Significant Progress: In our recent columns we have described how during the last session of the Hawaii State Legislature, the Hawaii Psychological Association (HPA), in collaboration with the Hawaii Primary Care Association, nearly obtained prescriptive authority (RxP) for their members working within federally qualified community health centers. HPA was ultimately successful in having a special Task Force enacted which was comprised of two legislators, two psychologists, and two psychiatrists. This group met four times over the last three months of 2005 with Ray Folen and Jill Oliveira-Berry (a Native Hawaiian psychologist) representing HPA. Key objectives included: 1) An exploration of access to mental healthcare in Hawaii, particularly in rural areas of the islands. And, 2) Proposed models from both the Hawaii Psychiatric Medical Association and HPA to enhance services, especially for the identified areas and patient populations that experience significant barriers to mental healthcare access (i.e., primary care patient populations, the uninsured, rural communities, etc.). With the convening of the 2006 legislature, House Bill 2589 was introduced with seven House signatures as introducers and co-introducers (including one of the Task Force co-chairs); a first in HPA’s RxP history. The bill would allow appropriately trained psychologists working in health centers to prescribe, as well as colleagues working in health clinics in federally designated medically underserved areas or clinics in mental health professional shortage areas. Ongoing collaboration with a physician is required, similar to the provisions of the Louisiana Medical Psychology Act, and the bill contains a number of references to APA’s recommendations. After 3 ½ hours of contentious debate, the House Health Committee reported the bill favorably by a vote of 4 yes and 3 excused. The bill now goes to another House committee (Consumer Protection and Commerce). Particularly impressive was the support expressed for the bill by the Hawaii Medical Service Association (HMSA) (Blue Cross/Blue Shield), which is the largest insurance company in Hawaii, as well as the medical directors of each of the community health centers. Our sincerest congratulations to Jill and Robin Miyamoto who are spearheading HPA’s legislative effort.
Prior to the introduction of this legislation, I had the opportunity of presenting at the HPA Primary Care Institute, which was co-sponsored by the Hawaii Primary Care Association. Former HPA President Kate Brown did an outstanding job educating the membership as to why it is critical for professional psychology to become actively engaged in providing primary healthcare. Exciting workshops were presented by Dan Egli and Susan McDonald. Enthusiastic “calls for action” were issued by the House and Senate co-chairs of the Task Force, who are HPA RxP champions, as well as one of the community health center medical directors who has been extraordinarily supportive of psychology over the years. Dan, who served on the original APA RxP task force back in the early 1990s, commented that in all his travels, he had never seen elected officials who understood the underlying access and quality of care issues so well.
As requested, Jim Quillin, President of the Louisiana Academy of Medical Psychologists, submitted testimony. “I write to you today on behalf of the Louisiana Academy of Medical Psychologists to provide support for HB 2589. As you may be aware, a very similar statute has been enacted in Louisiana, having been signed by our Governor in 2004, with enabling regulations finalized in January 2005. Since that time, 30 medical psychologists (MP) have been certified by the Louisiana Board of Examiners of Psychologists and are now authorized to prescribe medications recognized and customarily used in the management of psychiatric disorders. Like HB 2589, the Louisiana Medical Psychology statute fosters integrated, collaborative care between medical psychologists and primary care or attending physicians.
“You will undoubtedly hear testimony to the effect that the training being proposed in Hawaii is inadequate and that allowing psychologists to prescribe these medications will place patients at great medical risk. However, the extensive additional training outlined in HB 2589 is essentially identical to that received by medical psychologists in Louisiana. With respect to safety, medical psychologists certified in Louisiana saw a total of 7,260 patients in 2005, after receiving the authority to prescribe. Of those patients, 3,863 (53%) were provided prescriptions and a total of 9,345 prescriptions were written including refills. There were no adverse events associated with this expanded practice. I should add that the patient population treated included the full range of psychiatric conditions, and many patients were also significantly medically compromised by other health conditions. Several of our members are also now specifically credentialed to provide these services in nonpsychiatric hospitals. It is my understanding that the experience of DOD trained psychologists is essentially the same as ours.
“Patients express an extraordinarily high degree of satisfaction with medical psychologists and we have been welcomed with open arms by rank-and-file physicians in our communities, most of whom have little interest in professional turf issues and instead value the optimized outcomes afforded by qualified health care providers working within a collaborative model of care. I hope this information is of assistance to this committee in considering this particular piece of legislation. I am confident that Hawaii will continue its long tradition of supporting safe, effective and progressive healthcare change for the citizens of your great state. Please do not hesitate to contact me if I can provide any additional information. Sincerely.”
From a public policy frame of reference, it is intriguing that in both Louisiana and Hawaii the prime sponsors of psychology’s RxP legislation were themselves physicians. And, for our practitioners, it is important from time to time to reiterate Jim’s heartfelt view that: “As I’ve started prescribing, I’ve found myself pondering afresh the concern of some that we are ‘medicalizing’ psychology. To be brief, such concerns, while certainly understandable, appear to be unnecessary. While some of our new professional activities are unmistakably medical in character (i.e., vital signs/review of systems/labs, evaluation of drug-drug and disease-drug interactions, therapeutic monitoring, etc.), the ‘medical’ in medical psychology is an adjective that modifies rather than defines who and what we are – psychologists. The opportunity to provide a broader range of therapeutic options to my patients certainly has not seemed to diminish my sense of professional identity.”
“Sadly, the Hawaii Psychiatric Association has chosen to make grand assertions in an effort to undercut psychology’s efforts to provide full-service mental health care to those in unserved and underserved areas of our State.
In his testimony, former HPA President Ray Folen stressed the access and quality of care issues: “House Bill 2589 allows those being served in community health centers (CHCs) to have access to the full spectrum of mental health services they may need. I support this bill because I truly believe it is the right thing to do.... Despite promises made over the last 20 years, psychiatry had been unable to meet the need to provide psychoactive medications, particularly to those in rural, poor and underserved areas of our State. Prescriptive authority is only meaningful in an appropriate context, and the primary care setting is the one that makes the most sense to us. Primary care psychologists work in a primary care clinic. In our experience, family practitioners highly value these psychologists for a number of reasons. They find that integrating primary care and psychological services is essential to the goal of truly comprehensive treatment. The patients welcome the seamless continuity of their overall health care and appreciate the lack of stigma that has historically been associated with behavioral health care.
“Sadly, the Hawaii Psychiatric Association has chosen to make grand assertions in an effort to undercut psychology’s efforts to provide full-service mental health care to those in unserved and underserved areas of our State. Legislators are reportedly being told that 130 psychiatrists are serving Medicaid and Medicare patients. The truth is that the vast majority of them do not. As a result, a large number of Medicaid and Medicare patients, and most of the uninsured ones, are going to the 13 community health centers for their mental health care. Despite 20 years of promises, psychiatrists are located in only 3 of the 13 CHCs. Contrast that with psychologists, who are now serving Hawaii’s neediest and poorest populations in a majority of CHCs. Unlike psychiatry, we are providing the services and we are doing it now.
“Here is the actual offer that the Department of Psychiatry made to the community health centers: one psychiatric resident (with attending) to be available to each neighbor island health center for ½ day per month (only ½ day per month!) to provide follow-up care to 2-3 patients (the centers have thousands of patients in need of mental health services!). While I applaud any effort by psychiatry to provide services where they are needed, they have proven over the years that they cannot do the job. Only 3% of all psychiatry graduates are going into underserved areas....
“Psychologists have been prescribing safely since 1974: first in the State Health System of New York, then in the United States Indian Health Service, followed by the Department of Defense and the States of Louisiana and New Mexico. In every setting, the evidence is clear and unmistakable: psychologists prescribe safely and effectively. The psychologists in Hawaii’s Community Health Centers provide culturally-appropriate mental health care and serve as the psychopharmacology experts to the primary care physicians in the Centers. All of the CHC medical directors support this bill!...”
A More Global Perspective: The prescriptive authority (RxP) agenda is unquestionably important for the future of professional psychology and will be determinative as to the type of care which our patients will ultimately be able to receive. In our judgment, however, equally important in the long run as its potential for improving the availability of high quality psychological care is its catalytic role in developing an appreciation within the practitioner community for the enormity of the unprecedented changes that are occurring within the nation’s healthcare environment. As a number of our distinguished former APA Presidents have demonstrated (i.e., Joe Matarazzo, Charlie Spielberger, Norine Johnson, and Ron Levant), psychology is one of the nation’s bona fide healthcare professions, not merely a mental health speciality. As one of the learned professions, collectively we have a special societal responsibility to provide proactive vision in defining the parameters of the all important psychosocial-behavioral-economic-cultural gradient of healthcare. For professional psychology, it is absolutely critical that our practitioners understand how they can position their practices and clinical expertise to become an integral component of their own local healthcare environment.
The AMA News recently reported: “Managing Mental Health: Primary care physicians increasingly are diagnosing and treating depression. Insurers are responding. Even if you’re not a psychiatrist – especially if you’re not – you soon could be hearing from health plans about depression. While employers and plans for years have developed disease management and behavioral health carve-outs that were supposed to manage mental illness costs, their efforts are getting more aggressive in the face of evidence that depression can exacerbate physical conditions, and vice versa, thereby costing employers and plans a lot of money. Their efforts are also getting more aggressive in the face of evidence that in an overwhelming number of cases, it’s a primary care physician who is diagnosing and treating depression.... And at least one plan, Aetna, promises to pay extra for depression screenings, as long as doctors go through the plan’s training program....
“Insurers are looking at primary care physicians for two reasons. First, the primary care physician often is going to be the treating physician. The National Business Group on Health, a coalition of large employers... is saying that 67% of psychotropic drugs are prescribed by primary care physicians. Cigna, citing its own research, says 80% of the estimated 122 million annual antidepressant prescriptions are written by primary care physicians. The National Business Group on Health... also said 51.6% of patients treated for major depression are seen in the ‘general medical sector,’ defined as primary care physicians and other non-psychiatric physicians. The report quotes American Academy of Family Physicians research saying 42% of all clinical depression diagnoses are made by primary care doctors.... Employers and insurers also have seen the studies saying that depression can make other conditions worse, as well as chronic illnesses leading to a case of depression. They’ve also seen the studies saying how much that can cost.” This is not a new phenomena. During its deliberations on the Fiscal Year 1980 Department of Defense Appropriations bill (long before patient medical records could be computerized and routinely compared), the Senate Appropriations Committee noted that: “The Committee has become aware of statistics that indicate that from 30 to 50 percent of those labeled as having ‘mental health’ problems presently receive treatment from the general health care system, rather than from a practitioner specifically trained in a mental health specialty. Rendering appropriate psychotherapy is a highly complex procedure which has the potential for resulting adverse consequences, as well as for successful intervention.”
Can Quality Care Truly Be Cost-Effective?
The rapidly evolving emphasis on integrating psychological care into our primary healthcare system can perhaps be viewed as being primarily driven by the economics involved, as was predicted decades ago by another former APA President, Nick Cummings. The Centers for Medicare and Medicaid Services (CMS) recently reported that patients with five or more chronic conditions account for 23% of its beneficiaries but 68% of its spending, seeing an average of 13 different doctors and filling 50 prescriptions a year. By the year 2020, 25% of the American population will be living with multiple chronic conditions; the costs for managing them will reach $1.07 trillion. This is at a time when almost 46 million Americans are uninsured and an additional 16 million have health coverage that does not adequately protect them from catastrophic health expenses.
Fifty-four percent of the under-insured report going without needed care. From a political frame of reference, poll after poll indicates that the escalating cost of health care in our nation continues to be one of the top two or three items of concern for the voting public. The cost of family health insurance is rising faster than wages, with average premiums increasing 71% during the past five years. The challenge for psychology as we enter the 21st century is to position our profession to effectively be on the cutting-edge of the public policy and clinical debates that are unfolding as our elected officials grapple with the underlying issues of access, quality of care, and cost-containment. Russ Newman and the Practice Directorate are critical to our future.
