Prescribing Bills Proliferate Despite Numerous Defeats

Psychiatrists and other physicians were able to halt progress on a record number of legislative attempts to expand psychologist prescribing in states this year. However, further attempts to expand psychologists' scope of practice are still possible this year in three states.

Legislation to permit doctoral-level psychologists to prescribe medication was introduced but stopped in nine states so far during the 2009 legislative sessions. Two more state legislatures in which bills were introduced have not yet adjourned for the year, and two more may introduce psychologist-prescribing bills before they adjourn this year. This is the largest number of states ever to propose prescribing legislation in a single year, according to APA.

APA's district branches and state psychiatric associations have coordinated efforts to halt such bills and address access-to-care problems that psychologist-prescribing advocates have used as an argument for expanding psychologists' scope of practice. Their efforts led to the defeat or lack of action on 13 bills in nine states: Arizona, Hawaii, Illinois, Mississippi, Missouri, Montana, North Dakota, Tennessee, and Texas.

Psychologist-prescribing advocates made their largest inroads in Oregon, where a bill (HB 2702) was introduced to give the state psychology board sole authority to design a training program for psychologists, grant them licensure, and regulate the practice of prescribing psychologists.

The measure was supported by two well-placed psychologist-legislators—one a Democrat and one a Republican. Their support led to the Oregon House passing the prescribing bill in May. However, the bill's opponents convinced state senators to amend the bill to replace the prescribing authority with an “interim work group”—including appointees of the state boards of medicine, psychology, and pharmacy—to develop recommendations for an accredited training program for psychologists to prescribe medications safely for people with mental illness.

The approved legislation will require the work group to evaluate the training necessary to allow a prescribing psychologist to work with special populations, develop recommendations for legislation to change current statutes to accommodate prescribing psychologists, develop recommendations for oversight of prescribing psychologists, and evaluate the training program's implementation costs.

The Oregon Senate passed the amended version, and the House agreed to the Senate version of the bill in June. The governor is expected to sign the measure. Further legislation will be needed in the next legislative session—as early as a special session called for February 2010—to create the authority for any prescribing program to get under way.

“This was the best we could hope for with the attitudes toward the issue in this legislature,” said John McCulley, executive director of the Oregon Psychiatric Association, in an interview with Psychiatric News.

Physician advocates looking to halt expansions in the scope of practice of allied health care workers have long faced strong supporters of such efforts in the Oregon legislature. The support for expanded prescribing was seen in a law passed this year that gives naturopaths prescriptive authority for synthetic drugs. Previously, naturopaths were limited to prescribing“ naturally derived medicine,” including insulin, penicillin, and morphine, for example.

The outcome of the psychologist-prescribing push is “still up in the air depending on the training regimen recommended,” McCulley said. Psychiatrists have urged the use of a training program similar to the type provided to physician assistants, which is a medically based program that is broader than just psychopharmacology instruction and more rigorous than the program supported by Oregon's psychologist-prescribing advocates. The work group recommendations are expected to be ready for legislative review in early 2010.

McCulley urged psychiatrists in other states faced with similar prescribing campaigns to establish personal contact with their state legislators and develop ongoing relationships with them as the best ways to fend off“ well-funded” psychologist-prescribing campaigns.

More Legislative Actions Possible

Although most state legislative sessions have ended for the year, psychiatrists and their allies in three states continue to face the prospect of attempts to advance psychologist-prescribing bills in 2009.

A bill (SB 180) to allow psychologist prescribing was introduced in Wisconsin, for example, but later withdrawn after its sponsor expressed concern that its training provisions were insufficient, according to Jerry Halverson, M.D., legislative chair of the Wisconsin Psychiatric Association (WPA).

Psychologist-prescribing advocates' “strategy has been to blur the lines between psychiatrists and psychologists,” Halverson told Psychiatric News. “Legislators don't know any better if they are not educated” on the consequences to patients that could arise from granting psychologists the right to prescribe psychoactive medication.

The Wisconsin legislation to authorize the state's Psychology Examining Board to establish a training program and oversee “prescribing psychologists” had been discussed by legislators for several years, but a bill had never been introduced. Although the author withdrew the bill, psychiatrists remain wary after hearing that the bill's language may be offered as an amendment to the state budget later in the year.

“Psychologists push it as an access issue, while for psychiatrists it is a safety issue,” Halverson said.

Advocates of expanding psychologists' scope of practice highlight the findings of the only research on access to mental health care in Wisconsin—a state prison study—to argue that both psychiatrists and other physicians were in short supply in the state's rural areas. What is left unsaid, according to Halverson, is that rural areas also lack psychologists. A better way to address physician shortages is to encourage more of them to move to rural areas through tuition-reimbursement programs and expand use of telepsychiatry. Several Wisconsin psychiatrists already practice telepsychiatry, but the substantial technological costs and low insurance reimbursements have kept more from undertaking such efforts, Halverson said.

The WPA may undertake a statewide study that examines the extent of access problems and ways to alleviate them.

Prescribing Bill Fails in Ohio

Similar prescribing legislation was considered in Ohio this year.

The Ohio Psychiatric Physicians Association and individual psychiatrists raised strong concerns when language to authorize a psychologist-prescribing demonstration project was included in a massive criminal-justice bill. After physicians raised concerns, the bill's supporters relented and dropped the psychologist provision. However, a freestanding bill with similar language is expected later this year.

Another prescribing bill is expected in Michigan, where the Michigan Psychiatric Society has been working with allies to educate legislators on the issue.

The Michigan and Ohio legislatures may remain in session until December 31.

The Oregon prescribing bill is posted at<www.leg.state.or.us/09reg/measpdf/hb2700.dir/hb2702.intro.pdf>. The Wisconsin bill is posted at<www.legis.state.wi.us/2009/data/SB-180.pdf>.▪