Hawaiis Prescriptive Authority Quest A Proactive Agenda for the
Future: During last years session of the Hawaii legislature, the Hawaii
Psychological Association (HPA), under the leadership of Jill
Oliveira-Berry and Robin Miyamoto, was successful in having the legislature
establish an Interim Task Force to explore the feasibility of psychologists
prescribing. HPAs two legislative champions co-chaired the group. This
year, the Hawaii House of Representatives passed HR 2589, which would allow
appropriately trained psychologists practicing within federally qualified
community health centers and in medically underserved areas to
prescribe. The legislation was supported by each of the 13 community
health center medical directors; HMSA, the Blue Cross/Blue Shield plan of
Hawaii; and the Hawaii Nurses Association. HPAs quest became the topic
of radio debates and newspaper articles (including on the editorial page),
where it received the enthusiastic endorsement of the Hawaii Primary Care
Association. The Senate Health Committee recommended the adoption of the
House proposal and ultimately both legislative bodies agreed upon a
compromise under which the States Legislative Reference Bureau was
directed to study the issue and report back their findings to the
legislature for consideration in the 2007 legislative session. Included in
this report is to be a review of the Department of Defense RxP
experiences. In my judgment, HPA made considerable progress, particularly
in educating the broader community regarding the clinical expertise of our
profession, as well as truly engaging their membership in determining their
own destiny. An insiders view of the process Ray Folen:
Having previously passed through the House Health Committee, this
prescriptive authority bill was recognized as having some legs on it. It
is an access to care bill for the underserved and uninsured people of our
State seeking care in community health centers (CHCs). Psychologists, well
represented in these areas, are in most cases unable to get the psychiatric
support needed. Working collaboratively with primary care physicians has
proven to be a successful alternative. They trust the medical
psychologists psychopharmacology skills and want them to operate more
independently.
Psychology was well represented at the hearing. Robin and Jill,
co-chairs of the HPA RxP Task Force, delivered exceptionally persuasive
testimony, as did other HPA board members, doctoral-level psychology
trainees, CHC staff, CHC medical directors, the APA Practice Directorate,
the Louisiana Academy of Medical Psychologists, DoD prescribing
psychologists, social workers, and community-based organizations such as
the Hawaii Primary Care Association. A number of psychologists working in
CHCs testified and made compelling statements, but clearly the most
powerful message they communicated to the legislature was their very
presence in the rural and underserved communities.
Organized psychiatry, also realizing that the RxP bill had
legs, was particularly unkind at the hearing. Its amazing that some of
our legislators still find their self-serving arguments persuasive. Does
it matter that so few of them provide care to the underserved? Does it
matter that they have not initiated any meaningful efforts to address the
mental health problems of this population? Thankfully, some of our
legislators continue to champion our efforts to increase access to care,
despite the opposition.
Psychiatry fervently brought out the same tired arguments. They
reported that the number of Hawaii psychiatrists per capita is greater than
in most other states, but failed to mention that very few psychiatrists
will treat Medicaid, welfare or uninsured patients. Indeed, even in rural
Honolulu, it is near impossible for a welfare patient to get an appointment
with a psychiatrist. Psychiatry did their best to scare the legislature by
conjuring up visions of psychologists killing patients and, of course,
failed to mention evidence from the DoD reports, the GAO reports and the
Louisiana psychologists that suggested a far more positive
reality. Thankfully, several psychologists who testified late in the
session had the opportunity to correct these distortions.
More egregious were the outright lies and misrepresentations. A
state psychiatrist, attempting to minimize the severe lack of psychiatric
services, testified that every square mile of the State is covered by
psychiatrists in the Adult Mental Health Division, but forgot to mention
that the Division provides services only to the SMI population. After
Robin spoke eloquently and in detail about the additional training
prescribing psychologists receive, a psychiatrist told the legislators it
was an 11 week training program. After Robin provided a map showing
where psychologists were providing services in Medically Underserved Areas,
a psychiatrist testified that psychologists dont work in underserved
areas. We were also amused by the creativity of the testimony: one
psychiatrist said we dont read medical journals and therefore shouldnt
prescribe; another psychiatrist showed a graph with two years of RxP
training presented as two hours. When pressed by the legislators to define
the minimum training necessary to prescribe, the psychiatrists reluctantly
suggested the training required for licensure as an APRN. When asked what
that training entailed, they didnt have a clue! A Professor of Psychiatry
called both psychology and the legislature immoral for promoting the bill.
One of the more disturbing moments at the hearing was when a
noticeably medicated patient read testimony that had been prepared for her
in opposition to RxP. The patient stumbled over words she could not
pronounce and obviously had not seen before, parroting arguments that she
didnt appear to understand.
Over the past two decades we have placed many psychologists in
underserved areas of the State; psychologists are in 80% of all CHCs and
the goal is to have 100% by the end of 2006. We have articulated a
financial model that will allow CHCs to easily recoup the costs of hiring
medical psychologists. We have a school (Argosy University/Honolulu) with
a primary mission of training psychologists to work with diverse and
marginalized populations. We have a post-doctoral psychopharmacology
training program in place. On the other hand, psychiatry is placing only
3% of its graduates in underserved areas. It cant fill psychiatry
residency positions without recruiting 40% from foreign
countries. Psychiatrys goal at the hearing was to install fear and
confusion in the legislature. In the past, this strategy was
effective. It appears, however, that the reasoned word is gaining
ascendancy. And, we would add, that HPAs membership is fully
engaged. Aloha,
Pat DeLeon, former APA President Division 29 May, 2006
