Another scope of practice issue won for psychology!

[edieb]

From apa.org -- it's hard to believe M.D.s, who have NO testing experience, HAD more testing rights than Ph.D.s



In Brief
Psychologists earn new Medicare testing supervision privileges


The Centers for Medicare and Medicaid Services (CMS) finalized a rule change that will allow clinical psychologists to supervise technicians and other staff members who conduct psychological or neuropsychological testing. Previously, only physicians could supervise such individuals. Medicare defines a clinical psychologist as a doctoral-level practitioner recognized by Medicare as qualified to provide both therapeutic and diagnostic services.

The revised federal regulation, which was approved as part of the final rule on the 2005 Medicare fee schedule in November, became effective on Jan. 1. It provides psychologists the same level of supervision privileges as physicians: Both groups can generally direct and manage technicians but do not have to be present during testing.

"Previously, a psychologist could not supervise someone giving a psychological or neuropsychological test," says Diane Pedulla, JD, the APA Practice Directorate's regulatory affairs director. "The expansion of the rule puts psychologists on equal status with physicians in regards to testing."

The changes are the result of over two years of advocacy by the APA Practice Organization (APAPO)--which tackled the issue in response to psychologists' requests. CMS cited APAPO's reasoning when it released the proposed change for public comment in August. Psychologists' training in assessment and psychometric testing uniquely qualifies them, it said, to direct test selection and interpret test data. CMS also noted that the change would reduce the wait times many people in rural areas face when they need testing.

Nevertheless, the change does not affect other CMS requirements, notes Pedulla. Separate rules governing what is known as "incident to" billing state in part that, in order to seek reimbursement for technicians' services, psychologists and physicians must directly supervise the staff members involved. That means, says Pedulla, that they must be in the office suite and immediately available when technicians or other staff members conduct the testing. Additional requirements might apply under Medicare carriers' local policies.

--D. SMITH BAILEY


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For more information, contact APA's Government Relations Office at (202) 336-5889.

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[PsyDRxPnow]

This should have never been an issue in the first place. It was a no brainer that an individual who is specialized in psychological testing (psychologist) be the one overlooking testing then someone (physician) who maybe highly qualified in his or her scope of practice but not in psychological assessment.

p.s. I look forward to the progress of RxP in my state of Florida and in other states.

 

[edieb]

From Opponent to Supporter of Prescriptive Authority For Qualified Psychologists
Submitted by Robert J. Ferguson, Ph.D., NHPA Board Member
It is abundantly clear that prescriptive authority for psychologists has ignited controversy in both psychology and health care in general in the past decade. However, this matter has its roots from nearly two decades ago (DeLeon, Dunivin, & Newman, 2002) and represents another step in the natural evolution of professional psychology. In graduate training in the early 1990's, I dismissed prescriptive authority based on principal arguments heard to this day: 1) It is a fleeting scope of practice trend with no historical precedence; 2) prescriptive authority is only safe with the medically trained. After completing internship, postdoctoral training and being a faculty member at a medical school over the past decade, I have changed my mind. Much of my change in attitude is based on historical fact and a better understanding of health care provider training. Prescriptive authority for qualified psychologists is not a threat to public health, other health professions or to clinical psychology itself.

A bit of history. The last century witnessed the evolution of professional psychology to health profession. Psychologists first took on a professional identity in the late 1800's to early twentieth century growing from the role of basic behavioral scientist. Ensconced in the study of perception and physiological bases of behavior, psychologists began to use their tools of trade assessing and quantifying human behavior to evaluate cognitive abilities of intelligence, memory and aptitude (Sattler, 1988). This step from the vernal pool of basic science to consulting was not without its detractors, both from within and external to psychology. Clinical psychology, now a twenty-first century health profession, presently stands on another threshold of adding to its specialty list.

"This is quite a departure from the legitimate field of psychology…" Many watching the contemporary debate of prescriptive authority have heard remarks similar to this. However, this quote is excerpted from a 1917 article in the New York State Journal of Medicine (Cornell, 1917). The article was essentially a call to put an end to psychologists expanding their role as psychometrists and using standardized tests to render diagnoses. Now considered the province of clinical psychology (indeed, setting psychologists apart from other professions), standardized psychometric instruments were once regarded as tools only safe in the hands of those trained in medicine who dealt with patients stricken with illness of the nervous system. The arguments against professional psychology broadening the scope of practice we hear today are nothing new.

Another example of guild struggles comes with the close of World War II. Psychologists once again broadened scope of practice when the need for development of psychological treatments and psychotherapy grew. This was primarily through the Veterans Administration. Once again, clinical psychologists were met with detractors-- some within and many external to the field. Arguments against psychologists learning and using psychotherapeutic skills are a familiar refrain; risks to public health and little need. Many were concerned that without proper medical oversight, brain tumors or endocrine disorders would be mistaken for psychiatric disorders or problematic behavior and not properly evaluated or treated (see Resnick & Norcross, 2002). These arguments also appeared when psychologists sought third party reimbursement in the 1960's and in lawsuits regarding third-party reimbursement in the 1980's (Resnick, 1985). If history is a teacher, it is clear that much of the rhetoric in opposing prescriptive authority for qualified psychologists has been played and replayed.

"Psychologist training is no substitute for medical training." This is true. Psychologists will never make good physicians. Nor will physicians make good psychologists (nor dentists or optometrists). The argument that one must attend medical school to be a competent, safe prescriber lacks empirical support. Non-physician health care providers do not have less satisfactory outcomes than physicians (Cooper, Henderson, & Dietrich, 1998). Further, medical school carries a tremendously broad curriculum within which pharmacology is a small part. The Association for Medical School Pharmacology recommends a curriculum of 97 hours of pharmacology training in 4-year medical schools.

By contrast, prescriptive authority legislation for prescribing psychologists in NH and elsewhere consists of 450 hours of post-doctoral training. This exceeds recommended curriculum of the American Psychological Association that was derived from consultation with American College of Neuropsychopharmacology (ACNP). It should also be noted that Psychologists who specialize in psychopharmacology will be practicing with a formulary limited to psychoactive agents, whereas medical students going on to residency only learn specialty prescribing practices at that level. This might explain, in part, why that the majority of physicians prescribing psychoactive agents - who are non-psychiatric physicians- generally produce less satisfactory outcomes than their psychiatric colleagues. In light of the fact that fewer residents specialize in psychiatry (there are more residency slots to fill than there are residency candidates), psychologists who attain the proper training can help fill a quality gap and help the non-psychiatric physicians. It is unlikely that the intensive specialty of psychiatry can ever be supplanted since the need to treat severely ill individuals is not reduced. In summary, no, psychologists who prescribe do not need to attend medical school to become competent and safe prescribers.

As a former Maine Optometric Association president once said during the legislative movement for optometry to gain prescriptive authority: " [optometrists] don't need to learn how to set fractures or deliver babies to prescribe medicines that treat diseases of the eye." Psychologists already have the diagnostic and clinical skills embedded in present training. Broad medical training will not improve safety or quality in prescribing.

Psychology will become "medicalized"-- there are enough drugs already being prescribed! Though I have never understood what "medicalized" means, it is unlikely that a postdoctoral specialization will lead to all licensed psychologists becoming prescribers of psychoactive drugs. Rather, a prescribing psychologist will be qualified with appropriate training just as a neuropsychologist or a psychologist devoted to forensic work is. He or she will likely add the prudent dispensation of medication to psychological practice rather than replace it.

With respect to having psychologists give up psychological interventions and "cross over" to only using the prescription pad, it is important to remember that the authority to prescribe, is also the authority to un-prescribe. Yes, that is an APA sound bite, but there is substance. For instance, numerous patients in primary care may present with full panic disorder, or only transient first-time panic episodes associated with inordinate, episodic life stress. Regardless, many are placed on a benzodiazepine (antianxiety agent) such as Xanax-which has modest long-term efficacy. Many patients receive inadequate follow-up due to the overscheduled nature of primary care. Because the research track record of David Barlow's cognitive-behavior therapy for panic disorder is outstanding (87% efficacy in one clinical trial), this is a better, and arguably safer, treatment than benzodiazepine (in fact, data demonstrate that less than 25% of individuals ever receive efficacious treatments for anxiety disorders-one reason why more psychologists now work in primary care settings; NIMH, 1991). It is also known that when individuals taper benzodiazepines prior to cessation of behavior therapy, panic disorder outcomes are better with lower rates of relapse at follow-up (Bruce, Speigel & Hegel, 1999). However, psychologists without prescriptive authority are unable to taper medication. Even for psychologists who, in the best of circumstances, work with primary care physicians or psychiatrists in common office space, coordination of care and timing can become difficult and often can require multiple office visits to separate providers. This is expensive, cumbersome and flatly bad patient service. Conversely, the prescribing psychologist can combine treatments and fade one or the other while consolidating care.

The history of medicine and health care has clearly shown that when any profession seeks legal broadening of its professional domain, economic forces stir the controversy with public health hazard as an opposing argument. Without question, public safety is the first concern with respect to the current debate. However, safety needs to be evaluated by empirical facts on prescribing practices among all health professions and in the context of the history of clinical psychology evolving as a legitimate health profession. Hopefully, this text has helped shed more light on the topic.