Psychiatrists Help Defeat Hawaii Prescribing Bill

Despite strong support among leading legislators, a bill to allow psychologists to prescribe medications in Hawaii was derailed through the efforts of local physicians and APA. In its place, a nonbinding resolution was approved by the Hawaii Senate to direct state officials to study the issue.

The bill (HB 2589) would have authorized “trained and supervised medical psychologists working in federally qualified health centers or other licensed health clinics located in federally designated medically underserved areas” to prescribe psychotropic medications.

The Hawaii House of Representatives approved the prescribing bill in March, and it was moving quickly through the Senate until an extensive lobbying effort by the Hawaii Psychiatric Medical Association (HPMA) to educate the senators raised their concerns about the bill and resulted in the study measure.

The resolution (SCR 113) asks the Legislative Reference Bureau (LRB) to study prescriptive authority for psychologists who have “obtained the appropriate education, training, and experience to prescribe a limited formulary of psychotropic medications for the treatment of mental illness, while practicing in federally qualified health centers or licensed health clinics located in federally designated medically underserved areas or in mental health professional shortage areas.”

The Senate-passed resolution will move on to the House, which is expected to approve it. The state Senate is not expected to address the prescribing issue again this year.

APA financial and staff support were cited as critical in redirecting the prescriptive legislation into the nonbinding resolution, according to opponents of the bill. APA sent staff to Hawaii and provided extensive financial support throughout the legislative fight and during the late-session push against the prescribing bill.

“The defeat of the prescribing bill was the result of a concerted lobbying and information campaign by HPMA with key support from APA,” said Nick Meyers, director of APA's Department of Government Relations (DGR).

APA has made a long-term effort to support Hawaii and other district branches in the struggle over prescribing legislation. APA's direct staff support and information included DGR testimony against the bill and creation of a prescribing resource packet, and DGR staff called all HPMA members“ to alert them to the need for their personal intervention,” Meyers said.

“It really was a collaborative effort by APA and HPMA to defeat this bill, with APA providing a needed boost at the end to make sure that happened,” said Lydia Hemmings, HPMA executive director.

The LRB has a limited amount of research it can conduct in any year, but Hemmings said she expects legislative supporters of psychologist prescribing to push prioritization of research into mental health medication access problems.

The HPMA plans to address access problems before the start of the next legislative session in January 2007 through work with state health agencies to increase access to psychiatrists on more islands of the state.

The HPMA is also coordinating with the State of Hawaii Health Planning Development Agency to establish a family-physician medical school and residency program in part designed for master's-level graduates in psychology or social work enrolled at the School of Psychology at the University of Hawaii. Program supporters believe that these graduates would be better trained to address the substance abuse and mental health problems that predominate in rural, low-income settings where psychiatrists and mental health professionals are in short supply.

“These would still not be the specialists in mental health, but they would be better able to respond and triage and refer patients to a psychiatrist when necessary.” The graduates would be licensed physicians with a background in psychology, Hemmings said.

Return of Bill Likely

A psychologist-prescribing bill is likely to return in future legislative sessions. The 2006 version would have required psychopharmacological training from an institution of higher learning approved by the state psychology board. It also would have required a one-year supervised practicum involving 400 hours treating at least 100 patients with mental disorders. The practicum was to be supervised by a “licensed health care provider who is experienced in the provision of psychopharmacotherapy” (Psychiatric News, April 7). The prescriptive authority would have sunset in 2013 unless legislators extended it.

The bill's supporters, including the Hawaii Psychological Association and the Hawaii Primary Care Association—composed of directors of the state's community health centers—said it would benefit patients at rural community health centers who can wait from six weeks to three months to see a psychiatrist. They noted that in 2004 only six psychiatrists served in three of Hawaii's 13 community health centers, compared with 10 psychologists who served in nine of the centers.

Centers Avoid Hiring Psychiatrists

Hawaii psychiatrists and other physicians said that the access problem stems in part from the refusal of community health centers to hire psychiatrists. The claims that psychologist prescribing would provide cost-effective assistance ignores the likely need for an expensive quality-assurance system for the new prescribing group, money that would be better spent hiring a psychiatrist in every clinic, said opponents of the bill.

Hawaii psychiatrist Jeffrey Akaka, M.D., who lobbied against the bill, compared it to allowing “trained mechanics who never went to pilot school [to fly] a gassed-up Boeing 767 full of passengers.”

“It doesn't matter if the mechanic spent seven years studying how to repair airplane-cabin cooling systems or reading pilot journals. Nothing short of pilot school with thousands of hours of training under the supervision of pilots gets you a commercial pilot's license to fly human beings,” he said

In a letter to Hawaii state senators, the American Osteopathic Association wrote that “effective use of medications to treat brain disorders requires medical training with a thorough understanding of physiology, chemistry, drug interactions, and medical problems that may masquerade as or cause brain malfunctions.”

House members sought to limit potential dangers of psychologist prescribing by amending the bill to limit allowed medications under an “exclusionary formulary” to antidepressants, benzodiazepines, and possibly Ritalin and barbiturates.

The Senate's Committee on Health approved the bill, but the Committee on Commerce, Consumer Protection, and Housing took no action, stalling its progress.

The HPMA has opposed psychologist prescribing for more than 20 years. It has fought 25 psychology prescribing bills in that time.

A copy of the nonbinding resolution is posted at<www.capitol.hawaii.gov/site1/docs/getstatus.asp?qu=SCR113&showstatus=on&showtext=on&showcommrpt=on&press1=docs>.▪