As the Congressional deliberations on substantive legislation finally begin, now that the focus has moved from consideration of impeachment and the possible removal of the President from office, we were very pleased to meet one of the new APA Congressional Science Fellows, down in the Senate coffee shop. Robert Mendoza obtained his doctorate from the Graduate Institute of Professional Psychology, University of Hartford and has just completed a post-doctoral specialization in neuropsychology at the Harvard Medical School. Rob’s thoughts:

As I mentioned to you, I have been with Senator Bingaman’s office since the end of September. Other APA Fellows had rated their experience in his office so highly that I was quite pleased when his legislative director, Trudy Vincent, offered me a placement. Trudy is also a psychologist. The fact that I am originally from New Mexico has also helped make the experience even more personally meaningful for me. In addition, selecting an office that had involvement in a committee of health jurisdiction was also important (Senator Bingaman is on the Health, Education, Labor and Pension Committee).

The first few months of my odyssey were dedicated to finding out how to find my way back from the Capitol without getting lost and not trying to figure out the Omnibus Appropriations Act process (i.e., How could so many people vote for a bill that was read by so few and possibly not fully read by anybody?).

Nothing could really prepare a person for the start of the session. When it began, so did my experience on the Hill, which may be a reason to have the APA Fellowship begin in January or December, rather than September.

My portfolio consists of issues which you might expect to find: Patients’ Bill of Rights, SAMHSA re-authorization, Mental Health Parity, Patient Privacy, and a host of parochial issues…

The State of New Mexico is a poor state and with that status comes the usual related health and education problems. For example, the issue of managed health care reform in our state is, in an unusual way, a “luxury issue.” New Mexico leads the nation in uninsured people. We also have over 80,000 children eligible for Medicaid, but unenrolled. While a Bill of Rights is important, getting people to have health insurance at all is the main focus in our state.

Some of the New Mexico issues relate to Indian tribes. The State has 23 sovereign Indian nations. Can you imagine negotiating with 23 countries for everything that you do? This also means working very closely with ancillary agencies including the Indian Health Service and the Bureau of Indian Affairs.

My experiences have been enlightening, amusing, puzzling, concerning, entertaining, boring, and demanding. Some times all at once. At one point, during the Patients’ Bill of Rights “mark-up” I realized that rather than consider the rationale of the legislation or the potential value of negotiation, the process was days of both Republicans and Democrats creating reasons to defend one’s point of view. As I sat and witnessed the proceeding, it was a little like watching an automobile accident happen right in front of me in very, very slow motion

As I sat in the “mark-up” and surveyed those in attendance, I realized that at least in this committee and on that day, the process would be very different if agency detailees and Fellows were not a part of the proceeding. Well over a dozen of the aforementioned worker populations had been an integral part of the process, many of us were nurses, psychologists, physicians, and researchers. Yet with all that available consultative knowledge, the power of politics was overwhelming. Several of the health professionals fantasized about what it would be like to have our own discussion about these conflicting issues: Democratic and Republican health professionals from each of the Senators’ staffs going back and forth. Our narcissism drives us to believe that our process would ultimately be more efficient and productive. Lest we forget one critical piece of information: we are not the elected ones.

I have seen up close and personal that politics trumps everything whether it process or outcome. The elected person is the one who has to put him or herself out there to face a very diverse, critical, and demanding public. Is the current legislative process, and I am not thinking here about the system, the best process available with the best players on each team? I am not certain.

I have come to find life in the Federal Village to be very similar to other communities with its own rites of initiation, vernacular and customs, as well as its own little family secrets. At the same time, I have also found life on the Hill to be an unusual world where the office gossip is actually the headlines on the evening news. Given that kind of life under the microscope, one wonders what effect this has on personality functioning.

My world in the Bingaman office is nurturing and challenging. The staff motto is that it is always better to ask a well considered question, than provide an unconsidered answer. How could a psychologist not be at home in this environment?

Interestingly, the Democratic Policy Committee Action Report described the Senate Patients’ Bill of Rights deliberations as: “A Defeat for Patients…. Republicans on the Senate Health, Education, Labor and Pensions (HELP) Committee squandered an important opportunity to enact a real Patients’ Bill of Rights. On a party-line vote on March 18, 1999, the committee reported out a bill that essentially mirrors the Republican leadership bill, protecting the profits of the industry but failing to protect patients. HELP Committee Republicans developed a bill that provides too few protections for patients and too many loopholes for HMOs. The chairman’s mark, and the committee-passed bill, leave out more than 100 million Americans – two-thirds of those with private health insurance. They fail to grant key protections needed by children, women, persons with disabilities, and others with chronic conditions or special health care needs. They allow medical decisions to continue to be made by insurance company executives, instead of by physicians and patients. In spite of committee Democrats’ efforts to strengthen the chairman’s mark, the committee Republicans voted down virtually every meaningful improvement….” Lest anyone wonder about the extent to which the forthcoming Presidential and Congressional elections (i.e., which party will control the majority in the House and Senate next session of Congress) may be in the minds of those involved, the President himself recently participated in a Patients’ Rights health care forum, with psychologist-Congressman Ted Strickland visually present. Rob’s observations concerning the fundamentally political nature of the public policy process are quite astute.

One of the programs which comes under the jurisdiction of the Senate Health, Education, Labor and Pensions (HELP) Committee is the Health Professions legislation (Title VII of the U.S. Public Service Act). In enacting the Health Professions Education Partnership Act of 1998 (P.L. 105-392), the Congress clarified the federal definition of “psychologist” to mean an individual who –

(A) holds a doctoral degree in psychology; and (B) is licensed or certified on the basis of the doctoral degree in psychology, by the State in which the individual practices, at the independent practice level of psychology to furnish diagnostic, assessment, preventive, and therapeutic services directly to individuals.

There are two major public policy issues involved in this definition. The first, is the explicit Congressional recognition of the role of the states, and state psychology boards in particular, in defining who is to be deemed a “psychologist.” Historically, a number of federal programs have felt a need to differentiate at the federal level between the qualifications of individuals who might have obtained their doctorate from a clinical, counseling, or educational program. The second underlying policy issue is the reaffirmation that psychologists do, indeed, independently “diagnose and treat” their patients.

Advances in Prescriptive Authority

In our last column we highlighted the success of our colleagues in Guam in enacting prescriptive authority legislation. This was an outstanding accomplishment and once again, so many owe so much to so few. Guam has made a significant difference in shaping the future of our profession. Mike Sullivan (APA Practice Directorate) brought to our attention the recent health policy tracking service report of the National Conference of State Legislatures:

“Psychologists: On December 30, 1998 the Guam Legislature, by a unanimous veto override, enacted legislation giving psychologists prescriptive authority. The new law allows clinical psychologists to administer, prescribe and dispense any licensed drug as a delegated authority of the collaborative practice agreement with a licensed physician. The law requires the clinical psychologist to register with the local and federal drug enforcement administrators. In addition to other prescriptive authority criteria, the new law requires the Board of Allied Health Examiners, the Board of Medical Examiners and the Board of Pharmacy to approve the clinical psychologist prescriptive authority for it to take effect.”

Sounds rather straightforward.

In February, Mike Schwarzchild hosted a meeting of State Association Prescriptive Authority chairs (PEPTO), in the Windy City of Chicago. Representatives from 26 states attended. Presentations were received from leaders of optometry and nurse midwifery. Subsequently, Terry Koller, Executive Director of the Illinois Psychological Association, reported that:

The Illinois Psychological Association introduced House Bill #1736, Psychologists Prescriptive Authority. The bill was assigned to the House Registration and Regulation Committee on February 24th. The bill’s sponsor, Representative Carol Ronen, is a powerful supporter of prescriptive authority for non-physician providers and was the sponsor of the recently passed prescriptive authority bill for advanced practice nurses in Illinois. The Illinois bill is based on the APA model legislation but includes language to grandfather psychologists who have, or are obtaining, APA model training and maintain their knowledge by documenting that they have taken appropriate CE credits after graduation from the program. Thus, the bill grants certification to a psychologist who applies for prescriptive authority, has completed the requirements specified in the bill except that if the academic requirements have been met more than five years prior to the application for prescriptive authority, he or she has completed 24 hours of continuing education in the two years immediately prior to application. The Illinois Psychological Association expects that the bill will be heard in a special subcommittee hearing.

Similarly capitalizing upon the enthusiasm generated in Chicago, Gil Sanders and Paul Craig have reported that the Alaska Psychological Association was successful in getting legislation introduced, House Bill #139, with hearings expected in the near future. The Alaska Psychology Licensing Board has now begun their considerations of the legislation. Finally, Alan Barclay (Missouri) and Cal VanderPlate (Georgia) have recently indicated that steady progress continues in their respective states, although neither bill is expected to become law this session of their legislatures. Cal noted that:

We had considerable support in both houses, including strong support from our newly elected Governor and Lieutenant Governor, majority leader, both committee chairs, and others in leadership.... We had tremendous help from psychologists in Georgia who educated their reps and senators over the past year and came to the Capital during the session. Legislators have been impressed by our post-doc psychopharmacology curriculum, coordinated with Georgia State University Center for Brain Sciences and Health and the University of Georgia College of Pharmacy. We now have over 50 psychologists in training....

Other Interesting Psychopharmocology Developments

Another Chicago participant, Leigh Jerome, and her Hawaii colleague Rob Welch report:
Rob and I recently attended a briefing regarding the Middle States Compact, funded late last year. This prescriptive authority lobbyist group is making influential friends in several state legislatures. Advocates have been extremely receptive, impressed by the obvious benefits that prescriptive authority will provide for consumers’ of mental health services, especially those in the underserved areas where services are notably inadequate. A number of members expect definitive legislative initiatives by year’s end.

Boosted by their newly formed alliance with a well-respected, political strategy group in the Northwest Regional Association, it appears that efforts are entering a new era, raising the bar in terms of clout and organization. There is every reason to expect another major announcement, perhaps better than our recent successes in Guam and Illinois.

The rapid success of this influential organization is attributed to its very low-profile operations, and its ability to attract significant capital. In less than one year, the Compact boasts a war chest in the middle six-figure range, and the support of key legislative committee chairs. Several initiatives are moving rapidly through committee reviews without opposition.

This success demonstrates the need to be involved early enough to shape policy makers’ opinions before opposition forces can crystallize counter-positions or distract legislators. Compact members are reporting that organized opposition does not seem to be aware of the breath of their activities. It is unlikely that a credible opposition can be mounted at this late date.

Past-APA President Jack Wiggins:

Saths Cooper, Past-President of the South African Psychological Society – The Medicines Act in force here allows ALL health professionals prescription rights. We as psychologists need to submit a list of meds to the Medicines Control Council (our office will be doing this ASAP) which competent practitioners will be able to prescribe after taking our psychopharm course which begins next month and lasts ten months. We are on top of it and you may want to include us in whatever meaningful associations are key to this common end.... Needless to say this is welcome news. This has been in the works for over a year and, of course, it is not fully implemented as yet... Our hats are off to South Africa!

Thoughts from the DoD Fellows [personal and not representing the views of the Department or their Services]: Jim Meredith (USAF) –

I provide medication support to four non-prescribing providers and have found this to be much preferable to having to have a generalist physician or psychiatrist involved. I provide a message to my patients that is consistent with the cognitive-behavioral model that is predominant in our clinic. I make interventions supportive of the work their therapist is doing and am able to discuss the patients we share from the same viewpoint: i.e., provide skills and tools for empowerment rather than suggesting that these folk are victims of “brain disease.” In many cases I do assume full care of the patient, but only at the request of the referring provider and this is usually when only one or two sessions have occurred prior to the referral.”

Gil Seda (US Navy) –

I agree that managing other psychologists’ patients is a good idea. Ninety-five percent of my medication referrals are from other psychologists. For me to conduct psychotherapy on their patients would adversely affect the patient’s treatment with their psychologist. The treatment boundaries would be blurred. When psychologists prescribe, the nonprescribers may seek our pharmacological expertise. I think we can assist these providers without taking over all of the patient’s care. Furthermore, there is more therapy to medication management than many of us realize. Patients are more compliant with their medication when they understand the reasons for their medication and when they have a good relationship with their provider. I also believe there are some patients who only require medication management and do not require therapy because they have already completed an adequate course of therapy.

Elaine Orabona (USAF) –

Just thought I would share with you that I have just returned from two talks I gave to OB/GYN physicians and psychiatrists on premenstrual dysphoric disorder. First, while I was afraid of being introduced as a “prescribing psychologist” to a group of psychiatrists, I am pleased to tell you that they were exceptionally warm and gracious (maybe it is a Southern thing). They even asked me questions in a highly collegial manner and it was so refreshing given the catastrophizing I did prior to the talk. REALLY NICE surprise. Secondly, the Pfizer representative was very excited to have a prescribing psychologist speaking to the group and commented on the need for future speakers. Thirdly, you will be happy to know that an entire HALF of my talk was about lifestyle modifications that prove beneficial with this condition in addition to recommended instruments for behavioral monitoring. The OB/GYNs were especially interested in these and even asked for copies of the assessment forms. I hope this gives my colleagues another prompt for making themselves known to their local pharm reps and the talents we can offer. As they say, “do something that scares you everyday.” This was certainly the case for me.

And, perhaps most importantly since APAGS is our future – Scott Hamilton, Chair APAGS-ACT –
We discussed your request for APAGS representation on your RxP Presidential initiative at the consolidated meeting this past weekend. As you may be aware, two years ago APAGS formally endorsed the APA position with respect to pursuit of RxP. The APAGS subcommittee which I chair, the APAGS Advocacy Coordinating Team (APAGS-ACT), has begun an RxP information campaign for psychology graduate students across the country, particularly those in academic departments which may be receiving an anti-RxP biased viewpoint from their faculty. Among other things, we have a presentation scheduled for convention, and one of our ACT committee members is developing an “RxP fact sheet” to be distributed at the convention, SPPA conferences, and other meetings. We look forward to collaborating with you on RxP initiatives, and we welcome your suggestions on other strategies for reaching out to students and psychologists to educate them about this vital issue.

Interesting Times

We recently received an announcement of a forthcoming workshop entitled “Bringing the Benefits of Telehealth to Underserved Populations: Next Steps” to be held in Washington, DC. This is a follow-up to last year’s conference sponsored by the Friends of the National Library of Medicine, the Robert Wood Johnson Foundation, and the Center for Public Service Communications [nealn@cpsc.com]. Last year approximately 100 invited policymakers, clinicians, academics, and nonprofit advocacy groups participated, generating 25 recommendations for future action. Psychologist Rob Glueckauf was one of the participants. This year’s effort marks the start of Phase II of a multi-year initiative to plan for a more systemic approach to defining how medically underserved populations might use new and emerging information technologies. Simply stated, in our judgment, this is the future of health care.

Last year’s deliberations concluded that

Most Americans are part of a demographic group which will face distinct challenges in using new telecommunications tools to better access needed health services. Unique characteristics and risk factors among children and the elderly, minorities, inner city and rural poor, and persons with disabilities, argue for special consideration during the development and deployment of communications technologies....

The participants called for a broader definition of “Telehealth” to include a wide range of both technologies and potential applications, empowerment of individual members of at-risk groups so that they may better understand the potential which various technologies hold for them, sharing of information in “real-time” so that advances in the technology field may be instantly available to special groups in consideration of their needs, and perhaps most significantly, thinking “outside the box” so that technology development and the needs of users may be meshed more closely from the onset, before technologies are deployed for the general public. The need for a shifting paradigm with regard to health care professional education and training, so that professionals of the 21st Century will be better equipped to use emerging technology tools in the delivery of care and services for specific populations was also cited.

At the public policy level the conferees recommended an integration of federal telehealth and telemedicine programs and policies. Noting there are so many federal programs already underway, it was felt important to share funding sources and to ensure that federal funds are not being duplicated for similar efforts. Further, there was a call for a review of existing public policies related to confidentiality, privacy, licensure, telecommunications subsidies, medical liability, reimbursement, and other matters. It was urged that at the public policy level that the fundamental principle be adopted that cross-disciplinary and inter-disciplinary approaches are needed in providing telehealth to underserved areas, for the needs of the underserved do not fit into neat disciplinary boxes. Telehealth projects should be extended to the nursing and allied health fields; joint research projects between nations should be encouraged; and a concerted effort should be made to assess quality of care issues with regard to telehealth (i.e., systematic evaluation). Interestingly, the Veterans Administration recently announced a partnership to create a two-year Fellowship program aimed at developing curriculum in health care quality. This column’s “Foxism:” “He goes faster than advice do....”

Advocacy and Professional Issues

The 106th Congress Begins Its Work

By Patrick DeLeon, Ph.D., J.D.