Report Title:

Psychologists; Prescriptive Authority

Description:

Authorizes qualified psychologists practicing at federally qualified health centers or health clinics in medically underserved areas to prescribe a limited formulary of psychotropic medications. Establishes a formulary advisory committee to establish and revise the formulary. (HB2589 HD2)

HOUSE OF REPRESENTATIVES

H.B. NO.

2589

TWENTY-THIRD LEGISLATURE, 2006

H.D. 2

STATE OF HAWAII

 


 

A BILL FOR AN ACT

 

relating to psychologists.

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

SECTION 1. The legislature finds that in the low-income and rural areas of the state there is an urgent need for mental health care that is provided by persons with prescriptive authority. There are not enough prescribing mental health care providers available in the state to serve Hawaii's needs. Clinical psychologists do not possess prescriptive authority, however, if not for the federally qualified health centers and the services provided by clinical psychologists working at those centers, persons living in low-income or rural areas would receive little or no mental health services.

At present, only three federally qualified health centers have psychiatrists on staff. In contrast, 2004 data from the Hawaii Primary Care Association indicates that there are 9.71 psychologists employed in full or part-time positions to provide mental/behavioral health service in nine of the thirteen federally qualified health centers.

Native Hawaiians often account for a large proportion of the population living in rural and underserved areas. Since 1988, federal law has recognized the extraordinarily poor health of native Hawaiians who have the highest rate of untreated medical and psychological concerns, and higher rates than other indigenous and minority individuals in the United States. Recent concerns for this population include the crystal methamphetamine epidemic and related substance abuse issues that are occurring in communities such as Waianae and Waimanalo, and on Molokai and the Big Island. This epidemic, coupled with the economic and cultural distress of the native Hawaiian population, has created unprecedented demands for services from an already overtaxed mental health system.

The legislature finds that this urgent need for mental health care in rural and underserved areas in Hawaii may be met by providing limited prescriptive authority to psychologists once they have obtained the appropriate education, training, and experience. This limited prescriptive authority would be given only to psychologists who will provide care to Hawaii's communities in need, at federally qualified health centers or other licensed health clinics located in federally designated medically underserved areas. Patients of federally qualified health centers include the uninsured, the poor, native Hawaiian, other Pacific Islanders, and the homeless.

The authorization of limited prescriptive authority by the legislature is not without precedent. The legislature has previously provided limited prescriptive privileges to advanced nurse practitioners, optometrists, dentists, podiatrists, osteopaths, and physician assistants.

In addition, psychologists with appropriate credentials have been allowed to prescribe medications to active duty military personnel and their families in federal facilities and the Indian Health Service for years, and Louisiana and New Mexico recently adopted legislation authorizing prescriptive authority for psychologists without regard to the service setting.

Further, since 2000, fourteen psychologists, all residents of Hawaii, have received psychopharmacological training through the Tripler Army Medical Center, Native Hawaiian Psychology Training Program. These psychologists actively collaborate with primary care physicians to provide combined therapy and psychopharmacological care to a medically underserved patient population at seven federally qualified health centers at Bay Clinic, Hana, Molokai, Kauai, Waianae, Kalihi-Palama, and Waimanalo, and two native Hawaiian health care systems clinics located in federally designated medically underserved areas on Kauai and Molokai.

Under this program, thousands of native Hawaiians and other ethnic minorities, many with significant mental and behavioral health care problems, have received the necessary combined therapy and psychopharmacological care that was sorely lacking in their communities. For example, psychologists at the Waianae Coast Comprehensive Health Center completed approximately three thousand eight hundred forty patient encounters in 2004; seventy per cent of these patients received necessary psychotropic medication for the treatment of mental illness.

The American Psychological Association has developed a model curriculum for the education and training of prescribing psychologists. Independent evaluations of the Department of Defense Psychopharmacological Demonstration Project by the United States General Accounting Office and the American College of Neuropsychopharmacology have found that appropriately trained medical psychologists prescribe safely and effectively.

The legislature finds that providing timely access to accurate diagnosis and effective treatment of emotional and behavioral disorders would help to fulfil the State’s responsibilities to Hawaii’s "Felix" children and needy adults in underserved rural areas. In addition, timely, efficient, and cost-effective treatment of mental illnesses in federally qualified health centers would not only improve the quality of life for persons living in low-income and rural communities, but could also avoid the significantly greater social, economic, and medical costs of non-treatment for these underserved populations.

The purpose of this Act is to authorize psychologists who have obtained the appropriate education, training, and experience, to prescribe a limited formulary of psychotropic medications for the treatment of mental illness while practicing in federally qualified health centers or licensed health clinics located in federally designated medically underserved areas or in mental health professional shortage areas.

SECTION 2. Chapter 465, Hawaii Revised Statutes, is amended by adding a new part to be appropriately designated and to read as follows:

"Part  . PRESCRIPTION CERTIFICATION

§465-A Definitions. As used in this part, unless the context otherwise requires:

"Collaborative relationship" means a cooperative working relationship between a psychologist holding a conditional prescription certificate and a doctor of medicine in the provision of patient care, including diagnosis and cooperation in the management and delivery of physical and mental health care.

"Narcotics" mean natural and synthetic opioid analgesics, and their derivatives used to relieve pain.

"Prescribing mental health professional" means a medically trained and licensed physician or psychiatrist.

"Psychotropic medication" means only those agents related to the diagnosis and treatment of mental and emotional disorders, including controlled substances other than narcotics.

§465-B Conditional prescription certificate; application. (a) A psychologist may apply to the board for a conditional prescription certificate. The application shall be made on a form approved by the board, and be accompanied by evidence satisfactory to the board, that the applicant:

(1) Holds a current license in good standing to practice psychology in the State of Hawaii;

(2) Has successfully completed a planned sequence of psychopharmacological training from an institution of higher learning. The training shall be consistent with the American Psychological Association's Recommended Postdoctoral Training in Psychopharmacology for Prescription Privileges. The training shall include a minimum of four hundred and fifty hours of didactic classroom instruction in at least the following core areas of instruction:

(A) Anatomy and physiology;

(B) Biochemistry;

(C) Neurosciences (neuroanatomy, neurochemistry, neurophysiology);

(D) Pharmacology and clinical pharmacology;

(E) Psychopharmacology;

(F) Pathophysiology;

(G) Health assessment, including relevant physical and laboratory assessment; and

(H) Clinical pharmacotherapeutics;

(3) Has completed a supervised practicum of at least one year involving four hundred hours treating a diverse population of no fewer than one hundred patients with mental disorders. A licensed health care provider who is experienced in the provision of psychopharmacotherapy shall supervise the practicum. The practicum shall include at least two hours of weekly supervision and the supervisor shall not be in the employ of the person being directed or supervised;

(4) Has passed a national proficiency examination approved by the board that tests the applicant's knowledge of pharmacology in the diagnosis, care, and treatment of mental disorders; provided that the board shall establish what constitutes a passing score and the number of times an applicant may retake the examination within a specific time period;

(5) Applies for a Federal Drug Enforcement license for limited use as restricted by state law;

(6) Has malpractice insurance in place sufficient to satisfy requirements adopted by the board by rule, that will cover the applicant during the period the conditional prescription certificate is in effect;

(7) Is employed or contracted by, and will practice the prescribing authority at:

(A) A federally qualified health center established under Title 42 United States Code Section 1396;

(B) A licensed health clinic located in a federally designated medically underserved area as defined by Title 42 Code of Federal Regulations Part 62; or

(C) A licensed health clinic located in a mental health professional shortage area;

and

(8) Meets all other requirements, as determined by rule by the board, for obtaining a conditional prescription certificate.

(b) The board shall issue a conditional prescription certificate if it finds that the applicant has met the requirements of subsection (a).

§465-C Conditional prescription certificate; powers, duties, and responsibilities. (a) A psychologist holding a conditional prescription certificate shall:

(1) Continue to hold a current license to practice psychology in Hawaii;

(2) Continue to maintain malpractice insurance;

(3) Inform the board of:

(A) The name of the prescribing mental health professional under whose supervision the psychologist will prescribe psychotropic medication and shall promptly inform the board of any change of the prescribing mental health professional; and

(B) The name of the federally qualified health center, licensed health clinic located in a federally designated medically underserved area, or the licensed health clinic located in a mental health professional shortage area, in which the psychologist practices; and

(4) When authorized to prescribe controlled substances, file with the board, in a timely manner, all individual federal Drug Enforcement Agency registrations and numbers.

(b) A psychologist holding a conditional prescription certificate:

(1) May administer and prescribe psychotropic medication that is not prohibited by the exclusionary formulary list established pursuant to section 465-F;

(2) May order and review laboratory tests in conjunction with the prescription for the treatment of mental disorders;

(3) Shall not delegate prescriptive authority to any other person. Records of all prescriptions shall be maintained in the prescribing psychologist's patient records; and

(4) When prescribing psychotropic medication for a patient, shall maintain an ongoing collaborative relationship with the doctor of medicine who oversees the patient's general medical care to ensure that:

(A) Necessary medical examinations are conducted;

(B) The psychotropic medication is appropriate for the patient's medical condition; and

(C) Significant changes in the patient's medical or psychological condition are discussed.

(c) A prescription written by a psychologist with a conditional prescription certificate shall:

(1) Comply with applicable state and federal laws;

(2) Be identified as issued by the psychologist as "psychologist certified to prescribe"; and

(3) Include the psychologist's board number or the identification number assigned by the department of commerce and consumer affairs.

§465-D Prescription certificate. (a) A psychologist may apply to the board for a prescription certificate. The application shall be made on a form approved by the board and be accompanied by evidence satisfactory to the board that the applicant:

(1) Has been issued a conditional prescription certificate and has successfully completed two years of prescribing psychotropic medication as certified by the supervising prescribing mental health professional;

(2) Has successfully undergone a process of independent peer review approved by the board and the Hawaii board of medical examiners;

(3) Holds a current license to practice psychology in the State of Hawaii;

(4) Has malpractice insurance in place, sufficient to satisfy requirements adopted by the board by rule, which will cover the applicant as a prescribing psychologist; and

(5) Meets all other requirements, as determined by rule by the board, for obtaining a prescription certificate.

(b) The board shall issue a prescription certificate if it finds that the applicant has met the requirements of subsection (a).

(c) A psychologist with a prescription certificate may prescribe psychotropic medication if the psychologist:

(1) Continues to hold a current license to practice psychology in Hawaii and maintain malpractice insurance; and

(2) Annually satisfies the continuing education requirements for prescribing psychologists, as set by the board by rule, which shall be no fewer than twenty hours each year, at least half of which shall be in pharmacology or psychopharmacology.

(d) A psychologist holding a prescription certificate may:

(1) Administer and prescribe psychotropic medication that is not prohibited by the exclusionary formulary list established pursuant to section 465-F; and

(2) Order and review laboratory tests in conjunction with the prescription for the treatment of mental disorders.

§465-E Exclusionary formulary list. The exclusionary formulary list shall specify the types of medications that psychologists holding either a conditional prescription certificate or a prescription certificate shall be prohibited from prescribing or administering. The exclusionary formulary list shall include the following types of medications:

(1) All narcotics;

(2) All monoamine oxidase inhibitors (MAOI's);

(3) All antipsychotic medications;

(4) All amphetamines;

(5) All non-psychotropic medications;

(6) Lithium; and

(7) Serzone.

§465-F Formulary advisory committee; establishment, composition, and duties. (a) There is established a formulary advisory committee within the department of health for administrative purposes. The formulary advisory committee shall:

(1) Establish the recommended exclusionary formulary list; and

(2) Review the exclusionary formulary list adopted by the board of psychology no less than once per quarter and as frequently as it deems necessary, and recommend amendments to the exclusionary formulary list subject to the limitations set forth in section 465-E.

The board of psychology shall by rule pursuant to chapter 91 adopt the recommended exclusionary formulary list established by the formulary advisory committee and any recommended amendments to the list.

(b) The formulary advisory committee shall be appointed by the director of health and consist of:

(1) Two persons licensed as psychologists by the board of psychology;

(2) One person licensed in psychiatry by the board of medical examiners;

(3) One person licensed as a pharmacist by the board of pharmacy; and

(4) One medical director from a federally qualified health center in the state.

§465-G  Administration. (a) The board shall adopt rules pursuant to chapter 91 establishing the requirements and procedures for obtaining a conditional prescription certificate, a prescription certificate, and renewal of a conditional prescription certificate and prescription certificate, including continuing education requirements. The board may set reasonable application and renewal fees.

(b) The board shall adopt rules pursuant to chapter 91 establishing the grounds for denial, suspension, or revocation of conditional prescription certificates and prescription certificates, including provisions for suspension or revocation of a license to practice psychology upon suspension or revocation of a conditional prescription certificate or prescription certificate. Actions of denial, suspension, or revocation of a conditional prescription certificate or a prescription certificate shall be in accordance with this chapter.

(c) The board shall maintain current records on every prescribing psychologist, including federal registrations and numbers.

(d) The board shall provide to the board of pharmacy an annual list of psychologists holding a conditional prescription certificate or prescription certificate that contains the information agreed upon between the board and the board of pharmacy. The board shall promptly notify the board of pharmacy of psychologists who are added or deleted from the list."

SECTION 3. Chapter 465, Hawaii Revised Statutes, is amended by designating sections 465-1 through 465-15 as part I and inserting a title before section 465-1 to read as follows:

"Part I. GENERAL PROVISIONS"

SECTION 4. Section 465-3, Hawaii Revised Statutes, is amended to read as follows:

"§465-3 Exemptions. (a) This chapter shall not apply to:

(1) Any person teaching, lecturing, consulting, or engaging in research in psychology insofar as the activities are performed as part of or are dependent upon employment in a college or university; provided that the person shall not engage in the practice of psychology outside the responsibilities of the person's employment;

(2) Any person who performs any, or any combination, of the professional services defined as the practice of psychology under the direction of a licensed psychologist in accordance with rules adopted by the board; provided that the person may use the term "psychological assistant", but shall not identify the person's self as a psychologist or imply that the person is licensed to practice psychology;

(3) Any person employed by a local, state, or federal government agency in a school psychologist or psychological examiner position, or a position that does not involve diagnostic or treatment services, but only at those times when that person is carrying out the functions of such government employment;

(4) Any person who is a student of psychology, a psychological intern, or a resident in psychology preparing for the profession of psychology under supervision in a training institution or facility and who is designated by a title as "psychology trainee", "psychology student", "psychology intern", or "psychology resident", that indicates the person's training status; provided that the person shall not identify the person's self as a psychologist or imply that the person is licensed to practice psychology;

(5) Any person who is a member of another profession licensed under the laws of this jurisdiction to render or advertise services, including psychotherapy, within the scope of practice as defined in the statutes or rules regulating the person's professional practice; provided that, notwithstanding section 465-1, the person does not represent the person's self to be a psychologist or does not represent that the person is licensed to practice psychology;

(6) Any person who is a member of a mental health profession not requiring licensure; provided that the person functions only within the person's professional capacities; and provided further that the person does not represent the person to be a psychologist, or the person's services as psychological; or

(7) Any person who is a duly recognized member of the clergy; provided that the person functions only within the person's capacities as a member of the clergy; and provided further that the person does not represent the person to be a psychologist, or the person's services as psychological.

(b) Nothing in this chapter shall in any way restrict any person from carrying on any of the psychological activities as defined in section 465-1; provided that such person does not offer psychological services as defined in this chapter except as such activities are incidental to the person's lawful occupational purpose.

(c) A person may use the title of industrial/organizational

psychologist[,]; provided that the person registers with the board, and:

(1) Is professionally competent in the practice of industrial/organizational psychology; [and]

(2) Holds a doctoral degree from an accredited institution of higher education with training and education in industrial/organizational psychology, satisfactory to the board; and

(3) Provides psychological service or consultation to organizations which does not involve the delivery or supervision of direct psychological services to individuals or groups of individuals, without regard to the source or extent of payment for services rendered.

(d) Nothing in this chapter shall prevent the provision of expert testimony by a psychologist who is otherwise exempted by this chapter.

[(e) Nothing in this chapter shall be construed as permitting the administration or prescription of drugs, or in any way engaging in the practice of medicine as defined in the laws of the State.]"

SECTION 5. The board of psychology shall submit a final report, including any proposed legislation, not later than twenty days prior to the regular session of 2010, on its evaluation of the status of mental health care in the state after providing conditional and prescriptive authority to medical psychologists pursuant to this Act. All reports shall include recommendations as to whether the prescriptive authority should be modified, eliminated, or continued, to assist the legislature in assessing the viability of allowing psychologists to retain prescriptive authority.

SECTION 6. In codifying the new part added to chapter 465, Hawaii Revised Statutes, by section 2 of this Act, the revisor of statutes shall substitute appropriate section numbers for the letters used in designating the new sections in this Act.

SECTION 7. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

SECTION 8. This Act shall take effect upon its approval and shall be repealed on July 1, 2010; provided that section 465-3, Hawaii Revised Statutes, shall be reenacted in the form in which it read on the day before the approval of this Act.