Interim Hearing Next Step in Proposed "Prescription Privileges" Bill

PointCounterpointState Bill 694, Calif. state Sen. Richard G. Polanco's (D-Los Angeles) proposed legislation granting prescriptive authority to California psychologists, is soon to be scheduled for an interim hearing (date and time to be announced). Now is as good a time as any to review the state's existing law, Polanco's proposition, history on the subject and what elements are not being addressed in the bill.As it stands, the existing law:

(1) Provides for licensure and regulation of the practice of psychologists by the Board of Psychology (board) in the Department of Consumer Affairs (DCA), and the practice of pharmacy.

(2) Prohibits the practice of psychology from including prescribing drugs, and the pharmacy law prohibits any person other than a physician, dentist, podiatrist or veterinarian from prescribing or writing a prescription.

(3) Authorizes the board to refuse to issue any registration or license, or issue a registration or license with terms and conditions, or suspend or revoke the registration or license of any registrant or licensee if the applicant, registrant or licensee has been guilty of unprofessional conduct, as described.In contrast, Polanco's legislation specifically would:

• Revise these provisions to authorize a certified psychologist, as defined, to prescribe or write a prescription.

• Require the board to administer a certification process to grant licensed psychologists the authority to write prescriptions, and to develop procedures for certification with the advice of the Certified Psychologist Advisory Committee, that the bill would also establish.

• Authorize the board to charge fees for the issuance of, and renewal of, a certificate, and would provide for the deposit of these fees in the Psychology Fund, a continuously appropriated fund, thereby making an appropriation.

• Set forth certification eligibility criteria, and would also require each applicant for an initial certificate for prescriptive authority to agree in a written statement under penalty of perjury to spend no less than 80% of his or her total time as a certified psychologist for three calendar years providing services to underserved populations, as defined.

• Require the board, in consultation with the committee, to establish requirements for renewal of a certificate, and continuing education requirements.

• Require the board to provide certain information to the Board of Pharmacy, including an annual list of psychologists certified to prescribe drugs.

• Require the board to encourage licensed psychologists to take continuing education courses in psychopharmacology and the biological basis of behavior.

• Require the board to encourage institutions offering doctorate degree programs in psychology to include education and training in psychopharmacology and related topics.

• Require the board to develop education and training guidelines for psychologists whose practices include patients who may require psychopharmacological treatment.

• Authorize the board to issue a certificate of completion to recognize knowledge of pharmacology and biological basis of behavior.

• Authorize the board to examine candidates in various areas of professional activity.

• Include as unprofessional conduct a violation of a provision of law relating to prescribing or dispensing drugs by a certified psychologist. Background

Sponsored by the California Psychological Association, SB 694 is intended to address the "dire need for mental health treatment, specifically for medication, in rural counties with underserved populations throughout the state." The bill would allow doctoral-level psychologists who receive additional training and who are certified (pursuant to a certification process provided for in this bill and administered by the Board of Psychology) to prescribe medications that are recognized as effective for the treatment of patients served within the scope of practice for which psychologists are licensed.

To ensure that certified psychologists provide service to underserved populations, the bill requires that an applicant for certification sign an agreement to spend at least 80% of his/her total practice time for three calendar years immediately following certification providing service to underserved populations, as defined.

Polanco, coauthor of the bill, voiced his concerns about rural populations' limited access to prescribing physicians: "In California we have 14 counties in which not a single psychiatrist is listed by the American Board of Medical Specialties," he said. "There are 24 counties in the state with fewer than five psychiatrists. Not only are psychiatrists rare in some areas, but they are also more expensive, which further limits access."

The California Psychiatric Association (CPA), however, discounts this information indicating that the source of these numbers is out of date and inaccurate, and the numbers include only a little over half of California's psychiatrists. The CPA states that county lines are artificial boundaries and do not take into account the psychiatrists who "circuit ride" in less populous areas of the state.

The CPA's advocacy literature states: "The need for psychiatrists in rural California can be met by alternative methods of access to adequately trained psychiatrist physicians, such as by use of telemedicine; nondiscriminatory health care coverage by both managed care companies and MediCal; the recruitment efforts that have been undertaken by our association in cooperation with the counties; circuit riding; and perhaps through the establishment of a telemedicine hot line from the UC [University of California] hospital system, where consultations for primary care physicians with psychiatrists would be available 24 hours per day."

• Pros and Cons

Proponents of SB 694 argue that the doctoral-level training undertaken by psychologists qualifies them to deal with mental illness more so than most physicians. They cite a California Supreme Court ruling that psychologists are fully qualified primary care providers with respect to patients with mental illness. Sponsors say that the additional pharmacological training provided for in this bill, coupled with the current level of education and training required for licensure, provides assurance of quality care and consumer/patient protection.

Polanco concurred: "More than 75% of mental health prescriptions are written by general practitioners who have limited training in treating mental illness. It makes good sense to set up a system in which psychologists who meet additional educational requirements would be given the authority to prescribe medication."

Opponents contend that the training provided for in the bill is inadequate. Many feel that as time brings new and significantly more powerful drugs for the treatment of mental disorders to the market, the arguments against psychologists prescribing will increase.

The opposition cites the California Medical Association and the California Psychological Association's six-year demonstration program of the U.S. Department of Defense, wherein psychologists undertook three years of pharmacological training and supervised experience.

In evaluating the program, the General Accounting Office (GAO) noted that "all of the...graduates continue to practice under the supervision of a psychiatrist, and whether they will ever prescribe independently is unclear...We see no reason to reinstate this demonstration project."

• Public Policy Advocacy

The American Psychiatric Association's public policy regarding the issue is posted on its Web site, and quotes the 1995 testimony of James H. Scully Jr., M.D., the APA's deputy medical director for education. The testimony took place before the Subcommittee on Creation or Expansion of Scope of Practice, Senate Committee on Business and Professions, State of California on California SB 777-Psychologists/ Prescribing Privileges in 1995.

Speaking on psychologists' "adequacy of training," Scully said: "In seeking prescription privileges, psychologists frequently claim that they have 'more advanced training...in the treatment of mental and emotional disorders' than any other health professional. Of course, psychologists making this claim do not count medical school as part of a psychiatrist's training. This is a basic gross misunderstanding. Please understand that to be a psychiatrist, medical school is core, essential, critical."

He continued, "The study of psychology, an academic discipline, focuses on human behavior, not on medical and health sciences or human illness. A substantial portion of a psychologist's training is in statistics, research methodology and experimental psychology. As a physician, a psychiatrist's training begins with basic sciences...in undergraduate studies. This becomes the foundation for learning the health sciences...in medical school, which in turn provides the knowledge and clinical base for a four-year supervised residency to learn, for example, to diagnose illness, order and interpret medical and psychological tests, determine appropriate treatments, including pharmacological treatments, and evaluate and deal with side effects. This physician training occurs primarily in a hospital, where the psychiatrist is regularly caring for seriously ill patients."

• Lingering Doubts

Another question that continues to haunt the bill's opponents is "Wouldn't it be better just to upgrade general practitioners?"

From his testimony, Scully had this to say: "It is critical to note that more people with a mental illness who seek treatment (43%) get their care from their primary care physicians-not from psychologists, or psychiatrists or any mental health professional. Interestingly, this even includes serious mentally ill patients.

"Only around 40% of all people with mental illness who receive treatment get it from mental health professionals. This is National Institute of Mental Health data. There is some fascinating logic in psychologists' claims that physicians have done such a horrible job in using medication that psychologists are going to fix it all. Prescribing increasingly demands sophisticated, updated skills. Yes, there are problems. But is the solution to train psychologists less thoroughly and let them prescribe? Common sense says no!"

The deputy medical director concluded: "There is a major need for better training for primary care physicians. Patients are going to go to their primary care physicians. In western Europe, where there have been national health programs for many years, the primary care physicians are better trained in psychiatry and are able to handle the simpler cases reasonably well. It will be much more cost-effective to improve psychiatric training for physicians than to train psychologists, medically."

The list of opponents of the bill is long and impressive, including the California Medical Association, California Healthcare Association, Union of American Physicians and Dentists, American Medical Group Association, California Nurses Association, California Association of Ophthalmology, California Academy of Family Physicians, Kaiser Permanente, and the California Alliance for the Mentally Ill, to mention a few.

On a national level, in a recent show of support, the House of Delegates of the American Medical Association unanimously agreed to work closely with local psychiatric societies opposing legislative or ballot initiatives that would authorize psychologists to prescribe.