Legislative Affairs Feature -- December 2002
By Ken Ortolon
San Antonio psychiatrist Martha Leatherman, MD, sees it frequently. A psychologist treating an elderly nursing home patient has the nursing home staff "recommend" that the patient's primary care physician prescribe an antidepressant. Possibly not realizing the recommendation came from a psychologist, not a psychiatrist, the doctor puts the patient on antidepressants.
"I'm a geriatric psychiatrist, and I come in and clean up the mess over and over again," Dr. Leatherman said. "I've treated people who were delirious because of medication interactions. I've seen people who were being treated with antidepressants for pneumonia. I've had people who've been in severe congestive heart failure and are being treated with antipsychotics or tranquilizers for presumed dementia."
She fears this may become even more common if psychologists get their way. Emboldened by the success of their colleagues in New Mexico, where legislation granting psychologists prescription-writing authority became law earlier this year, Texas psychologists will seek similar authority from the Texas Legislature in 2003.
"This is a prescription for disaster," said Dr. Leatherman, who chairs the Government Affairs Committee of the Texas Society of Psychiatric Physicians (TSPP). "Psychologists receive extensive liberal arts training with a scientific overlay understanding behavior and motivation and psychological issues. They are very good at what they do and they are an integral part of the whole mental health care delivery system. However, they do not receive medical training."
Waco internist Joe H. Cunningham, MD, chair of Texas Medical Association's Council on Legislation, says TMA will stand with the psychiatrists in a fight against prescriptive authority for psychologists. And, he says, there can be no room for compromise.
Since the mid-1980s, psychologists in at least 12 states have attempted to gain independent prescriptive authority. In 2001, bills were introduced in both the New Mexico and Texas legislatures, but organized medicine defeated them. This year, however, a change in New Mexico political fortunes made the legislation viable there.
Randy Marshall, executive director of the New Mexico Medical Society, says physicians were able to prevent the prescriptive authority bill from being heard in the state Senate in 2001 with the help of key lawmakers, including the Senate's president pro tem, majority leader, and a key committee chair. Unfortunately for physicians, those senators were not chosen for those leadership positions when the New Mexico Senate convened this year.
"The Senate Public Affairs chairman, who had been very skeptical of the proposal, lost his seat and was replaced as chairman by a big advocate for the psychologists," Mr. Marshall said.
He said psychologists waged a well-funded and aggressive lobby campaign for the bill. They exploited a severe problem with access to mental health services in rural New Mexico, saying psychologists with prescribing authority could fill the gap. Mr. Marshall says the state's psychiatrists were slow to engage on the issue, and psychologists convinced New Mexico Gov. Gary Johnson to allow lawmakers to consider the bill during a session that normally would have been reserved for debate over the state budget.
"We were in a political nightmare because the legislature suddenly was making decisions based on politics and not on the merits," Mr. Marshall said. Faced with the virtual certainty that the bill would pass, New Mexico physicians agreed to a compromise. Governor Johnson signed the legislation into law in March.
The New Mexico law creates a category of "prescribing psychologist," permitting psychologists to independently prescribe psychotropic medications. It also creates a "conditional prescription certificate" allowing the holder to prescribe such medications under a licensed physician's supervision for his or her first two years of practice as a prescribing psychologist. The prescription certificate would no longer be conditional after two years, and the psychologist would be allowed to prescribe independently.
To obtain a conditional prescription certificate, an applicant must complete a doctoral-level program in psychology, be licensed in the state, and complete an organized program of pharmacology training that includes at least 450 hours of classroom instruction from an institution of higher education approved by the New Mexico Board of Medical Examiners and the Board of Psychologist Examiners. Applicants also must complete 80 hours of supervised practice in clinical assessment and pathophysiology, and 400 hours of practice treating at least 100 patients with mental disorders.
The medical and psychologist examiners boards are jointly responsible for setting standards for educational requirements, examinations, peer review, and collaborative practice.
The Texas Battle
Deanna Yates, PhD, president-elect of the Texas Psychological Association, says that group will seek passage of a similar bill in Texas. She says the issue is one of convenience for patients and improved access to care.
"We see patients in therapy, many of whom would benefit from being on medication at the same time," she said, adding it would be easier and cheaper for the patient not to have to see both a psychologist and a psychiatrist.
There's also a question of insurance, Dr. Yates says, as many mental health plans limit the number of sessions a patient can have in a year. Forcing patients to see a psychiatrist for a medication check eats up those limited sessions, she says.
But Dr. Leatherman says the issue is far more important than patient convenience. "Psychologists are not physicians. They would be prescribing medications that would not stay in people's brains but would go all over peoples' bodies, affecting organ systems the psychologists have limited exposure to and understanding of."
Dr. Cunningham says the training proposed for psychologists is inadequate to ensure or improve quality of care. "Prescribing is an integral part of practicing medicine. To be able to do that effectively, you need to have the entire spectrum of medical training."
Dr. Leatherman says the additional classroom hours proposed in the New Mexico law would not give psychologists the scientific training that physicians receive. And, the 400 hours of supervised patient care compares to about 30,000 supervised hours that physicians complete during postgraduate training.
She also is concerned about what will happen to patients who have complications from medication interactions or other problems. She says the New Mexico law provides no clear backup system for prescribing psychologists, leaving the patient little option but the emergency room if a problem arises.
But Dr. Yates says psychologists get more scientific training than physicians believe. "I did my residency in the medical school here in San Antonio. I rotated with psychiatrists. The training we get becoming psychologists is a great deal of the training that psychiatrists are getting. I went on hospital rounds and staffing with psychiatry residents. I sat in on medication management groups. I did it alongside psychiatry residents."
She adds that a licensed physician supervisor will have to "sign off that the psychologist is capable" of prescribing on his or her own.
With New Mexico the only state to pass a psychologist-prescribing bill, the military is the only organization with any experience with the issue. In 1989, the U.S. Department of Defense trained psychologists to prescribe. The program was dropped in 1997 after producing 10 graduates at a cost of $6 million.
Psychologists tout the military experience as a success story, but Dr. Leatherman says those psychologists practiced largely in hospitals where their patients had few underlying medical conditions, and plenty of physician backup was available.
Drawing the Line
Dr. Cunningham says physicians won't compromise on prescriptive authority, and the most unfortunate aspect of the debate is the damage it could do to efforts to improve the mental health system in Texas.
"The sad part is that there is no question that we have a dysfunctional mental health system and we need to increase access to care for our mental health patients. But we are being distracted from the things that need to be done to get parity in our mental health system by a small group who are trying to use that dysfunction to expand the scope of practice for their own purposes," he said.
"Would you want your sick child who might have leukemia or a heart problem treated by somebody who isn't a physician?" added Dr. Leatherman. "No, and we shouldn't do that to our most frail and vulnerable population in Texas."
Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.
Scope of Practice Perennial Fight in Legislature
Every new legislative session brings a host of scope-of-practice issues that pit physicians against allied health professions seeking to encroach on the practice of medicine. The 78th Texas Legislature in 2003 will be no exception.
While it is unknown which or how many scope issues might arise next year, Waco internist Joe H. Cunningham, MD, chair of Texas Medical Association's Council on Legislation, says TMA will stand with specialty societies to defend the practice of medicine.
"Allied health practitioners are attempting to use the regulatory boards to expand their scope of practice," Dr. Cunningham said. "This is a bad precedent."
Besides prescriptive authority for psychologists, issues likely to arise include a dispute with podiatrists who want to perform surgery above the ankle. In 2001, the State Board of Podiatric Medical Examiners adopted a new definition of the foot that states "the foot is the tibia, fibula in articulation with the talus, and all the bones to the toes, inclusive of all soft tissues (muscles, nerves, vascular structures, tendons, ligaments, and any other anatomical structures) that insert into the tibia, fibula in articulation with the talus, and all bones to the toes."
At the request of State Rep. Patricia Gray (D-Galveston), chair of the House Public Health Committee, Attorney General John Cornyn issued an opinion that the podiatric examiners board may not adopt a rule that enlarges the practice of podiatry beyond that permitted by law. The Texas Podiatric Medical Association then successfully sued in a Travis County district court to ban the board from enforcing the restrictions outlined in General Cornyn's opinion.
Dr. Cunningham says TMA may seek legislation to roll back those rules if further litigation is not successful.
"The use of the court system to expand scope of practice is as questionable as the use of the legislature," he said. "The education system is the only system suitable for changing an individual's scope of practice in health care."
Meanwhile, TMA continues trying to avoid scope-of-practice conflicts with most allied health professionals. For the past several legislative sessions, TMA has worked with nurse practitioners and physician assistants (PAs) through the Ad Hoc Committee on Collaborative Practice.
As of early October, TMA and organizations representing nurse practitioners and PAs were involved in professionally mediated negotiations on several issues, including delegation of authority to prescribe controlled substances, Medicaid payment parity, and a legislative moratorium on other scope-of-practice issues.
Dr. Cunningham says the ad hoc committee is "the shining example" of how organized medicine and allied health professionals can work together to best serve patients.
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