OUR HAWAII COLLEAGUES CONTINUE THEIR EXCITING RXP QUEST
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 HPAs 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 APAs
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 HPAs 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 psychologys
RxP legislation were themselves physicians. And, for our
practitioners, it is important from time to time to reiterate Jims
heartfelt view that: As Ive started prescribing, Ive 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.
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 psychologys 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 Hawaiis 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....
...but you did 
