Lessons Learned Will Help Capture Future Victories

As you can see in the article on Original article: page 1, New Mexico Gov. Gary Johnson (R) has signed HB 170, giving prescribing privileges to psychologists in New Mexico who have undergone 450 hours of classroom instruction by undefined expert teachers and an accredited supervised clinical training program, not necessarily including any inpatient experience. This makes New Mexico the first—and one hopes the only—state to permit psychologists to prescribe drugs and concludes a 20-year effort by organized psychology to secure the right to prescribe.

Because of the outcome, and particularly because we must be prepared for a newly energized push for prescribing privileges across the states, we wanted to give you a detailed analysis of the factors that led to the outcome in New Mexico, together with a summary of the major lessons we have learned as we prepare for additional battles. We apologize for the length of this article, but the situation is complex.

Let us note at the outset that the Psychiatric Medical Association of New Mexico (PMANM), APA, New Mexico’s family physicians, the AMA, and psychology groups opposed to prescribing did the utmost to prevent this outcome. We wish to express APA’s and our personal thanks for the efforts of our membership and dedicated district branch/state association (DB/SA) staff to defeat the bill in New Mexico. We note that we have received reports that organized psychology spent as much as $500,000 on its New Mexico strategy, and we have no idea at this time if this included campaign contributions.

Passage of HB 170 follows the decision of Gov. Johnson, having met with New Mexico psychologists and psychiatrists jointly and individually, to place the bill on his “call list” in a year usually reserved only for legislation related to the budget. The “call list” decision of the governor gave the bill a critical boost in momentum and allowed legislators of the governor’s party to sense his support, a development that psychologists and their allies exploited by focusing on his signal of willingness to sign the bill if passed.

Although augmented by the determination of psychiatrists across the country, New Mexico psychiatry’s struggle to defeat the prescribing bill was complicated by a variety of factors. For example, although any psychologist-prescribing initiative was strongly opposed by PMANM, the New Mexico Medical Society (NMMS) developed an alternative to HB 170 that was patterned on the training required for physician assistants. Action on that alternative was entirely superseded by a subsequent “compromise” brokered between NMMS and the New Mexico Psychological Association at a meeting convened at the direction of House Judiciary Chair Ken Martinez. Martinez requested that NMMS President Alan Haynes, M.D., a urologist, represent the opponents of the prescribing initiative. While PMANM was informed of the meeting, it was not presented as a negotiating session, and no psychiatrist was invited to participate.

While we will never know the specifics of the meeting, despite the clearly stated opposition of New Mexico psychiatrists and APA to any deal, NMMS made a political decision to compromise based—we can only assume—on competing political interests and the assessment by its own lobbyists that the legislation would pass. The endorsement of the medical society of a “compromise” negotiated without any involvement by psychiatrists was lamentable and provided the fig leaf of medical-board oversight. This, in turn, allowed proponents to claim that NMMS “supported” psychology prescribing, clearly complicating efforts to defeat the bill and secure a gubernatorial veto.

In fact, we have received a post-action analysis from a source close to the governor that strongly suggests he had little enthusiasm for prescribing but was persuaded that the NMMS-proposed medical-board oversight was sufficient to ensure that patient safety would not be compromised, and thus decided to sign the bill rather than risk enactment of subsequent legislation with no medical oversight after his term in office expired. We appreciate the creative logic, but suggest he failed his constituents.

With respect to APA’s efforts in New Mexico, we provide the following brief summary:

• APA, chiefly through funding support from the Commission on Public Policy, Litigation, and Advocacy, committed substantial amounts of direct financial support to PMANM, as well as countless staff hours of assistance.

• An action alert to the APA national grass-roots network and Assembly targeted members of the New Mexico Senate Public Affairs Committee, as well as Gov. Gary Johnson. An earlier action alert was aimed at members of the New Mexico House Judiciary Committee.

• The American Academy of Child and Adolescent Psychiatry sent an action alert to its New Mexico members.

• Staff of APA’s Division of Government Relations (DGR) helped prepare a letter from Dr. Harding to Gov. Johnson and to members of the House committee. DGR staff also solicited or helped produce letters from PMANM members and other psychiatrists.

• Through a conference call, Dr. Harding, APA President-elect Paul Appelbaum, M.D., and Richard Ciccone, M.D., chair of APA’s Commission on Public Policy, Litigation, and Advocacy, along with DGR staff, met with seven members of the PMANM leadership. Offers of assistance were reiterated, and the message was reinforced that APA and PMANM continue to oppose any bill that provides for prescribing via any method other than medical training and residency.

• DGR offered to sponsor witnesses such as psychologists opposed to prescribing and an expert in the Department of Defense program and initiated contact with those potential witnesses to determine availability.

• DGR provided talking points for use in a meeting with the governor, legislative talking points, materials for use in hearings, as well as data refuting proponents’ assertions about rural access and provider distribution. DGR staff also developed substitute language that sought to provide for a blue-ribbon commission to study the access-to-care issue in the state.

• APA worked nationally with the AMA, AAFP, the National Alliance for the Mentally Ill (NAMI), and others to urge opposition to the bill. The New Mexico Chapter of AAFP, individual psychologists, physicians, and members of patient advocacy organizations took a position against HB 170. Unfortunately, NAMI-NM retained its position of “neutral” on the bill. DGR continues to encourage ally development with patient groups and other nontraditional allies.

• AMA Executive Vice President Michael Maves, M.D., sent a letter to Gov. Johnson urging a veto of HB 170. Dr. Maves also initiated AMA contact with Republican governors urging them to communicate to Gov. Johnson their concern with the prescribing bill and its potential impact on patients across the country.

• Media activities included providing assistance in drafting and placing op-ed pieces and letters to the editor in major state newspapers. A full-page ad in opposition to the prescribing bill ran in the February 7 edition of the Santa Fe New Mexican. DGR also supplied PMANM with guidance on organizing and making visits to newspaper editorial boards.

• A full-page ad urging Gov. Johnson to veto HB 170 ran in the March 1 edition of the Albuquerque Journal. The ad, signed by PMANM, the New Mexico chapter of the AAFP, and three psychologist groups, reiterated the health and safety reasons for the governor to veto the bill. The Journal subsequently issued a strong editorial opposing the bill and urging Gov. Johnson to veto it.

Despite this defeat, we believe that our experience in New Mexico yields critically important lessons we must take to heart as we grapple with the prescribing debate at the state and federal levels.

• First, and foremost, psychiatry must not assume that because New Mexico has taken this unwise and dangerous step, the national struggle is effectively over. Psychologists have relentlessly pursued prescriptive authority for 20 years; APA, in partnership with our DBs/SAs, has argued successfully against these efforts in every case so far except, now, one. While the impact of New Mexico’s political decision will take some time to assess, we must not, for the sake of our profession and our patients, abandon this struggle.

• Rather than despairing, we must renew our commitment to patient safety. The main lesson of New Mexico is that the prescribing threat is real and must be fought with a renewed vigor, commitment, and tenacity involving not just the national and local APA leadership, but every local psychiatrist.

• Psychologists will undoubtedly model their national efforts on New Mexico, and their success will undoubtedly spur new efforts. They will target states with large rural areas that will be portrayed as underserved by psychiatrists. They will seek to exploit states with an independent and “liberal” antiregulation legislature and portray the struggle as pitting altruistic psychologists against rich and lazy psychiatrists who have no interest in delivering services to rural populations. They will also target states where the APA district branch or state association is small in membership number and—however erroneously—perceived by psychologists to be passive and politically inactive.

• APA must assume that psychologists will continue to be resource rich and totally committed to the struggle. We must understand the tenacity of local psychologists, who infiltrate patient advocacy groups usually opposed to psychologist prescribing, and the willingness of their national organization, with elected leadership running on a “prescribing platform,” to commit years of work and substantial fiscal support to the cause, a cause presented to legislatures with little regard for truth about psychology’s self-interest. Let us not forget that last year we identified that psychologists in New Mexico had targeted a state with a major rural mental health access problem and a small APA district branch whose resources were limited and would do so again in 2002.

Psychologists in New Mexico made a political case that local psychiatrists were unable to respond effectively to the perceived rural-access problem, hired the best lobbyists in the state to market their message, prepped the legislature with careful groundwork, demonstrated the political commitment of their membership to the issue and the financial commitment to legislators who supported them, and developed and nurtured personal relationships with key members of the House and Senate, as well as with the governor and his staff. They also effectively neutralized a state medical society that was out of touch with its membership on the prescribing issue and clearly hamstrung with competing interests. We must expect New Mexico to become a template for the rest of the states.

• District branches and state associations must recognize that New Mexico is not merely a wake-up call, it is a call to action to protect quality patient care. We are well aware that many of our DBs/SAs have fought the battle successfully for many years, and that these successful efforts have required many hours of personal involvement by talented and dedicated psychiatrists and outstanding DB/SA executive staff and paid lobbyists, working together where requested with the full staff and financial support of APA. Yet we clearly cannot take any legislature for granted, particularly those in states with large rural areas. Psychologists will hire the best professional lobbyists that money can buy and will be absolutely relentless in their pursuit of prescribing privileges. As we have learned, they will bend the facts to suit their purpose, and they will find legislators who will be receptive to their message. Psychiatrists must be particularly sensitive to the fact that state legislators have experience with similar struggles involving nurses, physician assistants, optometrists, and the like and may well not see prescriptive authority for psychologists as a threat to patient safety.

• APA must continue as it always has to seek input from local DBs/SAs about what works in their legislatures to counter psychologist-prescribing arguments. Throughout this long struggle, APA has sought always to be sensitive to the specific needs of local psychiatrists, since they are on the frontlines of the struggle and are clearly best able to determine what works—and what does not work—in their home state. This has been a sound strategy that has enabled APA to concentrate its staff and financial resources in ways that will complement, not compete with, local DB/SA efforts.

• Finally, local psychiatrists must be prepared to turn out in force as physician lobbyists and active participants in the state legislative and political process. The APA membership as a whole cannot rely on a very few psychiatrists working together with talented and dedicated DB/SA staff to do all of the work by themselves. The prescribing debate is as much about politics as it is about patient safety, and if local legislators perceive low political risk in voting for psychologist-prescribing authority, APA will surely face additional reversals at the state level. ▪

Dr. Harding is president of APA, Dr. Mirin is medical director, and Mr. Cutler is director of the Division of Government Relations.