A bill just signed into law by New Mexico's governor will allow psychologists to obtain prescribing privileges. Will this provide more care to underserved populations, or will it simply put patients at risk?
Psychologists in New Mexico will be permitted to prescribe psychotropic medications under the provisions of a law signed by Gov. Gary E. Johnson at the end of this year's legislative session.
American Psychiatric Association President Richard K. Harding, M.D., immediately issued a strongly worded denunciation of the governor's action, calling the measure "the result of a cynical, economically-motivated effort by some elements of organized psychology to achieve legislated prescriptive authority without benefit of medical education and training," and pledged that the APA will continue "to oppose all efforts to jeopardize the public health by allowing persons without a medical education to practice medicine."
But Joel Yager, M.D., head of the department of psychiatry at University of New Mexico and a member of the APA Council of Medical Education and Career Development, believes Johnson approved the hotly debated legislation precisely because he agreed with arguments by psychiatrists about the risks to the public from having inadequately trained personnel prescribing drugs.
"We were able to meet with his staff for an hour, and we and the psychologists had 15 minutes with him" the day before the bill was signed, Yager told Psychiatric Times. "I think he agreed with our arguments. Therefore, he signed the bill."
He said that the governor may have feared that a measure with fewer safeguards to protect patients might be forced through the legislature next year after he leaves office, so he signed this year's measure, which had been heavily amended to require extensive training of psychologists before they are granted prescriptive authority. The bill also gives equal responsibility for oversight of the training programs and regulations to the state's Board of Medical Examiners and Board of Psychologist Examiners.
"One of our consultants said she believes the governor felt that no one in the legislature is really smart enough to understand these issues, so he took it out of [their] hands," Yager added.
As a practical matter, the training and supervision requirements of the law, which take effect July 1, may discourage psychologists from seeking state approval to prescribe. Luis A. Vargas, Ph.D., chair of the Board of Psychologist Examiners, told PT that he estimated that only about 25 of the 550 licensed psychologists in the state would seek prescribing authority.
Vargas added that the approval process is very labor-intensive. Candidates must have a degree in psychology, complete 450 classroom hours of training in neuroscience, pharmacology, psychopharmacology, physiology, pathophysiology, "appropriate and relevant physical and laboratory assessment," and clinical pharmacotherapeutics. They also must pass a national examination approved by both regulatory boards.
In addition, the psychologist must complete an 80-hour practicum in clinical assessment and pathophysiology and an additional supervised practicum of at least 400 hours, treating no fewer than 100 patients with mental disorders under the supervision of a psychiatrist or other appropriately trained physician.
Once this work is completed, the state will issue a two-year provisional certificate to the psychologist, who must establish and maintain a relationship with a physician to monitor the physical effects of patient care. At the end of the two years, the state may issue a permanent certificate. However, the psychologist must continue to receive at least 20 hours of continuing medical education a year and maintain malpractice insurance in order to retain the certification.
The malpractice issue may present an even greater hurdle than the training requirements. A spokesperson for A.M. Best Co., which rates insurance carriers and publishes what is considered to be the bible of the industry, declined to speculate on whether or not malpractice insurers would accept the risk of psychologists prescribing. The company feels the issue is too new for them to have any data on which to base a decision.
Finally, there are questions about whether or not patients will welcome prescriptions from psychologists. A strong backlash among patients developed while the bill was being considered in the legislature. One consumer posted a message in an online discussion group that said:
This is scary. Psychiatrists are bad enough at diagnosing medical roots of presenting symptoms without letting people with no medical training play doctor. This is an outrageous insult to people diagnosed with psychiatric illnesses, separating them out as a lesser class of citizens with less right to proper medical attention.
Deborah Fickling, executive director of the Mental Health Association of New Mexico, told PT she has mixed feelings about the bill's passage. "We do have a shortage of psychiatrists in the state. In that respect, it will be very beneficial, especially in rural areas, to have another avenue of prescriptive authority. But we do have concerns about the lack of medical training."
Yager agreed that there is a manpower shortage. "There has in fact been an exodus, especially among child psychiatrists," he explained. "Part of this is economic. Medicaid pays less in New Mexico than it does right across the border in Texas or Colorado. There is a need, undoubtedly, for more mental health services, particularly in the rural communities. The problem is that the distribution of psychologists is pretty close to the distribution of psychiatrists. They're mostly concentrated in the cities, not out in the rural areas."
Albuquerque, for example, has 231 of the state's 550 psychologists, with another 62 in Santa Fe and 25 in Las Cruces.
Whether or not the new prescriptive authority will result in a change in the distribution of mental health care professionals remains to be seen, and the results may not be known for many years. Before any certifications can take place, the two regulatory boards must develop a working relationship and reach agreement on a broad range of issues regarding training, testing, supervision and peer review.
"There are some real challenges to the boards with the requirements for collaboration," Vargas said. "Since the boards are concerned with the safety of the public -- and our board has three public members on it -- I'm sure we'll work in the direction of greater protection for the public. The biggest challenge is the time commitment and investment of time and resources to that end."In addition to New Mexico, four states -- Hawaii, Illinois, Tennessee and Georgia -- have psychologist prescribing legislation pending. But Lee Dixon, director of the health policy tracking service for the National Conference of State Legislatures, told PT that none of the bills has progressed past the introductory phase, and he does not believe that any action will take place in this legislative year.