by Pat DeLeon, Ph.D., J.D.
APA Immediate Past President

One of the most inspiring APA events of the year is always the annual Practice Directorate State Leadership Conference which began in the Fall of 1984. This year 538 colleagues participated, the most ever. The RxP- agenda was throughly integrated throughout the four days, both in formal presentations and informal group discussions and caucuses. CAPP member John Corrigan and RxP- staffer Rochelle Jennings lead a discussion on: “strategies for dealing with resistance to prescriptive authority”, which had over 30 participants; the ever-present and enthusiastic PEPTO crowd, led by Michael Schwarzchild, rallied; and exciting reports were received from the leadership of the California, Connecticut, Georgia, Louisiana, and Texas psychological associations. The RxP- agenda is clearly in the public arena with numerous states reporting participating in formal legislative hearings and receiving extensive media coverage. CAPP Chair Ron Fox, Rochelle Jennings, New Mexico President Julie Lockwood, and Texas President-Elect-Elect Deanna Yates conducted an impressive workshop entitled: “laying the groundwork for introducing prescriptive authority legislation”. Personally, I was particularly pleased with the enthusiasm coming from the Maryland delegation. This is the state in which I currently reside and it is the only state where the psychology licensing board has invited me to their annual retreat meeting for an in-depth discussion of the RxP- agenda and its implications for their underlying mission of serving and protecting the public. It is extraordinarily clear that the elected leadership of an increasing number of our State Associations is solidly behind enacting RxP- legislation in the near future. However, there can be no question that the most emotionally rewarding aspect of the conference was participating in and getting caught up in the genuine excitement and enthusiasm being spontaneously demonstrated throughout, for the truly historic successes of our colleagues in New Mexico. History was in the making. As Past-APA President Ron Fox reflected: “It makes one proud to be associated with such dedicated and sincere colleagues.”

Reactions From The Front Line

[Elaine LeVine]: “As most of you are probably aware by now, we had a very dramatic year with New Mexico’s prescriptive authority (RxP-) efforts. We were continuously successful in our legislative effort to obtain prescriptive authority for properly trained psychologists. We passed through two committees of the House and gained a resounding victory of 37-21 on the floor of the House. We then passed through a Senate committee two times and were scheduled for the bill to be heard on the floor of the Senate. By our count, we had well over the necessary votes to win, and we had several very positive conversations with the Governor. Our opponents, basically from the school of medicine at the University of New Mexico (in particular, psychiatry), supported by their national organizations, obviously realized, too, that if the bill were presented on the Senate floor, we would win. They used every maneuver possible to prevent the bill from being heard, thereby stopping it for the present time. We are now trying to assess what happened and our points of strengths and weaknesses. I am pleased to have this opportunity to share some of my immediate thoughts with you in hopes it will help your State to keep the momentum for RxP- growing.”

“I believe that one of the factors that helped us accomplish as much as we did was our intense effort towards consensus and support, first among our colleagues and, secondly, in our communities. We actually began our prescriptive authority efforts about eight years ago. At that time, members of the New Mexico Psychological Association had many concerns about the prescriptive privilege agenda, and many did not support it. We learned early that much of the doubtfulness about the prescriptive authority agenda came from a lack of information. We conducted several surveys and held a state conference on prescriptive authority. In addition, we started a column in our state association’s newsletter regarding RxP-. The initial column was a debate about the pros and cons of prescriptive authority. Gradually, as our consensus grew, the column changed in tenor towards how we would gain prescriptive authority.”

“By the time we presented our RxP- bill to the New Mexico legislature in January, 2001, the New Mexico Psychological Association was cohesively behind the goal. That is not to say that everyone thought we should seek prescriptive privileges; however, it was clear that the majority of the membership wished to do so, and the minority, to a large extent, was willing to accept the consensus decision. Even so, our opponents were able to find two psychologists to speak against the bill. Although their testimony against us certainly did not help (and must be very difficult for legislators to comprehend), we had so many psychologists testifying in support of the bill that these two were clearly in the minority.”

“Another factor that helped us was that we had an academic program already in place with 12 students about ready to complete the APA 300-hour curriculum, and another 13 about halfway through. We have a critical need for more care in New Mexico, and we came to the legislature demonstrating in a practical way how we could and would help. They were impressed that psychologists have already embarked upon this intensive training. In contrast, our psychiatrist colleagues kept warning how dangerous we would be but offered no practical solutions to the lack of mental health care in New Mexico.”

“We were very proud of the support we gleaned from various professional and consumer groups and had letters in hand along with many witnesses to testify on our behalf. We had quietly sought these endorsement over the last several years from groups such as the National Alliance for the Mentally Ill (NAMI), the Association for Retarded Citizens, residential and treatment centers, and physicians (including psychiatrists in rural and other underserved areas). We even had a ‘neutral’ physician review our curriculum and the results of RxP- students’ tests and papers and testify that, after he reviewed the program, he believed it to be sufficient to train us to safely prescribe. I believe that our opponents were unprepared for the level of support we had garnered before coming forward with the bill.”

“The fact that we are psychologists, people with high integrity and motivation to help others, stimulated much positive momentum. We learned whose expertise we could count on in different positions and were able to put our egos aside and work together toward our common goal. John Gatling, who had worked with disabled clients throughout the State, was instrumental in gaining our initial agency endorsements. Mario Marquez developed superb lobbying skills, and we came to rely on him as our ‘front man’. Kevin McGinnis is verbally quick and insightful, and he knows the medical system well. Thus, he became an excellent expert witness. It was difficult to diminish the accomplishments of the Department of Defense (DoD) Demonstration Project because Major Brian Pfeiffer, a prescribing psychologist from the Department of Defense who is stationed at Cannon Air Force Base in New Mexico, was there at the right moments to set the facts straight. Our RxP- students, such as Martha Brisky, Elaine Jordan, Elizabeth Perry, Michael Cobb, and Elizabeth Dinsmore made their rural connections known at the pivotal times. We learned how to defend our position before they attacked. We became a tighter team as time went on and developed strong bonds of respect and affection.”

“Although the obvious legislative works occurs on the front line, New Mexico’s gains are truly a national accomplishment. The strategic and financial assistance from Ron Fox (Ron da-Gray), Robert Resnick (Dr. Bob) and other members of CAPP were invaluable. We knew we could rely on Russ Newman, Executive Director of the Practice Directorate, for wise counsel. At times, we felt like Mike Sullivan, Assistant Executive Director of State Advocacy, and Rochelle Jennings, APA Coordinator for RxP- efforts, were on the front lines with us. For all the words of encouragement, letters to legislators, and financial contributions from our individual colleagues across the nation (and even from England!), we are deeply indebted. The letters of support and advice to our team from APA President Norine Johnson and President-Elect Phil Zimbardo and many others charged us to move ahead. Sam Feldman of the Prescribing Psychologists’ Register (PPR) offered steady academic/financial assistance and was visionary in helping to dovetail PPR’s prescriptive privilege curriculum with our local University’s nursing curriculum in pathophysiology and physical assessment. New Mexico’s accomplishments were built upon a true national community of psychologists joining together for an important cause.”

“We had worked very hard to explain our program to legislators around the state before going to the legislative session. I wish we had done more in this regard. We were politically very naive in assuming that we could claim a victory on the merits of our goal. What we learned is that the more successful we were, the more our opponents resorted to very manipulative and, frankly, dishonest tactics. The last week of the legislative session had little to do with the merits of the bill but had everything to do with political maneuvering. Our opponents found every weak link and maximized upon it. Medical students at the University of New Mexico signed a letter stating that they would leave New Mexico if psychologists gained prescriptive authority. Three psychiatrists called judges in Albuquerque and falsely claimed that the New Mexico Psychological Association was ‘paying off’ the lobbyists from the other side to change their minds. Further, our opponents pressured our endorsers, pushing some of them enough that they retracted their endorsements (I really don’t understand how you can change your mind about an endorsement and appear at all credible to the legislators). Then, when they got people to retract their letters of endorsement, our opponents would say that we had lied and never received those endorsements. I worry that there were some employment casualties for some of our endorsers, but apparently our opponents didn’t care about that.”

“The opponents grossly distorted data. For example, there are 26 psychiatrists on the New Mexico provider list for outpatient treatment. In the last few weeks of the session, the psychiatrists testifying against the bill reported that there are over 150 psychiatrists taking Medicaid patients. Only a few days ago did I learn from an article in the Albuquerque Journal their inflated number included all the psychiatrists in El Paso, Texas and along the border area (which could be anywhere from Texas to California). They continually hammered people we would be grossly and inadequately trained and dangerous. Worst of all, they pressured legislators that they would pull out their support for them. On more than one occasion, a legislator told us that, in theory, he or she supported our position, but he or she would vote against us because the medical association had been big contributors to his/her campaigns in the past.”

“Being right and having good ideas is only a small part of the success in the political arena. The lack of control over important factors (such as making sure the legislators were being given accurate facts, the setting of meeting times, etc.) made this experience an emotional roller coaster. Maybe we should come up with a new DSM category called ‘reactive bipolar II disorder’ because the ups and downs associated with our ‘democratic’ system are so intense! One of our lobbyists, Joe Kupfer, explained that the maneuvering is a legitimate part of the political process because it is a way of weeding through the tremendous number of bills presented each year. [Mike Sullivan reports that this year alone there have been over 23,000 health-related bills introduced in the various state legislatures.] Psychologists really need good lobbyists to do that kind of work. Thinking about strategies and maneuvers and not taking the process personally is more ‘egosyntonic’ for them than for most of us. We were fortunate to have three excellent lobbyists: Peter Mallery, who has been the lobbyist for the New Mexico Psychological Association for many years; Tom Horan, who has been a wise and powerful lobbyist in the state; and Joe Kupfer, who was both a lobbyist and our PR expert.”

“As I sat outside the Senate the last few hours of the session, becoming increasingly aware of the manipulative forces that were preventing our bill from being heard, I said to a colleague, ‘This is so dark, I don’t think I can ever do it again.’ Although we had the votes, we didn’t have the weight to crash through our opponents’ barricades at the end. But halfway from the Roundhouse in Santa Fe to my home in Las Cruces, I found myself planning our next attempt. We came close because we have a goal with so many positive implications, not only about prescriptive authority for psychologists, but also for meeting the plight of the underserved and for correcting the limitations in the psychiatric model of the fifteen-minute treatment hour. We certainly are not going to let our opponents reign because of their money and power. So we will keep our dignity and use our intellect and the energy we receive from our knowledge. We are right and with our supporters around the nation we shall go across the finish line next time.” [Mike and I only wish Elaine and her colleagues could have personally heard the bursts of spontaneous applause they were receiving throughout State Leadership – New Mexico is making a real difference in the RxP- agenda.] Perhaps most significantly, the Health Policy Tracking Service (e.g., the literature of the National Conference of State Legislatures) for the first time ever was able to list a psychology RxP- bill as having passed one legislative chamber. In 1997, the Louisiana RxP- bill was reported favorably from Committee. The following year, Missouri followed with its legislation. This year, the next gigantic step was taken - Mahalo.

The 21st Century:

Russ Newman’s keynote conference address: “Expanding The Power Of Psychology” highlighted for the audience the unprecedented changes occurring within the telecommunications arena. We are all aware of how e-mail, for example, has changed our daily lives. Those of us with teenage children know how they can talk on the phone, do homework, and communicate via the Web simultaneously. The United States leads the world in logging on to the Internet from home with more than 98 million people logged online last December; Japan ranked second with nearly 15 million Web surfers. It is estimated that the number of Americans who use the Internet to retrieve health-related information is approximately 70 million and that the number of American adults with Internet access grew by 16 million in the last six months of 2000. Leigh Jerome reports that currently information doubles every 5 years; by the year 2020, it is estimated that information will double every 17 days. Practitioners must remain intimately aware of the advances occurring within their speciality. In my judgment, the 21st Century will foremost be an era of the educated consumer and technological revolution. These are clearly challenging times.

The Institute of Medicine (IOM) has long served as a health policy think-tank for the Congress and our nation’s health care leadership. In 1999 the IOM released its report entitled: “To Err Is Human: Building A Safer Health System”. This far reaching report suggested that 98,000 Americans died each year in hospitals as a result of medical errors; that medications are the most frequent medical intervention, with an average of 11 prescriptions per person in the United States; and that by utilizing a clinical pharmacist at the time medication decisions are being made and orders are being written, even in teaching hospitals the rate of preventable adverse drug events can be reduced by 66 percent. This year, the IOM follow up report, “Crossing The Quality Chasm: A New Health System For The 21st Century”, was released, again receiving major attention by the media.

Almost every health policy expert has concluded that our nation’s health care system is currently in the “horse and buggy” days of utilizing information technology. As change comes, it will be monumental. The IOM reports that: “The American health care delivery system is in need of fundamental change. Many patients, doctors, nurses, and health care leaders are concerned that the care delivered is not, essentially, the care we should receive. The frustration levels of both patients and clinicians have probably never been higher. Yet the problems remain. Health care today harms too frequently and routinely fails to deliver its potential benefits. Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case....”

The IOM further noted that information technology must play a central role in the redesign of the health care system if a substantial improvement in quality is to be achieved over the coming decade. Automation of clinical, financial, and administrative transactions is essential to improving quality, preventing errors, enhancing consumer confidence in the health system, and improving efficiency. For example, an express goal should be to eliminate most handwritten clinical data by the end of the decade. New skills required will require new approaches by professional educators. The 21st Century health care system envisioned by the IOM – providing care that is evidence-based, patient-centered, and systems-oriented – also implies new roles and responsibilities for patients and their families, who must become more aware, more participative, and more demanding in a care system that should be meeting their needs. Specifically, the IOM recommended: “An multidisciplinary summit of leaders within the health professions should be held to discuss and develop strategies for (1) restructuring clinical education to be consistent with the principles of the 21st-century health system throughout the continuum of undergraduate, graduate, and continuing education for medical, nursing, and other professional training programs; and (2) assessing the implications of these changes for provider credentialing programs, funding, and sponsorship of educational programs for health professionals.”

Psychology’s clinicians will be very pleased to learn that the IOM truly appreciates and values the psychological, interpersonal and “skill” aspects of providing quality care, as well as the scientific basis of decision making. “In today’s health system, it is widely believed that the best care for individuals is based on the training and experience of professionals. The new rule, on the other hand, could be stated: “The best care results from the conscientious, explicit, and judicious use of current best evidence and knowledge of patient values by well-trained, experienced clinicians.” At their best, health care services match knowledge and need. When care does not match knowledge, it may fail to help.... The health care system today is too tolerant of mismatches between knowledge and action.... The new rule calls for standardization around best practices as appropriate for a given patient or the subpopulation to which a patient belongs. Such evidence-based decision making can free clinicians to make choices that science cannot guide – decisions based on relationship; observation; and the other senses, including touch.... The commitment to standardizing to excellence – using the best available information – does not begin with a slavish adherence to simplistic practice guidelines. With today’s information systems, protocols can incorporate variations based on the individual patient’s condition.... The 21st Century will truly be a challenging and exiting era for psychology’s educators and practitioners.

Why Are We Not Surprised?

In response to the Clinton Administration’s proposal deeming psychology eligible for Medicare GME support: The ApA is opposed.... To put these critical programs in potential financial jeopardy in order to finance the training of psychologists we do not believe is in the best interest of the health care system when there is no evidence of need for adding these personnel into the present health care system.... (W)ill be an unfortunate sham, which has the potential to dissuade patients from seeking valid medical care. Aloha,

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