Continuing Progress at the State Level

On April 3, 2017, Idaho became the fifth state in the nation to allow prescriptive authority to psychologists. After three years of work by the Idaho Psychological Association, the legislation passed both houses without opposition and with only two nay votes. How did this happen? Here are a few of the factors that may have contributed.

• Psychiatrists negotiated with us. The shortage of prescribers in our state is the worst in the nation and physicians and legislators are aware that the situation is desperate in some rural areas. The physician chair of the House Health and Welfare committee became convinced by repeated meetings with our soft-spoken lobbyist that the training was rigorous. We learned that the rest of the medical association was leaning our way. The main concern of our colleagues in psychiatry was that the training be at least equivalent to that of an advanced practice psychiatric nurse practitioner (NP). They brought in an experienced NP to vet our training and the language of equivalence is written into the bill.
• One of our state universities agreed to put together a two year full-time masters in psychopharmacology program taught through the pharmacy program. We know that the training offered elsewhere is excellent but we couldn’t convince our MD colleagues that it was equivalent to a full-time program. A full-time training where they could have input tipped the scales for them.
• We strongly believe collaboration is best for both patients and practitioners. We have written it into the law and have an advisory committee of psychologists, physicians and a pharmacist to assist our Board of Psychology on RxP issues. To move from a conditional certificate to a full certificate, two years of supervised prescribing past the masters is required. To work with children or the elderly, one of those years must be in that specialty.
• Our state association was involved and we received unflagging backing from our members, our Executive Director Deb Katz, our association President Page Haviland, and our lobbyist. A link to our full bill is: https://legislature.idaho.gov/wp-content/uploads/sessioninfo/2017/legislation/H0212.pdf
• We also have been asked why the most conservative state in the union would pass such a bill. Our answer is that the legislation is completely non-partisan. It appeals to liberals, conservatives, even libertarians. The core idea is that once we demonstrate need and can vouch for rigorous training, it comes down to free-market issues. Since we can prove that psychologists can prescribe safely, we then ask only that the playing field be level and that we be allowed to prove our worth. We request no money from the state nor do we ask for any guild protection. If the market works as it should, in a few years we should be able to demonstrate more practitioners, more widespread service, a movement into rural areas and a better fee structure.
• One unanticipated outcome: Three years ago we continuously were asked to define the differences between a psychologist, a psychiatrist and a counselor. We are not asked that so much anymore. Psychology appears to have established itself as a group of highly trained professionals looked upon with favor by our legislators. There are only a few hundred of us in this very rural state. It is deeply satisfying to see the profession become known and appreciated [Susan Farber, former IPA President].”

An historical note—one of the initial RxP training programs involved the School of Pharmacy at the University of Georgia and Georgia State University faculty, pursuant to the vision of Dr. Linda Campbell, former member of the APA Board of Directors, and Cal VanderPlate. More recently, Dr. Judi Steinman at the University of Hawaii at Hilo College of Pharmacy provided RxP training for those in Hawaii and the Pacific Basin. In addition, Drs. Morgan Sammons and Robin Henderson report that the State of Oregon House of Representatives passed their RxP legislation unanimously this spring. Interdisciplinary collaboration is the future for psychology and for our nation’s overall health care system.

Developments at the Federal Level

During a recent Give an Hour event, hosted by President Barbara Van Dahlen, USUHS psychology graduate student Elizabeth Belleau met VA Secretary David Shulkin and Harold Kudler, chief consultant for mental health service. Among other issues, they discussed the exciting potential for active duty mental health graduate students to obtain supervised clinical experience within the VA—especially since these future colleagues personally appreciate the nuances of military culture and will themselves eventually become VA beneficiaries. HRSA reports that 30% of the new hires by Federally Qualified Community Health Centers (FQHCs) over the past two years have been Veterans. Dr. Heather O’Beirne Kelly, APA’s Director of Military and Veterans Health Policy—a position created earlier this year by Interim CEO Cynthia Belar and President Tony Puente—recently had the opportunity to present testimony before the U.S. House Appropriations subcommittee with jurisdiction over the VA:

• The Department of Veterans Affairs (VA) is the largest single employer of psychologists, who work both as research scientists and clinicians committed to improving the lives of our nation’s Veterans. As the largest provider of training for psychologists, the VA also plays a vital role in ensuring that the mental health workforce is equipped to provide culturally competent and integrated mental health services to Veterans and their families.
• VA psychologists play a dual role in providing care for Veterans and conducting research in all areas of health, including high-priority areas particularly relevant to Veterans, such as: mental health and suicide prevention, traumatic brain injury (TBI), substance abuse, aging-related disorders and physical and psychosocial rehabilitation. VA psychologists are leaders in providing effective diagnosis and treatment for all mental health, substance use and behavioral health issues. In addition, VA psychologists often receive specialty training in rehabilitation psychology and/or neuropsychology, which helps to improve assessment, treatment, and research on the many conditions affecting Veterans, including: post-traumatic stress disorder (PTSD), burns, amputation, blindness, spinal cord injuries and polytrauma. Equally important are the profoundly positive impacts of psychological interventions on the care of Veterans suffering from chronic illnesses such as cancer, cardiovascular disease, HIV and chronic pain.”

Every day 20 Veterans commit suicide which is unquestionably a major public health tragedy that calls for innovative interventions. Secretary Shulkin has entered into a partnership with the Department of Health and Human Services to allow the assignment of U.S. Public Health Commissioned Corps members to provide direct patient care to Veterans in VA hospitals and clinics in underserved communities. During her testimony, Heather raised two related issues. She discussed psychology’s historical leadership role in developing and providing telepsychological care (within the VA and the Department of Defense) and she recommended as an innovative strategy for addressing suicides by Veterans through enhancing access, continuity, and integration of care: “Granting specially-trained psychologists prescriptive authority analogous to that granted by the Department of Defense for almost 20 years, which will alleviate mental healthcare access issues.” After her testimony, one of the subcommittee members followed her out of the hearing room and stated that “I want that pilot program.” Will an already prescribing USPHS psychologist be assigned?

A Vision for the Future

In his prior position as VA Under Secretary for Health, Secretary Shulkin was instrumental in providing full practice authority for VA advanced practice registered nurses (APRNs) (with the exception of nurse anesthetists) as long as they were working within the scope of their VA employment. APRNs now can provide care, regardless of historical state or local legal restrictions, without the clinical oversight of a physician. This includes taking comprehensive histories, providing physical examinations; and diagnosing, treating, and managing patients with acute and chronic illnesses and diseases. It also allows APRNs to prescribe medications and make appropriate referrals.

Under the Secretary’s leadership, in April of this year the VA announced its top five priorities which included Suicide Prevention—Getting to Zero. The number two priority was Improving Timeliness, highlighting the potential contributions of telehealth. The Department reported having established 10 Tele-Mental health hubs and 8 Tele-Primary Care hubs. Not surprisingly, 45% of telehealth services are for rural veterans. Overall, there were 2.14 million episodes of telehealth care provided to 677,000 Veterans, of which 336,000 were TeleMental health visits. Under the leadership of Drs. Robert Zeiss and now Ken Jones, the VA Office of Academic Affiliations has been providing significant support for psychology post-doctoral training initiatives. The VA has long fostered internship level training in psychology, with over 675 positions nationally located in 49 states plus Puerto Rico and the District of Columbia. Post-doctoral training did not truly take off until the 2000-2001 academic year, when the number of funded residency positions expanded from five to 38. These numbers have grown steadily, with a particularly large increase in 2008-2009, when the positions increased from 117 to 204 in just one year. Currently, that number stands at approximately 440 annually—covering a wide range of clinical areas, as Heather noted in her testimony. Psychology is well positioned to capitalize upon, and provide leadership for, the exciting potential for innovation which the proponents of telehealth envision.

Dr. Art Kellermann, Dean of the School of Medicine at USUHS and a member of the National Academy of Medicine (formerly the Institute of Medicine), has similarly called for Embracing Telehealth while Rethinking the U.S.’s Military Health System:

“In deployed settings, the military health system uses telehealth to support health care providers working in small forward operating bases and on ships at sea. Global teleconferencing allows trauma experts across 12 time zones to regularly meet, discuss complex cases, and identify opportunities to improve. Despite its success with telehealth overseas, the military health system was slow to adopt it at home due to stringent information security requirements and budgetary constraints. Section 718 of the NDAA [National Defense Authorization Act] directs the military health system to rapidly expand the use of telehealth in its clinical operations.”

Licensure mobility is critical to the effective use of telehealth services and psychology has been well served by the vision of Dr. Steve DeMers, CEO of the Association of State and Provincial Psychology Boards (ASPPB) in establishing their Interjurisdictional Compact (PSYPACT). Drs. Linda Campbell and Fred Millan served as co-chair of the joint APA/ASPPB/APAIT Task Force for Telepsychology Guidelines.

“And those who look only to the past or present are certain to miss the future.”

Aloha.

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Pat DeLeon, Ph.D.