. Again, the level and complexity of work is what one would expect from a full member of the staff. Without membership, there is restricted input into many important decisions that impact programming and ultimately on patient care.

2. Prescriptive Authority

One of the most difficult current challenges for VHA is how to extend care into those areas, particularly in rural America, where VA facilities do not exist or are at great distance from the veteran.  One option that VHA has long resisted, but should more carefully consider, is granting expanded authority for appropriately trained psychologists to provide both psychological and psychopharmacological care to veterans in these underserved rural areas.  Experience in both states where licensed psychologists have this expanded statutory authority to prescribe (New Mexico and Louisiana) , as well as a decade of data from the original DoD psychopharmacology program, have shown these practices to be safe and effective for the public.

Both New Mexico and Louisiana, states with large rural populations, have passed laws to allow psychologists to prescribe.  New Mexico, which passed its prescriptive authority law in 2002, and Louisiana, which passed its law in 2005, permit appropriately trained licensed psychologists with additional postdoctoral training in psychopharmacology tp prescribe.  These laws have been very successful, and to date nearly 50 psychologists prescribing in these states have written more than 40,000 prescriptions without adverse incident.

Furthermore, a federal demonstration project set up nearly two decades ago has set a clear precedent that psychologists can successfully prescribe in a large federal health system.  The Department of Defense Psychopharmacology Demonstration Project (PDP) also proved that psychologists can be trained to prescribe safely and effectively.  Begun in 1991, ten psychologists participated in the PDP, which was designed to train and use psychologists to prescribe psychotropic medications.  These psychologists treated a wide variety of patients, including active duty military, their dependents and military retirees, with ages ranging from 18 to 65.

The PDP was highly scrutinized.  The American College of Neuropsychopharmacology (ACNP) conducted its own independent, external review of the PDP and in 1998 presented its final report to the DoD. Likewise, the General Accounting Office (GAO) issued a positive report on the PDP.  Both reports repeatedly stressed how well the PDP psychologists had performed, and noted that with prescriptive authority, psychologists were able to offer holistic, integrative treatment, which includes psychotherapy and medication, where appropriate. 

It is clear that already licensed doctoral psychologists are being trained to prescribe safely and effectively.  The precedent for the VA system to recognize psychologist prescriptive authority is clear both from state action and the DoD’s program. In addition, APA Division 18 psychologists—Psychologists in Public Service—including those who serve in the VA, are already supporting training of a cadre of public service psychologists to be able to prescribe as recognition expands along with the need for services.  The VA should begin to utilize such professionals to the full extent of their licensure and training.  Psychologists are willing and able to help fill the gap and ease the strain on the VA health system particularly in rural areas.

Summary and Examples

Two dramatic, but not apparently unusual examples of how these problems are affecting services have recently crossed my desk.  In one, a new hire, who happens to be a former State Psychological Association President and representative to APA’s Committee on Early Career Psychologists, was dismissed during his probationary year after being hampered in his abilities to effectively discharge his dual leadership duties as the facility’s new Local Recovery Coordinator as well as the Acting Supervisory Psychologist.  In another facility, a more senior psychologist who was approved by the National Standards Board was denied locally for a GS-14 upgrade for her position as Psychology Program Manager and tendered her resignation on April 1st.  

APA considers the issues and problems addressed in this testimony as serious obstacles to making VA the workplace of choice for psychologists. Without clear advancement systems in place, VA faces critical long term recruitment and retention problems. As psychologists come to believe that there is little possibility for advancement, regardless of the level or complexity of responsibilities, fewer VA psychologists will be willing to accept positions of greater responsibility. In addition, high potential trainees whom the VA would like to recruit will increasingly see VA as a “dead end” for their careers, and will be attracted to other career options that offer more potential for advancement. 

Thank you for this opportunity to provide testimony today on behalf of the American Psychological Association.  We stand ready to assist with the Committee’s work to further improve recruitment and retention of psychologists to assist in providing care to this nation’s honored veterans.