Interview with Arlene Pietranton Ph.D., Executive Director, American Speech Language Hearing Association (ASHA)

AO/BECK: Hi Arlene, thanks for meeting with me, and congratulations on your new position as Executive Director of ASHA. I'd like to review your educational and professional history and then we'll get to your thoughts on the issues at hand.

PIETRANTON: Sure Doug, that sounds great. Thanks for inviting me.

AO/BECK: Let's start with your education please. Where did you go to school?

PIETRANTON: Well, all of my degrees are from The George Washington University in Washington, DC. My undergraduate degree was in Biology, I completed that in 1974 and then I earned my masters degree in Speech Pathology in 1976. I left the DC area for a couple of years and came back to take a position as Chief of Speech-Language Pathology and Audiology Services at The George Washington University Medical Center in 1978. In the 80's I started on a part-time basis in a doctoral program. I worked full-time, got married, had children and volunteered with various professional and civic organizations, so it took a while, but in 1992 I defended my dissertation and in 1993 I was awarded a PhD in Psychology from The George Washington University.

AO/BECK: What was your dissertation topic?

PIETRANTON: My dissertation topic was " P-300 Measurements in Left CVA and Right CVA Subjects" as an Indicator of Cognitive Recovery in Post-Stroke Patients."

AO/BECK: Very interesting. I think of those measures as being more in the audiology armamentarium, is that correct?

PIETRANTON: That is usually correct. But my doctorate was in experimental psychology and very much interdisciplinary. My dissertation committee included an audiologist, speech language pathologist, neurologist, cognitive psychologist, and experimental psychologist. It was a fundamental study with patients who had experienced a right CVA versus a left CVA and involved preliminary explorations of the potential diagnostic and prognostic value of the P-300 as a cognitive indicator with those populations.

AO/BECK: That's very impressive work. Can you tell me about your employment history, including when you became an ASHA employee?

PIETRANTON: Sure, my first paid professional position was as a speech-language pathologist in a school for children with special needs in the mid- 1970s. Following that I worked as an itinerate speech-language pathologist at the Cooper Medical Center in Camden, NJ, a position that allowed me the opportunity to provide a wide variety of speech-language pathology services across the age spectrum in a number of settings, such as patients' homes, skilled nursing facilities, ambulatory clinics, and acute hospitals. Beginning in the late '70s through the mid-'90's I worked at The George Washington University Medical Center in Washington, DC in a variety of positions. I was hired as the Chief of Speech Pathology Services. In that position, I provided clinical services - primarily to adults with neurogenic, voice, and alaryngeal communication needs and I had administrative responsibility for the department, which I helped to expand to include a state of the art audiology program that included the full complement of audio diagnostic procedures, hearing aid fitting and dispensing, and an active newborn hearing screening program. In the early 90's, GWUMC decided to reorganize it's rehabilitation services and I was selected as the first Director of Rehabilitation Services. In that position, I developed and implemented a model across Audiology, Occupational Therapy, Physical Therapy, and Speech-Language Pathology that unified the administration of those services as independent entities and included Clinical Director positions in each area. My last position at the GWUMC was from 1993 to 1994 when I served as the first Administrative Director for the new Neurologic Institute. In that position, I coordinated the implementation of a plan to reorganize existing programs and departments to create a unified, multidisciplinary Center of Clinical Excellence. I administered the overall operation and development of the Neurological Disorders programs, including clinical service delivery, practitioner relations, capital and business planning, and financial performance during the Institute's inaugural year.

I joined the ASHA staff in 1994. My first position was Director of the Health Services Division. I facilitated the development of practice policies related to the delivery of audiology and speech language pathology services in various healthcare settings, represented the professions in various arenas such as the Joint Commission on Accreditation of Health Care Organizations, and helped to develop resource materials for members related to trends and issues such as clinical pathways, managed care, treatment outcomes, etc. Then from 1996 until 2003, I served as ASHA's Chief Staff Officer for Speech-Language Pathology.

AO/BECK: And you became the Executive Director of ASHA as of January 1, 2004, which I believe makes you only the third executive director in their 79 year history?

PIETRANTON: Yes, Kenneth O. Johnson was the first executive director. His tenure ended around 1980 or so, and that's when Fred Spahr became executive director. Fred was at the helm for some 25 years and then I began as executive director on 1-1-2004.

AO/BECK: As executive director, what are your primary responsibilities?

PIETRANTON: As you know, ASHA is very much a member-driven organization. One of the primary responsibilities of ASHA's executive director is to work with the Executive Board and the Legislative Council who are the elected representatives of the ASHA members to identify and address issues of concern to the members. Based on the thoughts and concerns of the members, the decisions of the Executive Board and the Legislative Council, the executive director works with the ASHA staff to make sure the goals are understood and the work moves forward in a timely and effective manner.

AO/BECK: Very good. So your task is to facilitate ASHA's agenda? In some respects, it must be like being the mayor of a small city! Aren't there 110,000 members of ASHA?

PIETRANTON: Yes, that's about right. There are about 90,000 SLP members, and about 13,000 audiology members . Of course, some people are dually certified, and others are speech-language-hearing scientists, so the actual number that ASHA represents is about 110,000.

AO/BECK: Arlene, would you please review ASHA's current Focused Initiatives?
PIETRANTON: There are four focused initiatives that we are working on in 2004. They are: Health Care Reimbursement, PhD Shortages, School Programs and Services, and Cultural and Linguistically Diverse Populations.

AO/BECK: Can you please review them one-by-one? Let's start with Health Care Reimbursement please.

PIETRANTON: The Health Care Reimbursement Focused Initiative has to do with how insurance coverage rules and reimbursement rates increasingly affect access to, and scope of services provided by, audiologists and speech-language pathologists. One of the projects we're working on involves the development and dissemination of information and tools for ASHA members so they can effectively negotiate with private health plans to help ensure appropriate coverage and equitable reimbursement rates. Another involves information and tools to help ASHA members effectively navigate state funded insurance programs (e.g., Medicaid, CHIPs) We're also working on strategies to increase the number of employers offering comprehensive speech-language pathology and audiology services in their health benefits package and to increase the number of states introducing legislation mandating appropriate coverage of audiology and speech-language pathology services. A particularly exciting aspect of this Focused Initiative is the establishment of the "STARs" (State Advocates for Reimbursement) - a state-based network of members who are committed to advocating on reimbursement issues in the private payor arena.

AO/BECK: OK. Let's move on to the topic of Doctoral Shortage please. Are you speaking about all doctorates, or essentially the Ph.D.?

PIETRANTON: PhDs. There is a critical shortage of PhDs in higher education that affects the preparation of professionals as well as research in communication sciences and disorders. In both professions there are dwindling numbers of individuals who are entering and/or staying in academia who are available to prepare the next generation. So the intent here is to develop a larger pipeline of folks interested in pursuing a PhD with an interest in a career in teaching and/or research. The desired outcomes include an increased number of potential doctoral level personnel to fill short and long-term faculty vacancies in communication sciences and disorders. Another outcome is increased availability and use of new models of education applicable for all levels (undergraduate, master's and doctoral) and all types of programs (PhD granting and non-PhD granting) to allow students to begin preparing for PhD education early in their careers.

AO/BECK: Very good. Would you please explain the School-Based Programs and Services inititative?

PIETRANTON: Data indicates many ASHA members in the schools have caseloads that are simply too high to provide quality services, that state and local policies/procedures require excessive paperwork, and that salaries are not commensurate with the specialized knowledge and skills needed to provide quality services. We'd like to see states and local agencies use total workload time activities, including but not limited to IEP meetings, administrative tasks, diagnostic time, paperwork, consultation, planning time, and frequency and duration of direct clinical service to determine the number of cases served. We also want to make sure that school-based ASHA members have information on ways to meet the requirements of IDEA - with a minimum of paperwork. And we are working with a number of states and local education education agencies to recognize the ASHA Certificates of Clinical Competence as a means for providing salary supplements for school-based audiologists or speech-language pathologists.

AO/BECK: OK, and lastly, would you please review the Culturally Diverse Populations initiative?

PIETRANTON: This initiative addresses demographics and caseload changes related to culturally and linguistically diverse populations served. The three desired outcomes of this Focused Initiative are to: increase awareness of the professions among racial/ethnic minorities; increase the number of racial/ethnic minorities enrolled in academic programs in communication sciences and disorders; and to increase the number of racial/ethnic minority members of ASHA.

AO/BECK: If I may go back a step or two, and please correct me if I'm wrong.... Isn't there a "doctorate mandate" by ASHA, whereby members must have a doctorate to enter the professions by 2011 or 2012?

PIETRANTON: The requirement for a doctorate is for individuals seeking certification, not membership, and will be applicable for audiologists beginning January 1, 2012. SLP certification standards have not changed as of this point, they continue to require a master's degree.

AO/BECK: Do you think that will change for SLP?

PIETRANTON: My understanding is that the last skills validation studies, which were conducted independently for both professions, resulted in a change requiring a doctorate degree for audiologists and the affirmation of a masters degree for speech language pathologists. Of course, it could change in the future - the standards are re-evaluated from time to time, but at this time, I don't see a change coming down the pike. I think it's important for all of us to realize - and appreciate - that the standards for earning a Certificate of Clinical Competence in audiology or speech-language pathology are determined through a rigorous standard-setting process that lends validity to those standards, which in turn establish us as credible professions that are based on substantial and defensible standards.

AO/BECK: There are many people in audiology who believe they practice by virtue of their license, not their CCC-A, and they would like to discontinue or not have a mandatory CCC-A. Can you address that please?

PIETRANTON: First, I think it's important to remember that licensure, as it relates to our professions is a little different than licensure with some other clinical professionals, such as physicians or nurses. For example, in the case of state medical boards, they work in concert with the Federation of State Medical Boards, which is the entity in medicine that engages in the kind of standards-setting process, validation of a national exam, etc. that the ASHA Council for Clinical Certification does for our professions. I would hope that all of us realize that the CCC in speech-language pathology and audiology is the only objectively and rigorously established standard for our professions and as such serves as a fundamental "quality control" benchmark to assure that as professionals we have adequate training, education, and clinical skill sets to practice the profession of audiology or the profession of speech-language pathology. I absolutely respect the need for licensing and I respect the work of state licensing boards -- but believe we must also realize that the intent of licensure is to protect the public from harm. When we set the standards for our professions we do so for the purpose of assuring that individual certified as competent to engage in the practice of our professions will practice competently - so that those who receive our services will benefit.

AO/BECK: So ASHA is going to hold fast to the CCC as the pre-requisite requirement for licensure?

PIETRANTON: Licensure and certification serve complementary purposes. Again, in professions such as ours, where the state licensure system does not have a standards setting infrastructure the standards associated with the Certificate of Clinical Competence are the only ones at this time that are defensible and give our professions credibility.

AO/BECK: Another issue along those lines is the issue of "renewing" the CCC annually. I don't have to renew my master's or my doctorate, and my state license requires annual CEs. So I believe many people want to know, why do they need to send in an annual fee to maintain/renew the CCC after they have earned it the first time?

PIETRANTON: Good question. Clearly earning and maintaining certification - or any other credential - is a different process than earning an academic degree. If you stop and think about it - most credentialing - as well as licensing - programs involve renewal fees, which are needed for the financial support of the program, many of which are operated under the auspices of not-for-profit organization, such as ASHA. We also need to remember that not all states have CEU requirements for continued licensure and not all state licensure requirements are consistent with current standards for the CCC. Now that ASHA requires CEs for renewal of the CCC, it is an ongoing mark of competence and an important assurance for patients and professionals alike that an audiologist or speech-language pathologist who holds the CCC is competent to practice their profession.

AO/BECK: Do you, or ASHA have a particular opinion on the issue of over-the-counter hearing aids?

PIETRANTON: We're following it closely. It's been discussed by volunteer leadership groups such as the Audiology assembly and the Government Relations and Public Policy Board. ASHA informed members of the petitions filed with the FDA via the ASHA website and the ASHA Leader early on and provided information for members to review the petitions and provide comment directly to the FDA, should they desire.

AO/BECK: What about Medicare reimbursement for hearing aids? Does ASHA have a position on that?

PIETRANTON: To the best of my knowledge at this point, ASHA does not have a position on it, it's a rather mixed bag, if you will. The positive side is there are patients who might be able to afford a hearing aids as a result of Medicare benefits On the other hand, Medicare could adopt an unreasonably low reimbursement rate that might serve as a model for private insurers.

AO/BECK: I can tell you after almost 20 years of clinical practice, what happened many times was the patient would say..."Good news, I have insurance coverage for hearing aids." We'd call and get pre-approval, and it would turn out they had $350 worth of coverage. But the patients needed the most appropriate hearing aids, the digitals, with noise reduction and directional mics, and if possible FM too, and feedback reduction and those systems could easily cost me 3 or 4 times what the insurance would cover! So I would explain to the patient what their coverage was, and that no, they could not get the digital, or the FM, or the directional, or the noise reduction circuit, or the feedback elimination circuit, and in fact what they could get was a brand new shell with 30 year old technology, which I did not recommend as it would not be the most appropriate device or the best hearing aid for them in their listening environment. And as a professional it put me in a horrible position, and the patients resented it, as did I.

PIETRANTON: Yes, those are many of the reasons that even though Medicare coverage of hearing aids might sound appealing at first, it can really turn out to be a negative thing, so we must proceed cautiously if we're to advocate for reimbursement that would truly benefit our patients and provide fair reimbursement for the instrument, including exploring different coverage models, such as a tax credit or a benefit up to a certain dollar amount. On a related note, as you know, ASHA's efforts in the public policy arena are driven by the annual Public Policy Agenda. ASHA's 2004 Public Policy Agenda is posted on the ASHA Web site I would urge members to review the Agenda and as indicated, contact any of the members of the Government Relations and Public Policy Board (GRPP Bd) with input or suggestions for items that need to be addressed.

AO/BECK: OK, let's switch gears a little...Reimbursement caps for SLP services, can you kind of tell me where we are with that? I lost track of that one!

PIETRANTON: When Congress adjourned the Medicare bill included a commitment for a moratorium on the $1500 cap that will go through December 31, 2005, meaning that while the cap has not been repealed, it won't be in effect throughout 2004 or 2005

AO/BECK: What are some other key ASHA activities in the SLP realm?

PIETRANTON: On the legislative, regulatory, and reimbursement front, 2004 will be an important year with: the anticipated Congressional reauthorization of IDEA; further clarification of impact of NCLB on our services in school settings; continued work at the federal, state and local levels related to the role of speech-language pathologists in literacy and use of a workload vs. caseload approach; and ASHA's efforts related to direct patient access of both audiology and speech-language pathology services. Also in the reimbursement arena, ASHA will continue to actively represent the professions on the AMA Relative Value Update Committee and Health Care Professions Advisory Committee in the CPT arena. From a speech-language pathology practice perspective, there are new practice policy documents under development related to telepractice, the Preferred Practice Patterns are being updated, a Guidelines document addressing SLP services in the NICU is under development as are documents regarding the role of SLPs working with persons with mental retardation or developmental delay, an updated position statement regarding the role of SLPs and Otolaryngologists in FEEs is in the works. On the Audiology practice policy front, in 2003, the Scope of Practice was updated and new documents related to practice areas such as cochlear implant and the role of audiologists in occupational hearing conservation were developed. Documents related to the roles of audiologists working with older persons and acoustics in educational settings are currently under development. There are also about a dozen new practice policy documents approved in 2003 that are available for members on the ASHA web site - as are the 2004 Medicare Fee Schedule for Audiology and the 2004 Medicare Fee Schedule for SLPs.

AO/BECK: Arlene, what about relations between ASHA, AAA, AAO-HNS, ADA, IIHIS and other national groups associated with hearing health care? Will you be reaching out to work collaboratively with them?

PIETRANTON: Oh great question Doug. I intend to actively reach out to various constituencies and various related organizations. In terms of Audiology, there are a number of meetings I will be attending such as the Pediatric Audiology Conference that ASHA is sponsoring in February, and I will be in Utah for the AAA meeting in April. On the SLP side, I'll be at ASHA's Health Care Conference in February and the ASHA Schools Conference in July, I also plan to attend the Canadian Association of Speech-Language Pathologists and Audiologists, the International Association of Logopedics and Phoniatrics and a number of state association meetings this year and I hope to have the opportunity to make connections with other organizations in and related to our professions.

AO/BECK: I think it's frustrating and counter-productive to see our national groups at odds with each other. Do you think you can build mutually beneficial relationships with the other associations?

PIETRANTON: I understand it's been frustrating, and I agree with you completely that much of it's been counter-productive. I think it's important that we collaborate, I also think its essential that those collaborations are authentic, and bring about some greater good on behalf of the profession.

AO/BECK: One last question before I let you run....Are there any activities underway at ASHA to allow audiologists to bill for AR services?

PIETRANTON: That's a great question Doug. ASHA's advocacy efforts resulted in the Medicare Audiologic Rehabilitation Act of 2003 (H.R. 3464) being introduced by Congressman Inslee in the Fall of 2003. We've been assured it will carry over to the new Congress. This bill would allow for audiologic rehabilitation services when furnished by an audiologist to be reimbursed by Medicare. By the way - members can visit the Take Action site on the ASHA Web site for more information about the legislative items we've discussed and ways that they can contact their Members of Congress to express their support for these items.

AO/BECK: Arlene, I know your time is precious and I appreciate your being so generous and giving me this time to review some of these topics with you.

PIETRANTON: Well, thank you too Doug. We've covered a wide range of topics and I appreciate your interest and time too!

AO/BECK: Thanks again Arlene. For readers who would like to write or call you, can you please give us the best contact information?

PIETRANTON: Sure, no problem at all. I would welcome hearing from any ASHA member on any topic - at any time. While I won't always be the best contact person for a particular topic, I will know who is and will be happy to help make those connections. I can be reached at apietranton@asha.org or 800-498-2071, ext. 4115. I'd also like to remind your readers that much of ASHA's resource materials and updated information related to audiology and speech-language pathology are available "24-7" on the ASHA Web site www.asha.org.