Hawaii Psychiatrists Help Block Psychologist Prescribing Bill

A coalition led by the Hawaii Psychiatric Medical Association (HPMA) was able to defeat a bill allowing psychologists to prescribe medications when the Hawaii H Aouse of Representatives sent the bill back to committee on May 3. The move effectively ended prospects of passage this year.

Opponents of the bill—including APA, the HPMA, the AMA, and the Hawaii Medical Society—argued that granting prescriptive authority to psychologists would jeopardize the provision of safe, high-quality care for Hawaii’s patients.

“We’re relieved that it’s over, but we know we have more work ahead of us because the bill will come back and January is right around the corner,” said Julienne Aulwes, M.D., of Tripler Army Medical Center and president of the HPMA, referring to the month when the legislature comes back into session.

Teamwork in Hawaii and coordination with APA headquarters were keys to the legislative victory.

“We put together a great team of other medical organizations, consumers, and members of the HPMA to foster relationships with legislators,” said Area 7 Trustee Jeffrey Akaka, M.D., of Honolulu, the HPMA’s legislative representative. “Nobody can do this alone.”

Those relationships were cultivated over many years, as members of the HPMA presented lawmakers with carefully researched, published data on which to base their case that medical training is required to properly diagnose, treat, and monitor patients given psychotropic medications.

Mental health consumers also contributed to the outcome, expressing their concerns to legislators about the potential for substandard care.

The first psychologist prescribing bill in the United States was introduced in Hawaii in 1985. Since then, APA and HPMA have repeatedly emphasized to lawmakers that such legislation would result in “unsafe prescribing” because the required training was insufficient compared to years of medical school and postgraduate psychiatric residency.

As of 2014, 28 states and two territories had considered bills that would authorize prescribing by psychologists. New Mexico passed a prescribing law in 2002, and Louisiana did so in 2004. Illinois passed its law in 2014, but regulators there are still working out the details of the training requirements so the law has not been implemented yet.

APA has always opposed prescribing privileges for psychologists, primarily citing safety concerns arising from the complex effects of psychotropic medications on the body.

“These bills would put patients at risk, allowing people with only a crash course in medicine to dispense powerful psychotropic medications,” according to an APA document on the issue. Several lawsuits have been filed in Louisiana alleging harm from drugs prescribed by “medical psychologists,” as they are termed in that state.

Another concern is that data from New Mexico and Louisiana reveal that some psychologists have gone beyond prescribing for psychiatric disorders and written prescriptions for cardiovascular medications, muscle relaxants, and anticholesterol drugs.

One argument for granting prescribing privileges to psychologists is that it would expand care options in underserved areas, especially rural counties. However, so far, prescribing psychologists in New Mexico are still concentrated in the metropolitan areas around Las Cruces, Albuquerque, and Santa Fe, just like most other medical and mental health professionals. In Louisiana, the largest concentrations are in and around two cities, the state capitol of Baton Rouge and Lafayette, the state’s fourth largest city. Fifty of Louisiana’s 64 parishes (counties) have no prescribing psychologists.

To address the limited access to mental health care across Hawaii’s far-flung islands, the HPMA is backing a number of initiatives in the state, such as expanding the use of telepsychiatry and transforming clinical practice with increased professional training,

The HPMA is also working to share psychiatric expertise with other physicians in Hawaii.

“The ECHO Hawaii Project organizes weekly video teleconferences with rural primary care providers to provide informal case discussions about difficult cases,” said Aulwes. She participates in the program and seeks to recruit more of her colleagues to do the same. ■