Report Title:

Psychologists; Prescriptive Authority

 

Description:

Establishes a means under state law by which appropriately trained and supervised psychologists practicing at federally qualified health centers or clinics in medically underserved or a mental health professional shortage areas may prescribe a limited formulary of psychotropic medications.

 

 


HOUSE OF REPRESENTATIVES

H.B. NO.

1456

TWENTY-FOURTH LEGISLATURE, 2007

 

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 persons living in the rural areas of our state have inadequate access to mental health treatment services, and would receive little or no mental health care if not for the federally qualified health centers located in these areas.  Patients of these centers include the uninsured, the poor, other Pacific Islanders, and the homeless (thirty-six per cent, fifty-six per cent, seven per cent, and five per cent, respectively).  Sixty per cent of the patients of federally qualified health centers in rural areas, are native Hawaiians.  Both in Hawaii, and when compared to indigenous and minority populations in the United States, native Hawaiians have the highest rate of untreated medical and psychological illnesses.

     There are psychiatrists on the staff of only three of the thirteen federally qualified health centers in Hawaii.  As licensed physicians, these psychiatrists have the ability to provide psychopharmacological care to their patients.  There were also 9.71 psychologists working in nine of these centers, but currently, the scope of practice of a licensed psychologist does not include prescribing medications.  However, some of these psychologists do provide psychopharmacological care in active collaboration with primary care physicians as a result of the native Hawaiian psychology training program.

     Since 2000, fourteen psychologists in Hawaii, all native to Hawaii, have received psychopharmacological training through the Tripler Army Medical Center, native Hawaiian psychology training program.  These psychologists now provide mental health therapy combined with psychopharmacological care within collaborative relationships with primary care physicians at seven federally qualified health centers at Bay Clinic, Hana, Molokai, Kauai, Waianae, Kalihi-Palama, and Waimanalo, and at two native Hawaiian health care system clinics on Kauai and Molokai.

     To date, psychologists trained under the native Hawaiian psychology training program have provided combined therapy and psychopharmacological care to thousands of native Hawaiians and other ethnic minorities.  For example, in 2004, psychologists at the Waianae coast comprehensive health center completed approximately three thousand eight hundred forty patient encounters, and seventy per cent of these patients received necessary psychotropic medication for the treatment of mental illness.

     Providing combined mental health therapy and psychopharmacological care through appropriately trained psychologists is not unique to Hawaii.  For years these services have been provided by psychologists with appropriate credentials through the Indian health service, and to active duty military personnel and their families in federal facilities.  Recently, Louisiana and New Mexico gave psychologists prescriptive authority without regard to the service setting.

     In addition, 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 psychologists prescribe safely and effectively.

     Research data soundly demonstrates that the number of prescribing mental health care providers in Hawaii is insufficient to serve the needs of Hawaii's people.  The crystal methamphetamine epidemic that is especially severe in rural areas, 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 resultant delays in providing treatment add to suffering of those with mental illness and are exacerbating Hawaii's future social, economic, and medical costs.

     The legislature finds that the native Hawaiian psychology training program has demonstrated that there already exists a means to address the urgent need to provide timely, appropriate, and cost-effective therapeutic and psychopharmacological health services in rural areas.  There are already psychologists working in federally qualified health centers that could be trained to provide these services.  In addition, psychologists are being placed in rural areas under the native Hawaiian health care professions scholarship program, which requires scholarship recipients to work in federally designated medically underserved areas for the number of years (typically four) they received scholarship funding.  Under this program, psychologists of native Hawaiian ancestry working in federally qualified health centers, native Hawaiian health system clinics, and other federally designated health clinics, are now delivering mental health care in a culturally appropriate manner to underserved populations.

     Furthermore, the American Psychological Association has developed a model curriculum for the education and training of prescribing psychologists.

     The purpose of this Act is to address the urgent need for timely, appropriate, and cost-effective therapeutic and psychopharmacological health services in rural areas by establishing a means under state law by which psychologists practicing in licensed health clinics located in federally designated medically underserved areas or mental health professional shortage areas may become appropriately trained, obtain the necessary licenses and credentials, and with appropriate supervision and in collaboration with the patient's primary physician, prescribe a limited formulary of psychotropic medications for the treatment of mental illness.

     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 physician licensed under chapter 453 and a psychologist holding a conditional prescription certificate in the provision of patient care, including the diagnosis of patients, and the management and delivery of physical and mental health care.

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

     "Prescribing mental health professional" means a psychiatrist or other physician licensed in accordance with chapter 453.

     "Psychotropic medication" means only those pharmaceutical 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 a regional, accredited institution of higher learning approved by the John A. Burns school of medicine and the Tripler Army Medical Center's psychiatry residency program.  The training shall be consistent with the American Psychological Association's Recommended Postdoctoral Training in Psychopharmacology for Prescription Privileges.  The training shall include a two-year postdoctoral program of no less than four hundred fifty hours of 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 at least one hundred eighty hours of a supervised practicum:

          (A)  Of at least one year;

          (B)  Involving four hundred hours treating a diverse population of no fewer than one hundred patients with mental disorders;

          (C)  Supervised by a licensed health care provider who is experienced in the provision of psychopharmacotherapy and is not in the employ of the person being directed or supervised; and

          (D)  Including at least two hours of weekly supervision;

     (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)  Has malpractice insurance that satisfies the requirements adopted by the board by rule, and covers the applicant during the period the conditional prescription certificate is in effect;

     (6)  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

     (7)  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).

     (c)  The conditional prescription certificate shall be immediately relinquished to the board should the psychologist no longer meet 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 the required 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 if any other prescribing mental health professional will assure supervision; 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 promptly inform the board if the psychologist will be practicing at a different clinic;

          and

     (4)  Apply for a Federal Drug Enforcement license for limited use as restricted by state law and 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-E;

     (2)  May order and review laboratory tests related to prescriptions for the treatment of mental disorders under this chapter;

     (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 physician 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.

     (d)  A psychologist holding a conditional prescription certificate may only prescribe psychotropic medications to patients under the psychologist's care who are enrolled at the health center or clinic identified by the board under section 465-C(3)(B).

     §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)  Holds 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, the Hawaii Primary Care Association, 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 that satisfies requirements adopted by the board by rule, that covers the applicant during the period that the prescription certificate is in effect; and

     (5)  Meets all other requirements, as determined by the board by rule, 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;

     (2)  Annually satisfies the continuing education requirements for prescribing psychologists, 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;

     (3)  Continues to be employed or contracted by the health center or clinic identified under section 465-C(3)(B); and

     (4)  Continues to maintain an ongoing collaborative relationship with the physician who oversees the prescribing psychologist's 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.

     (d)  A psychologist holding a prescription certificate may order and review laboratory tests related to prescriptions for the treatment of mental disorders under this chapter.

     §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 fewer 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 psychologists licensed under chapter 465;

     (2)  Two psychiatrists licensed under chapter 453;

     (3)  Two pharmacists licensed under chapter 461; and

     (4) The medical director of a federally qualified health center in the state.

     §465‑G  Administration.  (a)  The board shall adopt rules pursuant to chapter 91:

     (1)  Establishing the requirements and procedures for obtaining and renewing a conditional prescription certificate, a prescription certificate, including continuing education requirements and reasonable application and renewal fees;

     (2)  Establishing the grounds for denial, suspension, or revocation of conditional prescription certificates and prescription certificates; and

     (3)  Allowing for the suspension or revocation of a license to practice psychology upon suspension or revocation of a conditional prescription certificate or prescription certificate.

     (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 also contains the information required by agreement 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 Hawaii State health planning and development agency shall evaluate the effect on the status of mental health care in the state of providing conditional prescriptive authority and prescriptive authority to psychologists pursuant to this Act.  The Hawaii State health planning and development agency shall submit a report of that evaluation, including any proposed legislation, to the legislature not later than twenty days prior to the convening of the regular session of 2015.  The report shall also include recommendations as to whether the prescriptive authority should be modified, eliminated, or continued.

     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, 2015; 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.

 

INTRODUCED BY:

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