Contributing Editor’s Column
Exciting Opportunities in the 21st Century
Pat DeLeon
It is very important that those of our colleagues who are in private practice come to appreciate the extent to which psychology really is all one family and that, for example, advances occurring within the public sector will ultimately have a direct impact upon all of our daily lives. Similarly, psychology must collectively appreciate the critical importance of psychological practice expanding (or perhaps evolving) into the more generic healthcare arena, which is undergoing unprecedented changes, rather than “merely” conceptualizing our clinical expertise as exclusively “mental health.” In my judgment, this would include obtaining prescriptive authority (RxP) and seeking out “new markets,” such as working within nursing homes and long term care facilities. Jerry Morris, long-time advocate for prescriptive authority, recently shared with us the MoRxP Newswire in which Raymond “Jay” O’Brien issued an insightful Call for Leadership from Senior Psychologists: “I would like to address a problem encountered trying to gather support for RxP that has to do with some of the reasons psychologists decline to participate. It has become evident to me that I’m growing a little older and so are many of my colleagues. Many have said to me that they are not opposed to the RxP effort but they just don’t believe it is important for them. One reason is because some feel they are closer to retirement than to a desire to add considerable training after a protracted legislative battle. Believe me, I understand this.... However, I think we who have benefitted from the previous efforts of others before us to build this profession now need to take the responsibility and opportunity to continue the building for those who come after us. The fact that we may not necessarily be the direct beneficiaries should not be the only factor in determining if we think it is important to participate and support the effort. Actually, the contrary is substantially true. That is, we who have greater seniority and have grown with the profession are probably more suited to appreciate the need to help through both personal effort as well as financial support... if only to help the next generation of psychologists. A family looks out for its future generations.
Nancy Bacher, former President of the Florida Psychological Association (FPA), invited Russ Newman and prescribing psychologists Elaine Orabona-Mantell, Elaine LeVine, and Jim Quillin to share with her FPA membership the extraordinarily high quality of care that appropriately trained psychologists bring to the prescriptive clinical decision-making process. Russ: “Prescribing psychologists will use medication in a qualitatively different manner than psychiatrists. They will use pharmacotherapy based on a psychological model of treatment in contrast to a medical model. The implications of this difference may be profound. The psychological model of treatment can be described as a systems-oriented, holistic, integrative approach.... When other treatments are available, with a psychological model, the power to prescribe is also the power to unprescribe.” The Institute of Medicine reports medication errors are harming at least 1.5 million people a year, with treating medication errors in hospitals alone costing an estimated $3.5 billion yearly and another $887 million for Medicare beneficiaries. This is at a time when family health insurance costs have risen 70% ($4,500 per family) since 2000, with an additional 6 million Americans becoming uninsured. We have much to offer.
“In an era of telehealth technology and instant virtual communications, geographical distances will no longer be an acceptable rationale (i.e., excuse) for less than optimal healthcare”
An Exciting Journey: [Louisiana Psychological Association President Jim Quillin, a private practitioner]: “The culmination of a decade of work and four legislative sessions came in 2004 when the Governor of Louisiana signed the Medical Psychologist statute authorizing specially trained psychologists (medical psychologists) [MPs] to prescribe medications in the management of psychiatric disorders. Following implementation of this statute with the promulgation and publication of the necessary enacting regulatory language by the Louisiana Board of Examiners of Psychologists, appropriately credentialed MPs began practicing with this expanded capability. However, the state mental health system, dominated and controlled by psychiatrists who had vigorously opposed this legislation, refused to make the necessary allowances for state service MPs to practice within the fullest extent of the law. The low mark (to date) for this opposition came immediately following Hurricane Katrina when the state’s Office of Mental Health quietly scrapped plans to utilize its own state employed MPs in the delivery of emergency psychiatric services associated with the storm and its aftermath, reassigning key state office MP personnel instead to non-clinical activities and support services of various kinds. Thus, in late 2005, the Louisiana Psychological Association (LPA) and its sister organization the Louisiana Academy of Medical Psychologists (LAMP) again joined forces with APA’s Practice Directorate and CAPP to address this unacceptable state of affairs.
“Early on an antiquated ‘Mental Health’ statute was targeted for revision as, among other problematic provisions, it held that only a physician could order or prescribe medication for patients in the state’s mental health system. Interestingly, during the development of a legislative strategy to correct this problem, it was learned that the Louisiana Nurse Practitioners Association had also been eyeing this statute and, in the hopes of revising it so that nurse practitioners (NPs) could function independently within the state psychiatric system, had planned to pre-file a bill in the 2006 legislative session that would make NPs and MDs functionally equivalent within this system. We elected to amend this legislation, after its introduction so that MPs could prescribe within the state’s mental health system and to work cooperatively with the NPs toward some of our common interests. Politics, as you know, however, can make for some strange bedfellows.
“At the outset, the psychiatry controlled Office of Mental Health, upon learning of our plans to amend this bill approached the NPs with the intent of trying to work out a compromise that would give NPs some increased role in the public mental health system. The crux of the proposed bargain, however, was to have been the rejection of any effort to pass an amendment involving the explicit recognition of MPs in this legislation. Understandably, the NPs needed to seriously consider such a compromise as it might have been in their best interest to help throw MPs under the bus if it would help assure the passage of their legislation. However, at the initial legislative hearing it quickly became clear to the NPs that psychology was an exceptionally formidable player and that the best way to avoid the underside of the bus themselves was to tuck in behind us and follow our blocks. At that committee hearing, the matter was deferred for a week and the Office of Mental Health ceased to be a significant player in this matter. However, the Louisiana State Medical Society, the Louisiana State Psychiatric Medical Society, the Louisiana State Board of Medical Examiners and, interestingly, the Office of Louisiana Advocacy Services (who were vehemently opposed to NPs having the authority of issuing ‘emergency certificates’ or PECs for short term commitments, as could physicians and certain psychologists under prevailing law) all opposed the legislation on the table. In an interesting turn of events, at a second hearing in the same committee the following week, psychology was approached by the Medical Society. It seemed that their greatest concern was the emerging independence of the NPs and, unlike their psychiatric-counterparts, they were relatively less exercised by the prospects of MPs being explicitly recognized in this instrument. Understandably, we were interested in how our joint interests could be achieved but we were not willing to jettison the NPs, and as the session unfolded we continued to work with all sides toward a framework of language that might be acceptable to the principles in this matter.
“Here I must honestly tell you that of all the sides on this issue, the Medical Society was the easiest organization with which to work. They were straightforward and open to equitable compromise. In the end, with our assistance, much work and the leadership of the Chair of the House Health Committee, such a compromise was struck. It removed the language recognizing NPs in the mental health statute and instead recognized only Psychiatric Mental Health Nurse Practitioners. For psychology in general, the compromise language changed a provision limiting the authority to execute a PEC to only clinical or counseling psychologists to psychologists with ‘a clinical specialty,’ specialties that will be determined by the Louisiana Board of Examiners of Psychologists. It also included psychologists, medical psychologists and psychiatric mental health nurse practitioners in the definition of ‘primary care providers’ of mental health services. Moreover, the compromise language provided for the specific credentialing of medical psychologists and psychiatric mental health nurse practitioners to practice within the fullest extent of their respective authority within the state’s mental health facilities. Lastly, the language restricting the prescribing of medications in the state system to physicians was changed to read as follows: ‘No medication may be administered pursuant to the provisions of this Chapter, except upon the order of a physician, medical psychologist or psychiatric mental health nurse practitioner. The physician, medical psychologist or psychiatric mental health nurse practitioner is responsible for all medications which he has ordered and which are administered to the patient.’
“LAMP, LPA, the medical society, the psychiatric society, and the nurse practitioners all signed off on this language (the Advocacy Office still opposed psychiatric nurse practitioners having PEC authority). Unfortunately, sweeping compromise such as this take a great deal of time and effort and, while it subsequently swept through the House Health Committee unanimously (an earlier version had passed the Senate at both the committee and floor levels), it languished on the House floor late in the session jammed up behind hundreds of other bills. In order for it to become law, it had to pass the House floor and return to the Senate floor for concurrence, as it was considerably altered from its original language. All of this had to occur in the last week of the legislative session.
“On the Friday before the last day of the session the following Monday, our bill was scheduled to be heard on the House floor. Just as it was called up, a term limited Representative asked the Speaker for a personal privilege and rose to say his formal good-byes to his fellow legislators. He finished at 6:05 PM and as our bill was then called up, the Secretary of the House advised the Speaker that under changes made in the Louisiana Constitution several years earlier, no bill, except those being heard for concurrence from the other chamber could be heard after the 85th day of the legislative session or 6:00 PM that day!! After quickly reviewing the constitution, it was determined, however, that with a two-thirds vote by both chambers this provision of the Louisiana Constitution could be overridden and a bill kept alive.
“While this had never successfully been done before, we were determined to be the first to do so and, after making the appropriate motions, had this historic move put to a vote on the floor. However, the House was in a foul, late session mood and angry that the Senate was not moving on House bills at this late hour. Two former Speakers of the Louisiana House rose in opposition as ours was a Senate bill and, requiring a two-third vote margin we received only 67 of the 70 necessary votes.
“We (LAMP/LPA lobbyists, Bud Courson and Jim Nickel, the NP lobbyist and myself) retired to the quiet of the by now nearly deserted area just outside the House chamber and were joined by the House sponsor of this bill who, physically and psychologically exhausted, was weeping and apologizing because we had failed. In a scene that will stick with me forever, Bud gently hugged this long time champion of health causes and told her not to feel badly. He spoke softly to us as we huddled in the gathering dimness of the evening, whispering that we had come too far and reminding us that miracles are our specialty. We resolved to return again Sunday evening, Father’s Day, to make another run at this historic effort. A few minutes later after we had coordinated our schedules and said our good-byes, I walked to a nearby bench where my wife had been waiting so that we could go to dinner when suddenly, out of the corner of my eye, I saw Bud sprinting back toward the House Chamber. I caught him as he reached a side doorway gazing in at something only he could see. After what seemed an eternity, he turned to me and simply said, ‘Now is the time.’ We eased into seats in the empty gallery behind the floor. One of the former Speakers who had spoken in opposition to us was seated just in front of us. He whirled in his seat towards us and said defiantly that this vote would also fail. Moments later, he was proven wrong, as the Louisiana House of Representatives voted by a vote of 81 to 10 with 13 absent to override the constitution and allow our bill to be heard. Later that night just before adjournment, we moved to the other Chamber where the Senate voted by 35-0 to likewise suspend the constitution and allow a vote on our bill. On Father’s Day, the Louisiana House of Representatives took up our bill and voted it out favorably by a 90 to 7 margin with 7 others absent. The following day, the last day of the 2006 legislative session, the Louisiana Senate followed suit and passed out bill out with a favorable 35-0 vote. Governor Kathleen Blanco signed this bill into law on June 29th as Act 664. It becomes effective August 15th.
“As I tried to sleep the night we were able to override a constitutional barrier to keep our hopes alive, my mind replayed the history I’d been privileged to witness that evening. I thought about psychology and how far we’ve come. I thought about those who have despaired of achieving legislative success and wished they had been with me. I thought of a cold day in a duck blind many years ago when my father told me that there would come times in my life when I’d remember what he was to tell me – ‘Son, if you don’t quit, you win.’ He was right.”
For those who are personally interested in pursuing the RxP agenda, there are outstanding training programs targeted towards full-time practitioners. And, I would suggest that one should seriously consider becoming credentialed as a “medical psychologist” in the State of Louisiana. Licensure mobility was a very high priority for APA Past President Ron Levant and Russ has been working closely with the Association of State and Provincial Psychology Boards (ASPPB), the American Board of Professional Psychology (ABPP), and the National Register of Health Service Providers in Psychology to make this a reality and thereby bring our profession into the 21st century. In an era of telehealth technology and instant virtual communications, geographical distances will no longer be an acceptable rationale (i.e., excuse) for less than optimal healthcare. The 21st century will present exciting opportunities for those with vision and those who dare to vigorously pursue the future and especially for those “who don’t quit.”
Aloha,
Pat DeLeon, former APA President – Division 42 – August, 2006
