In February both the New Mexico House and Senate voted by wide margins to expand psychologists’ scope of practice to allow them to write prescriptions for psychoactive drugs without requiring that they first attend medical school.
At press time, the state legislature had sent the bill to the governor. Under New Mexico law, the governor had 20 days to either sign the bill into law or allow it to die without his signature.
While New Mexico Gov. Gary Johnson (R) had not by press time in mid-February said whether he would sign the bill, the day before the legislative session began in mid-January, he included it in his own list of bills he wanted the legislature to act on during the session, known as a "call list." That action was seen by many as indicating he was prepared to sign it into law. If he signs the bill, it will take effect on July 1.
APA and the Psychiatric Medical Association of New Mexico (PMANM) waged an intense lobbying and education campaign, but pressure from psychologists and powerful, sympathetic lawmakers carried the day. In an all-member update sent the day after the February 13 passage of the bill in the New Mexico Senate, APA President Richard Harding, M.D., and President-Elect Paul Appelbaum, M.D., emphasized that APA "is by no means finished fighting. . . . Our immediate task is to convey to Gov. Johnson the costs—in patient safety and health care dollars—that will result from implementation of such radical legislation."
A similar version of the legislation came within minutes of passing during the state legislature’s previous session (Psychiatric News, April 20, 2001). It was derailed, only temporarily it turns out, when time ran out on the legislative calendar forcing lawmakers to adjourn before they could vote on prescribing privileges for psychologists.
"This year, all through the fall and into the end of the year, the governor told us he was not going to put it on his call list," Allen Haynes, M.D., president of the New Mexico Medical Society (NMMS), told Psychiatric News. "After the first of the year, he said he was thinking about it. Then the day before the session began in January, he called a few psychiatrists into his office along with a few clinical psychologists, and they debated it right there in front of him." The outcome of the debate, Haynes said, was obvious.
Haynes told Psychiatric News that NMMS officers were then faced with a bill from the previous year that included "very minimal educational standards" and no supervision or oversight from a medical board, "and we had to try to look for something that would improve the odds for patient safety."
NMMS representatives worked with representatives of the New Mexico Board of Psychologist Examiners to amend the bill, strengthening the educational requirements, adding joint regulatory oversight of the New Mexico Board of Medical Examiners with the psychology board, and adding a "conditional prescribing" period.
In a February 7 letter to the governor after the House passed its version of the bill, Harding emphasized how psychotropic drugs "are among the most potentially dangerous drugs for patients" and how the interactions of these drugs with each other and with other types of medication "can result in a deadly combination."
Deciding on the correct medications, including combinations and dosages of each, is challenging for all physicians, Harding stated. To give psychologists, who have little or no medical training, the right to prescribe these medicines will not remedy any of the problems psychologists allege exist in New Mexico.
"On the contrary," he said, "it would be an ill-conceived invitation to more and likely unanticipated difficulties for citizens most in need of safe, appropriate medical care."
Haynes agreed, telling Psychiatric News, "I think that everyone realizes that the ideal would be to get the full training—the equivalent of what you’d have for a physician," but, he continued, in an impoverished state like New Mexico, which lacks both health care personnel and resources, that was not likely to happen.
Harding noted as well that lawmakers in 13 other states have been confronted with the same arguments in favor of psychologist prescribing and, after examining the validity of the arguments, have all rejected such proposals.
Gale Thaler, M.D., president of the New Mexico district branch, told Psychiatric News that its members "lobbied hard to educate as many legislators as possible about the problems with the bill. . . . Our main concern is and has been the safety of our patients." She added that "it is a bad precedent" for lawmakers to grant prescribing privileges to psychologists, who have never been to medical school or even received pharmacy training.
She stressed that she and her colleagues strongly disagree with bill proponents who argue "that it is cheaper to have psychologists prescribing medications than psychiatrists. Without medical training they are more likely to prescribe unnecessary medications, and their reimbursement rate is not much less than ours."
As for the psychologists’ contention that they will plug the alleged gaps in rural mental health care, Thaler maintained, "Studies have shown that they don’t relocate to rural areas any more than psychiatrists do."
Haynes agreed, saying that there are no more clinical psychologists available in rural areas than there are psychiatrists. But, Haynes pointed out, from the legislature’s point of view, the state had already granted independent prescribing privileges to nurse practitioners, physicians assistants, and clinical pharmacists. Thus, the extension to clinical psychologists was not difficult for legislators to endorse.
The final bill requires that doctorate-level psychologists who want prescribing privileges must attend 450 hours of classroom training in pharmacology, neuroscience, physiology, pathophysiology, and clinical pharmacotherapeutics.
These training courses will require approval by both the New Mexico Board of Medical Examiners and the New Mexico Board of Psychologist Examiners, according to the bill.
Once they complete this classroom training, psychologists will have to spend 400 hours treating people with mental disorders under the supervision of a psychiatrist or other physician. Each psychologist-prescribing candidate must treat at least 100 people.
Once these requirements are fulfilled, psychologists can then apply for a "conditional prescription certificate." If granted, this would allow them to begin a two-year period in which they may prescribe psychoactive medications, defined as "a controlled substance or dangerous drug" requiring a prescription, administered for the treatment of mental disorders, and "listed as a psychotherapeutic agent in Drug Facts and Comparisons or in the American Hospital Formulary Service."
For the first two years, all prescriptions must be written under the supervision of a licensed physician whose name must be reported to the state medical and psychology boards overseeing the program. There is no requirement that the supervising physician be a psychiatrist. In addition, there is no limit on the number of patients that a psychologist can treat during the conditional period or on the number of psychologists that one physician can supervise.
Once the board is satisfied that a psychologist has successfully completed the two-year conditional period, it will issue a prescription certificate permitting the psychologist to prescribe without a physician’s oversight with the proviso that the psychologist must participate in 20 hours of continuing education each year. The physician who supervised the conditional period must certify that the prescribing psychologist "successfully completed two years of prescribing psychotropic medications."
The bill mandates that the psychologist with prescribing privileges "shall maintain an ongoing collaborative relationship with the health care practitioner who oversees the patient’s general medical care to ensure that necessary medical examinations are conducted, the psychotropic medication is appropriate for the patient’s medical condition, and significant changes in the patient’s medical or psychological condition are discussed."
The AMA has also conveyed its distress over this legislation to Gov. Johnson. In a February 11 letter the AMA’s newly appointed executive vice president, Michael Maves, M.D., pointed out, "Unlike physicians and other allied medical professionals with limited prescriptive privileges, psychologists have no background in medicine. Adding a course in pharmacology to the requirements for a degree in psychology does not fill this void."
Maves reiterated to the governor the AMA’s "steadfast position that psychologists lack the appropriate training and education to prescribe medications under any circumstances."
The text of the bill, "Prescriptive Authority to Psychologists" (HB 170), is posted on the Web at http://legis.state.nm.us/Sessions/02%20Regular/bills/house/HB0170.html. ▪