Hawaii Prescribing Bill Advances Despite Reduced Training Standards

Two similar bills that would grant Hawaiian psycholog ists prescribing privileges have advanced in the Hawaii state legislature, despite their inclusion of lower training standards than previous bills.

Bills were passed in March by the Hawaii House of Representatives (HB 1456) and Senate (SB 1004) that would establish a system to train, license and credential, and supervise psychologists to prescribe “a limited formulary of psychotropic medications for the treatment of mental illness.”

The legislation calls for training for psychologists that would include a two-year postdoctoral program of at least 450 hours of classroom instruction. Legislation approved by the Hawaii House last year had required 500 hours of classroom instruction. The bills also would require a one-year supervised practicum in which at least 100 patients are treated under the supervision of a “licensed health care provider who is experienced in the provision of psychopharmacotherapy.”

“It should be a no-brainer that you can't replace 11 years of [medical] training with 11 weeks of class and a year of supervision,” said Jeffrey Akaka, M.D., a Hawaii psychiatrist and speaker-elect of the APA Assembly.

The Hawaii Psychiatric Medical Association (HPMA) strongly opposes the measures arguing that psychologists lack comprehensive medical training, accreditation standards, and clinical supervision. District branch members have been active in lobbying against the proposal.

Both bills have passed the chambers in which they were introduced but are different enough to require further legislative approval by the opposite chamber. Among the differences are more limited geographic areas where psychologists could prescribe and stronger physician supervision in the Senate bill.

The bill's supporters, including the Hawaii Psychological Association and 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.

Psychiatrists dispute the claim that community-based mental health needs are not being met due to lack of psychiatrists. They report that there are 17.4 psychiatrists in Hawaii per 100,000 residents, significantly higher than the national average of 11.2 physicians per 100,000 residents.

CMHCs Lack Psychiatrists

The problem, according to HPMA, is that Hawaii's uninsured and underinsured residents have insufficient access to psychiatrists through the state's community mental health centers. Several of the centers have taken on the additional paperwork needed to obtain federal funding for staff psychiatrists, but most centers have chosen not to do this, Akaka said. “The main barrier is funding,” he said.

The legislative push for psychologist-prescribing privileges in Hawaii has been under way for more than 20 years, but this year's bills have moved further than previous ones. Similar legislation was approved by the House last year, but the Senate put off approval pending further study.

APA Provides Assistance

Although the governor has taken no formal position on the legislation, objections raised by the Hawaii State Department of Health suggest to psychiatrists that Gov. Linda Lingle (R) is unlikely to sign such a measure, according to opponents of the prescribing bills.

During the current legislative session, APA has again provided personnel, financial, and strategic support to Hawaii psychiatrists.

“Every year it has been hard fighting this in Hawaii, and this year is no different,” said Paula Johnson, deputy director of APA's Department of Government Relations.

A January review of data concerning psychologist prescribing by the Hawaii Legislative Reference Bureau concluded that if the legislature were to approve a psychologist-prescribing program, it should include a training model with classroom and clinical training requirements at least as rigorous as a Department of Defense (DoD) pilot psycholog ist prescript ive training program in the 1990s. The DoD program, the Psychopharmacology Demonstration Project (PDP), included at least one year of full-time classroom training at the Uniformed Services University of the Health Sciences and one year of full-time clinical training supervised by a psychiatrist. After privileges were granted, psychologists remained under the supervision of a psychiatrist for two years.

Akaka and other opponents of the prescribing bills pointed out that in many areas the proposed training courses fall far short of the DoD program, which required an 11 times longer supervised practicum and supervision by psychiatrists, not “a licensed health care provider who is experienced in psychopharmacotherapy.”

As legislators assess the prescribing bills, psychiatrists plan to emphasize alternative ways the state could address alleged shortcomings that prescribing advocates say drives their bill.

In addition to several suggested approaches to fund psychiatric services at the state's federally funded health clinics, psychiatrists have urged legislators to support the use of telepsychiatry. Eighteen states have implemented some type of telepsychiatry program to provide services to otherwise underserved areas.

In 2006 telepsychiatry became available in Hawaii through the Community Clinic of Maui and the Molokai General Hospital. Psychiatrists go to each site once each month and provide additional visits through telepsychiatry. The program also trains psychiatry residents in the use of telepsychiatry.

A growing base of trained psychiatrists may eventually expand telepsychiatry services to schools, other community health centers, and prisons, according to testimony from the Hawaii Psychiatric Medical Association.

A copy of the House bill is posted at<www.capitol.hawaii.gov/sessioncurrent/Bills/HB1456_HD1_.htm>. The Senate bill is posted at<www.capitol.hawaii.gov/sessioncurrent/Bills/SB1004_SD1_.htm>.▪