Fall 1999 - IP; Washington Update

Advocacy and Professional Issues

The Maturation of Professional Psychology - National Perspective/Patrick DeLeon

Washington Update/Ron Levant

Practice Directorate and MTV Launch Youth Anti-Violence Initiative/Tricia Alvarez

New Developments and a New Division in Psychopharmacology/Jack Wiggins

**Advocacy and Professional Issues**
	The Maturation of Professional Psychology - National Perspective/Patrick DeLeon
	Washington Update/Ron Levant
	Practice Directorate and MTV Launch Youth Anti-Violence Initiative/Tricia Alvarez
	New Developments and a New Division in Psychopharmacology/Jack Wiggins

WASHINGTON UPDATE
Prescriptive Agenda Advances

The prescription privilege agenda continues to develop and mature. Earlier this year at the State Leadership Conference many of us had the honor of meeting some of the psychologists from Guam who spearheaded their RxP legislation — Mamie Balajadia and George Kallingal from the Guam Psychological Association. Several of us also attended a dinner with the RxP leaders from half a dozen states that are moving most rapidly on the legislative front. Several of these states have chosen (quite wisely in my view) to tie their legislative program with an educational program, in order to have a cadre of fully trained prescribing psychologist at the ready.

The GAO Report

At the federal level, the Senate Armed Services Committee included language addressing the issue of psychology obtaining prescriptive authority during its deliberations on the fiscal year 1999 Department of Defense Appropriations bill [P.L. 105-261]: “The Psychopharmacology Demonstration Project (PDP) was funded by Congress in 1991 to train military psychologists in the prescription of psychotropic medications, pursuant to section 8097 of the Department of Defense Appropriations Act for Fiscal Year 1992. The committee understands that ten military psychologists successfully completed this training prior to termination of the program. The committee directs the Comptroller General to conduct a study to determine the extent to which these health providers have been integrated into the Military Health System, to include the quality of care provided to military personnel and their beneficiaries, contributions of these providers to cost effectiveness, and their impact on medical readiness.”

In response (and despite the protestations of AMA and ApA), the GAO released its newest report in June, 1999, which evaluated the performance of the 10 graduates of the Psychopharmacology Demonstration Project: “Prescribing Psychologists — DoD Demonstration Participants Perform Well but Have Little Effect on Readiness or Costs.” According to the 26-page report: “Without exception [prescribing psychologists’] supervisors - all psychiatrists - stated that the graduates’ quality of care was good.” The report also notes that a panel of external evaluators hired by the DOD indicated that the “graduates had performed well in all locations where they were assigned, that they had performed safely and effectively as prescribing psychologists, and that no adverse outcomes had been associated with their performance.” Despite initial difficulties prescribing psychologists had being accepted by physicians, nearly all the physicians interviewed stated the “psychologists’ performance subsequently convinced them that the graduates were well trained and knowledgeable. Several physicians also told [the GAO] that they came to rely on the graduates for information about psychotropic medications.”

“The Military Health System (MHS) provides for the mental health care needs of the approximately eight million active-duty members, retirees, and their dependents. To meet these needs, MHS employed 431 psychiatrists and 430 clinical psychologists in fiscal year 1999.... By June 1997, when the project was terminated, ten psychologists had completed their training and were subsequently assigned to various Air Force, Army, and Navy military medical facilities across the country. At the time of our review, nine of the ten program graduates were still treating patients and prescribing medications at military hospitals and clinics....”

“The ten PDP graduates seem to be well integrated at their assigned military treatment facilities. For example, the graduates generally serve in positions of authority, such as clinic or department chiefs. They also treat a variety of mental health patients; prescribe from comprehensive lists of drugs, or formularies; and carry patient caseloads comparable to those of psychiatrists and psychologists at the same hospitals and clinics.

Also, although several graduates experienced early difficulties being accepted by physicians and others at their assigned locations, the clinical supervisors, providers, and officials we spoke with at the graduates’ current and prior locations — as well as a panel of mental health clinicians who evaluated each of the graduates — were complimentary about the quality of care provided by the graduates.”

A press release on the GAO report prepared by the APA Practice Directorate noted that: “The report also states that the prescribing psychologists improve military medical readiness at their peacetime locations by reducing the time that patients must wait for treatment and by increasing the number of patients who can be treated.” The report notes that officials at the graduates’ facilities stated that “patients who needed to see two providers for treatment could wait up to three weeks to get an appointment with a psychiatrist. Prescribing psychologists, however, can treat some patients needing drugs who otherwise would require an appointment with a psychiatrist. Since these patients see only one provider -their prescribing psychologist - the time and effort needed to receive treatment is reduced.”

“In addition, the report noted that combat medical readiness is minimally affected because psychotropic drugs are generally not the treatment of choice in combat situations, and granting prescribing privileges to only ten psychologists is unlikely to affect system-wide combat readiness. The GAO report also stated that the DOD spent somewhat more on its ten prescribing psychologists than it would have spent on providing mental health services using the traditional mix of psychologists and psychiatrists. But the report acknowledged that the GAO’s analysis included one-time start-up costs of the training program.”

The Bottom Line of the GAO Report: Psychologists can be trained to safely and effectively prescribe psychotropic medications. This conclusive study thus debunks the ApA’s perseverant drone that prescribing psychologists will endanger the public health.

Meanwhile at the VA

On May 4, 1999, the Department of Veterans Affairs (VA) had proposed a new rule on medication prescribing, which would have revised current federal regulations to allow health care professionals, other than physicians, to prescribe medications as authorized by the VA and to conduct medication reviews. In addition, the rule would have allowed VA health care professionals to issue prescriptions by electronic means as well as by telephone. Needless to say, this new rule was potentially of great significance to psychology.

In a May 21, 1999 Federal Register notice the VA withdrew the proposed rule, stating that it intends to reconsider the issues raised in the proposal and publish a new proposal with clarifications.

Based on information that the decision to withdraw the rule may have been inappropriately influenced by organized psychiatry, Russ Newman, Ph.D., J.D., wrote a letter on June 16, 1999 to Kenneth Kizer, M.D., M.P.H., the Under Secretary for Health in the Department of Veterans Affairs, portions of which I quote below:

“We are, frankly, dismayed and perplexed by the decision to disrupt the rulemaking process and withdraw the proposed rule before the end of the comment period. We have no doubt that the VA carefully considered the issues before publishing the proposal. Yet, we have received information leading us to suspect that pressure from organized medicine forced the VA to retreat from revising the current regulation. The American Psychiatric Association posted a notice on the Internet taking credit for persuading the VA to withdraw this regulation. In fact, this Internet posting occurred prior to the Federal Register announcement that the rule was being withdrawn.

“To the extent that the VA has yielded to the guild interests of organized psychiatry and disrupted the administrative rulemaking process, we have serious concerns about this turn of events. The withdrawal of the proposed rule denied knowledgeable sources the opportunity to provide comments concerning the role of non-physicians in health care. Had the rulemaking process been allowed to continue, any changes to the proposed regulation would have been attributed to the VA’s decision upon open consideration of the comments. Now, however, it becomes highly suspect that those who have made their views privately known to the VA will influence the development of any new proposal. To protect the reputation of the VA and the integrity of the rulemaking process we recommend that the proposed rule be reintroduced as originally published on May 4, 1999.”

“The question of prescriptive authority is of key importance to psychologists, many of whom are interested in becoming trained and qualified to prescribe medications for their patients. As you are likely aware, in 1991 the Department of Defense initiated a project to train military psychologists to prescribe psychotropic medications known as the Psychopharmacology Demonstration Program (PDP). In a report issued on June 1, 1999, the General Accounting Office (GAO) presented its findings on the PDP. The GAO reported that clinical supervisors and others rated the quality of care provided by graduates of the program from good to excellent....The report noted that nearly all of the physicians acknowledged that the graduates’ performance demonstrated that they were well trained and knowledgeable....”

“We recognize and applaud the VA’s efforts to provide high quality health care to veterans across the country. To uphold the VA’s right to decide how best to utilize its staff and to promote the integrity of the rulemaking process, we strongly recommend that the VA reintroduce its original proposal to allow health care professionals, other than physicians, to prescribe medications, as authorized by the VA.”

As always, I welcome your thoughts on this column. You may most easily reach me by email: rlevant@aol.com Ronald F. Levant, Ed.D., A.B.P.P., is Recording Secretary of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, a member of the Board of Directors of Division 42 (1991-94), and a member of the APA Board of Directors (1995-97). He is Dean, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, FL.

Ronald F. Levant, Ed.D.

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			WASHINGTON UPDATE Prescriptive Agenda Advances The prescription privilege agenda continues to develop and mature. Earlier this year at the State Leadership Conference many of us had the honor of meeting some of the psychologists from Guam who spearheaded their RxP legislation — Mamie Balajadia and George Kallingal from the Guam Psychological Association. Several of us also attended a dinner with the RxP leaders from half a dozen states that are moving most rapidly on the legislative front. Several of these states have chosen (quite wisely in my view) to tie their legislative program with an educational program, in order to have a cadre of fully trained prescribing psychologist at the ready. The GAO Report At the federal level, the Senate Armed Services Committee included language addressing the issue of psychology obtaining prescriptive authority during its deliberations on the fiscal year 1999 Department of Defense Appropriations bill [P.L. 105-261]: “The Psychopharmacology Demonstration Project (PDP) was funded by Congress in 1991 to train military psychologists in the prescription of psychotropic medications, pursuant to section 8097 of the Department of Defense Appropriations Act for Fiscal Year 1992. The committee understands that ten military psychologists successfully completed this training prior to termination of the program. The committee directs the Comptroller General to conduct a study to determine the extent to which these health providers have been integrated into the Military Health System, to include the quality of care provided to military personnel and their beneficiaries, contributions of these providers to cost effectiveness, and their impact on medical readiness.” In response (and despite the protestations of AMA and ApA), the GAO released its newest report in June, 1999, which evaluated the performance of the 10 graduates of the Psychopharmacology Demonstration Project: “Prescribing Psychologists — DoD Demonstration Participants Perform Well but Have Little Effect on Readiness or Costs.” According to the 26-page report: “Without exception [prescribing psychologists’] supervisors - all psychiatrists - stated that the graduates’ quality of care was good.” The report also notes that a panel of external evaluators hired by the DOD indicated that the “graduates had performed well in all locations where they were assigned, that they had performed safely and effectively as prescribing psychologists, and that no adverse outcomes had been associated with their performance.” Despite initial difficulties prescribing psychologists had being accepted by physicians, nearly all the physicians interviewed stated the “psychologists’ performance subsequently convinced them that the graduates were well trained and knowledgeable. Several physicians also told [the GAO] that they came to rely on the graduates for information about psychotropic medications.” “The Military Health System (MHS) provides for the mental health care needs of the approximately eight million active-duty members, retirees, and their dependents. To meet these needs, MHS employed 431 psychiatrists and 430 clinical psychologists in fiscal year 1999.... By June 1997, when the project was terminated, ten psychologists had completed their training and were subsequently assigned to various Air Force, Army, and Navy military medical facilities across the country. At the time of our review, nine of the ten program graduates were still treating patients and prescribing medications at military hospitals and clinics....” “The ten PDP graduates seem to be well integrated at their assigned military treatment facilities. For example, the graduates generally serve in positions of authority, such as clinic or department chiefs. They also treat a variety of mental health patients; prescribe from comprehensive lists of drugs, or formularies; and carry patient caseloads comparable to those of psychiatrists and psychologists at the same hospitals and clinics. Also, although several graduates experienced early difficulties being accepted by physicians and others at their assigned locations, the clinical supervisors, providers, and officials we spoke with at the graduates’ current and prior locations — as well as a panel of mental health clinicians who evaluated each of the graduates — were complimentary about the quality of care provided by the graduates.” A press release on the GAO report prepared by the APA Practice Directorate noted that: “The report also states that the prescribing psychologists improve military medical readiness at their peacetime locations by reducing the time that patients must wait for treatment and by increasing the number of patients who can be treated.” The report notes that officials at the graduates’ facilities stated that “patients who needed to see two providers for treatment could wait up to three weeks to get an appointment with a psychiatrist. Prescribing psychologists, however, can treat some patients needing drugs who otherwise would require an appointment with a psychiatrist. Since these patients see only one provider -their prescribing psychologist - the time and effort needed to receive treatment is reduced.” “In addition, the report noted that combat medical readiness is minimally affected because psychotropic drugs are generally not the treatment of choice in combat situations, and granting prescribing privileges to only ten psychologists is unlikely to affect system-wide combat readiness. The GAO report also stated that the DOD spent somewhat more on its ten prescribing psychologists than it would have spent on providing mental health services using the traditional mix of psychologists and psychiatrists. But the report acknowledged that the GAO’s analysis included one-time start-up costs of the training program.” The Bottom Line of the GAO Report: Psychologists can be trained to safely and effectively prescribe psychotropic medications. This conclusive study thus debunks the ApA’s perseverant drone that prescribing psychologists will endanger the public health. Meanwhile at the VA On May 4, 1999, the Department of Veterans Affairs (VA) had proposed a new rule on medication prescribing, which would have revised current federal regulations to allow health care professionals, other than physicians, to prescribe medications as authorized by the VA and to conduct medication reviews. In addition, the rule would have allowed VA health care professionals to issue prescriptions by electronic means as well as by telephone. Needless to say, this new rule was potentially of great significance to psychology. In a May 21, 1999 Federal Register notice the VA withdrew the proposed rule, stating that it intends to reconsider the issues raised in the proposal and publish a new proposal with clarifications. Based on information that the decision to withdraw the rule may have been inappropriately influenced by organized psychiatry, Russ Newman, Ph.D., J.D., wrote a letter on June 16, 1999 to Kenneth Kizer, M.D., M.P.H., the Under Secretary for Health in the Department of Veterans Affairs, portions of which I quote below: “We are, frankly, dismayed and perplexed by the decision to disrupt the rulemaking process and withdraw the proposed rule before the end of the comment period. We have no doubt that the VA carefully considered the issues before publishing the proposal. Yet, we have received information leading us to suspect that pressure from organized medicine forced the VA to retreat from revising the current regulation. The American Psychiatric Association posted a notice on the Internet taking credit for persuading the VA to withdraw this regulation. In fact, this Internet posting occurred prior to the Federal Register announcement that the rule was being withdrawn. “To the extent that the VA has yielded to the guild interests of organized psychiatry and disrupted the administrative rulemaking process, we have serious concerns about this turn of events. The withdrawal of the proposed rule denied knowledgeable sources the opportunity to provide comments concerning the role of non-physicians in health care. Had the rulemaking process been allowed to continue, any changes to the proposed regulation would have been attributed to the VA’s decision upon open consideration of the comments. Now, however, it becomes highly suspect that those who have made their views privately known to the VA will influence the development of any new proposal. To protect the reputation of the VA and the integrity of the rulemaking process we recommend that the proposed rule be reintroduced as originally published on May 4, 1999.” “The question of prescriptive authority is of key importance to psychologists, many of whom are interested in becoming trained and qualified to prescribe medications for their patients. As you are likely aware, in 1991 the Department of Defense initiated a project to train military psychologists to prescribe psychotropic medications known as the Psychopharmacology Demonstration Program (PDP). In a report issued on June 1, 1999, the General Accounting Office (GAO) presented its findings on the PDP. The GAO reported that clinical supervisors and others rated the quality of care provided by graduates of the program from good to excellent....The report noted that nearly all of the physicians acknowledged that the graduates’ performance demonstrated that they were well trained and knowledgeable....” “We recognize and applaud the VA’s efforts to provide high quality health care to veterans across the country. To uphold the VA’s right to decide how best to utilize its staff and to promote the integrity of the rulemaking process, we strongly recommend that the VA reintroduce its original proposal to allow health care professionals, other than physicians, to prescribe medications, as authorized by the VA.” As always, I welcome your thoughts on this column. You may most easily reach me by email: rlevant@aol.com Ronald F. Levant, Ed.D., A.B.P.P., is Recording Secretary of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, a member of the Board of Directors of Division 42 (1991-94), and a member of the APA Board of Directors (1995-97). He is Dean, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, FL.
	Ronald F. Levant, Ed.D.
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