Mental Health Care Access Study Likely to Omit Psychologist Prescribing
Following a public hearing & work session last week, a majority of the Health & Human Services Committee appear unwilling to include the extension of prescriptive authority to mental health practitioners without medical education & training in a study of access to services in Maine's mental health system.
On Tuesday, 2/10/04, the Health & Human Services Committee held a public hearing on L.D. 1713, Resolve, to Establish the Commission to Study Access to Prescription Medication for Persons with Mental Illness. Sponsored by H&HS Committee Senate Chair Mike Brennan (D-Cumberland), the proposed study included a provision asking, "whether prescriptive authority for psychotropic drugs should be extended to other health care professionals. In examining this issue, the commission shall review the experience of other states that have extended such prescriptive authority."
In 2002, New Mexico became the first state to pass legislation granting prescription rights to psychologists who undergo advanced training. No psychologists in New Mexico have been authorized to prescribe because the administrative rules to implement the new law have not yet been finalized. The New Hampshire legislature rejected a bill to grant prescriptive authority to psychologists in 2003 and just recently voted to defeat a study proposal. Similar initiatives also have failed in Florida, Georgia, Hawaii, Illinois, Oregon, Tennessee, Texas, Wyoming, Oklahoma, Nebraska, Louisiana, and Connecticut. Maine is the 15th state to consider the issue.
The following individuals spoke in favor of L.D. 1713 at the public hearing:
- Senator Brennan
- Jude Walsh, Bureau of Medical Services, DHS
- Christine Gray, Ph.D., President, Maine Psychological Association
- Jeff Matranga, Ph.D., a Waterville psychologist
- John Nutting, former legislator and Congressional candidate; family member of a person with mental illness (While in favor of a study, Mr. Nutting expressly testified in opposition to that portion of the study looking at expanding prescribing authority)
- Bob Howe, lobbyist for the Maine Nurse Practitioner Association
The following individuals spoke in opposition to the inclusion of the scope of practice issue in L.D. 1713:
- Jack Berman, a rehabilitation counselor from Portland
- Richard Hobbs, M.D., Vice President, Maine Academy of Family Physicians
- William Matuzas, M.D., President, Maine Psychiatric Association
- Thomas DeLuca, D.O., President-elect, Maine Osteopathic Association
- David Moltz, M.D., Maine Psychiatric Association
- Donald Burgess, M.D., Vice President, Maine Chapter, American Academy of Pediatrics
- Edward Pontius, M.D., Legislative Chair, Maine Psychiatric Association
- Jerald Floreza, M.D., Maine Psychiatric Association member from Washington County
- Gordon Smith, Executive Vice President, Maine Medical Association
Several other physicians, including Richard Fortier, M.D. and Neil Korsen, M.D., submitted written testimony to the committee.
During the public hearing that lasted about 2 hours, committee members probed witnesses in an effort to clarify the "access issues" in the mental health system. The following points came out during this discussion:
- The access issues are not primarily issues of access to medications; Maine seems to have sufficient practitioners with prescriptive authority, but too often medication is prescribed because of a lack of access to therapy or other treatment;
- Maine's per capita number of psychiatrists appears to be above the national average, but Maine has a shortage of child psychiatrists, reflecting a national problem;
- Maine may have a sufficient number of psychiatrists and psychologists, but they are not distributed throughout the state sufficiently to serve the needs of the entire state;
- Low reimbursement for mental health practitioners in private practice is a significant part of the access problem;
- Better collaboration among primary care physicians, psychiatrists or NPs/PAs with specialized psychiatric training, and psychologists and other therapists must be part of the solution to the access problem;
- Telemedicine also is part of the solution;
- Patients & family members who offered opinions on the scope of practice issue seem to prefer that psychiatrists and psychologists practice in their areas of expertise.
The H&HS Committee conducted its first work session on the bill the very next afternoon. After a wide ranging discussion of issues plaguing Maine's mental health service system, a consensus emerged that the scope of practice issue should be dropped from the study because a lack of practitioners with prescriptive authority is not a core issue and because a divisive "turf battle" would be an obstacle to achieving progress on more important aspects of the problem. Members also debated how a study should be structured. Republicans generally seemed to favor an "internal" study conducted by DBDS & DHS, perhaps in conjunction with the department merger discussion. Senator Brennan and some Committee Democrats seemed to favor an "external" study conducted by a mix of legislators and stakeholders. In the end, Senator John Martin (D-Aroostook) and Representative Ed Dugay (D-Cherryfield) suggested that the Committee direct DBDS & DHS to convene a stakeholder group to gather data and clarify the issues before the next work session, scheduled for Wednesday, 3/3/04.
While it is unclear whether any study will emerge from the L.D. 1713 debate, and what the structure and focus of any study group may be, it seems quite clear that the question of extending prescriptive authority to psychologists or other practitioners who do not have medical education and training will not be part of it.
Read the MMA's Testimony on L.D. 1713 - Psychologist Prescribing Issue
TESTIMONY OF THE MAINE MEDICAL ASSOCIATION
IN OPPOSITION TO
L.D. 1713, RESOLVE, TO ESTABLISH THE COMMISSION TO STUDY ACCESS TO PRESCRIPTION MEDICATION FOR PERSONS WITH MENTAL ILLNESS
Joint Standing Committee on Health & Human Services
Room 202, Cross State Office Building
Tuesday, February 10, 2004
Good afternoon Senator Brennan, Representative Kane, & Members of the Joint Standing Committee on Health & Human Services. I am Gordon Smith, Executive Vice President of the Maine Medical Association, a professional organization representing approximately 2600 Maine physicians.
Maine’s system of care for persons suffering with mental illness or substance abuse, or those living with mental retardation and developmental disabilities, presents many challenges – developing sufficient community capacity to enable individuals to live near their families and to lead productive lives, finding an appropriate role for community hospitals in the provision of inpatient care, and pursuing equitable private insurance coverage for mental illness on par with coverage for medical or surgical care – to name just a few. In addressing these challenges, the Maine Medical Association (MMA) has collaborated with many, if not most, of the organizations that will offer an opinion on L.D. 1713 today. We agree that much work remains to be done to improve the care in Maine’s mental health, mental retardation, and substance abuse services system and that the study proposed in L.D. 1713 may lead to the improvement we all seek. Unfortunately, the MMA cannot support L.D. 1713 as drafted because physicians do not believe that one aspect of the proposed study can possibly lead to improvement in Maine’s system of care.
Specifically, the MMA objects to Section 5, sub-section 3 on page 2 of the bill that asks:
3. Whether prescriptive authority for psychotropic drugs should be extended to other health care professionals. In examining this issue, the commission shall review the experience of other states that have extended such prescriptive authority;
While this paragraph may seem innocent enough, it is not. Although the bill’s sponsor may not have intended it to do so, it brings to Maine the political and economic agenda of some members of the American Psychological Association, the national professional organization representing licensed psychologists. Extending prescriptive authority to psychologists would seriously threaten the quality of mental health care and patient safety, would further the fragmentation of our health care system, and would do nothing to improve access to mental health care in rural Maine. The MMA urges you to strike this provision from the duties of the proposed study commission.
How does the training of a psychiatrist differ from that of a psychologist and why do physicians believe that state legislatures should not grant psychologists the authority to prescribe medication to patients?
A psychiatrist is a physician – an individual who has followed an extensive science and math-based undergraduate curriculum of prerequisites to medical school admission; who has completed four years of medical school according to either an allopathic (M.D.) or osteopathic (D.O.) curriculum; and then who has gone on to pursue a residency and usually board certification in psychiatry, the specialized study of diseases of the brain. The sciences and pharmacology are emphasized throughout this education and training. Psychiatrists and other physicians are trained to diagnose and treat human illness, which includes the brain and the rest of the body and the use and side effects of medication in treating those illnesses.
A psychologist is a social scientist – an individual who has a doctoral degree and extensive training in human behavior. Their training is not, however, based upon a medical or scientific model. Contrary to our country’s prerequisites for medical school admission and for medical school accreditation, there is no uniformity among the required science courses in the education and training leading to licensure as a psychologist. Despite unfortunate scope of practice battles like the one that could be set up by this bill, most physicians believe that psychologists are respected colleagues who should contribute to improving the health of our population by focusing on their strengths – therapy, testing, and the ability to spend more time with patients.
You may say to yourself that a study of extending prescriptive authority to psychologists doesn’t sound too harmful. On the contrary, we are concerned that the very nature of legislative studies is to seek compromise and consensus. It is a "slippery slope." The MMA will not compromise patient safety and sees no prospect of reaching consensus on this issue. The experience with this issue in other states and in the federal government demonstrates that no further study of this scope of practice issue is necessary.
Only one state has passed legislation granting prescriptive authority to psychologists. In 2002, on the second occasion that its legislature considered it, New Mexico passed a bill that would grant prescriptive authority to psychologists who complete 450 hours (about a semester of medical school) of coursework; undergo a 400-hour, 100-patient practicum under physician supervision; and pass a national certification exam. In 2004, no psychologist has been granted such authority because the governing regulations have not yet been finalized. Based upon our research, Maine is the 15th state to have considered this issue - with the exception of New Mexico no state has proceeded down this dangerous path. Such initiatives have failed in Florida, Georgia, Hawaii, Illinois, Oregon, Tennessee, Texas, Wyoming, Oklahoma, Nebraska, Louisiana, Connecticut, and New Hampshire. In 2003, the New Hampshire legislature rejected a bill to grant prescriptive authority to psychologists and last week the New Hampshire House voted overwhelmingly to accept a legislative committee's recommendation against further study of the issue.
The federal government has granted psychologists prescriptive authority in one limited demonstration project often cited by those seeking to “medicalize psychology.” The Department of Defense conducted a “Psychopharmacology Demonstration Project” from 1991 to 1997. In the demonstration project, 10 military psychologists were authorized to prescribe within the strictly managed environment of military medicine following 2 years of classroom study and 1 year of clinical experience. In a study reviewing the demonstration project, the Government Accounting Office (GAO) concluded that it did little to enhance the “medical readiness” of military personnel and that it was too expensive. The cost of the program was $6.1 million or $610,000 per graduate.
During this debate in 15 or more venues around the country, psychologists advocating for prescriptive authority offer two primary arguments for granting them this expanded scope of practice: patient choice and rural access.
The MMA acknowledges that we are in an era of patient empowerment and that patients want more choice in who provides their health care. While patient wishes are important considerations for the medical community today, patient choice cannot be the guiding principle for state legislators who have an obligation to ensure that those providing health care services meet some minimum standards of competence to ensure patient safety.
Some psychologists also seek to become “pseudo-psychiatrists” in order to fill the gaps in rural health care systems. While Maine may have more licensed psychologists than licensed psychiatrists, there is no reason to believe that psychologists are any more likely to settle in rural areas than are psychiatrists or any other specialists. All specialty health care providers in rural areas face obstacles including developing a sufficient patient base to sustain a private practice, difficulties with call and finding coverage for vacations, and professional isolation. Rural areas of Maine may never have enough psychiatrists, particularly child psychiatrists, and, in fact, Maine may never have enough psychologists in rural areas.
But, an inadequate supply or distribution of specialty providers does not mean that we cannot improve access to mental health services in rural Maine. Our rural areas have no shortage of qualified medical personnel to manage the medication needs of individuals with mental illness. Maine has sufficient primary care physicians, nurse practitioners, and physician assistants to fill this need.
The Maine Psychiatric Association has acknowledged that psychiatrists need to do a better job of supporting primary care practitioner management of mental health treatment, including medication management. Studies suggest that as much as half of mental health care may be obtained appropriately in the general medical sector. Psychiatrists must become consultants and evaluators working in collaboration with primary care practitioners and other mental health providers. Maine has made some tremendous advances in the use of “telemedicine” and you will hear from others about how telemedicine is being used to bridge the gap between psychiatry and primary care in rural areas of our state.
Today, most people accept that a "best practice" goal of our health care system is to provide each patient with a "medical home" with a primary care practitioner. Proposing to divert medication management from the primary care physician would undermine this goal and further fragment our system of care.
Finally, the MMA urges you to reject the part of the proposed study that would consider expanding the scope of practice of psychologists or other practitioners who have insufficient medical and scientific training. Those practitioners who wish to prescribe medications have a roadmap to such authority under current Maine law – they can achieve a medical-model based education as a physician assistant or nurse practitioner, including all of the prerequisites and clinical internships required of those practitioners. Thank you for considering our concerns and I would be happy to respond to any questions you may have. [return to top]
Happy Presidents' Day; Maine Medical Association Open for Business
Today is a state and federal holiday but the Maine Medical Association office is open from 7:00am to 6:00pm to serve its members, as usual. [return to top]
U.S. Senate to Consider S. 2061 on Medical Liability Reform for OB-GYN
In an unexpected move, the U.S. Senate is now expected to vote next week on a new medical liability reform bill, S. 2061 sponsored by Senators Gregg and Ensign. The bill, entitled the "Healthy Mothers and Healthy Babies Access to Care Act of 2003", would provide liability protections for obstetrical and gynecological services. The bill establishes a cap on non-economic damages of $250,000 and also includes provisions regarding the statute of limitations, collateral sources, joint and several liability, attorney contingent fees, expert witness requirements and punitive damages.
As the AMA House of Delegates at its interim meeting in December voted to oppose liability legislation which carved out only certain providers for protection, the presence of S. 2061 is creating a difficult situation and causing much discussion among the specialties and the AMA. At a conference call on Feb. 12th, it was stated that the AMA would consider a position on the legislation at an upcoming Board meeting.
As the bill was just reported out of Committee last Tuesday, MMA has not had an opportunity to independently consider the legislation. As Senators Collins and Snowe are likely to solicit MMA opinion, any members wishing to express a view on the issue should contact either Andrew MacLean at firstname.lastname@example.org or Gordon Smith at email@example.com/. The MMA has been in contact with both the AMA lobbyists and representatives of ACOG regarding the present situation.
As Senate support for medical liability legislation in 2003 did not approach the 60 votes necessary to overcome a Democratic filibuster, it is not likely that S. 2061 will pass. On the other hand, it is an election year and the medical liability crisis, and its impact on access to care, is an election issue in many states. Therefor, it may be possible to enact a narrower bill than that previously considered. Political pundits will have their own opinions as to whether the bill is offered now for a Senate vote just to use the issue against the democrats in the election, or whether the vote is a legitimate attempt to ease the medical liability situation in obstetrics.
The only argument against medical society support for the bill centers around the pros and cons of carving out protection for one specialty. On the one hand, passage may slow the momentum for broad-based medical liability reform, on the other hand, one could argue that its passge could establish a precendent that could then benefit all physicians. What do you think? Let us hear from you. It is an important issue. [return to top]
Dirigo Health Maine Quality Forum Advisory Council Update
The Maine Quality Forum Advisory Council, established in the Dirigo Health legislation, held its fourth meeting on Feb. 13th. The Council's work focused on establishment of the Provider Group to advise the Council, the Council's role in technology assessment, the definition of quality and the preliminary short and long term goals of the Council. The Council also heard an update on the selection of an Executive DIrector for the Forum. Three or four potential candidates remain from the larger pool and at least two of the finalists are physicians.
The subcommittee working on criteria for the selection of the Provider Group has recommended that about 27 individual providers be appointed to the Group. At least five of these would be physicians, icluding two primary care physicians and two specialists. The fifth would be a psychiatrist, although other physicians might be included by representing hospitals, rural health clinics, etc.
For its definition of quality, the Council took from the existing definition used by the Centers for Medicare & Medicaid Services, and enhanced it by adding the IOM's six items from its 2001 Report titled, "Crossing the Quality Chasm." The result is:
"Good quality health care means doing the right thing at the right time, in the right way, for the right person and getting the best results." (Centers for Medicare and Medicaid Services)
The IOM noted six aims for improvement, which define "high quality" care as health care that should be:
1. Safe- avoiding injuries to patients from the care that is intended to help them.
2. Effective- providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively).
3. Patient-centered- providing care that is respecful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
4. Timely- reducing waits and sometimes harmful delays for both those who receive and those who give care.
5. Efficient- avoiding waste, including waste of equipment, supplies, ideas and energy.
6. Equitable- providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
The Council finished the morning meeting by discussing a list of preliminary short and long term goals.
Preliminary Short and Long Term Goals
1. Provide input into the State Health Plan regarding QA/Q1 priorities
2. Select performance measures and national benchemarks against which Maine's performance can be evaluated. In the short term, this would include fact gathering on available measures, selection of key measures, and the development of work plan for analyzing and reporting results.
3. Design a strategy for scanning the environment on emerging technologies and making recommendations to the CON process regarding proposed technologies.
4. Develop a structure for managing and conducting the activities required of the MQF and its Advisory Council.
5. Identify 1-2 areas for quality improvement and plausible interventions that can make a difference without duplicating existing efforts.
1. Seek input from the public health community to better understand the health issues facing the State and preventive strategies that could be endorsed through the MQF.
2. Work with the MHDO and oher organizations in the collection, analysis and report of selected peformance measures.
3. Merge cost and quality data to look at the value of health care.
4. Standardize the collection of cost data so that accurate facility comparisons can be reported.
5. Solicit feedback from the public and providers on the performance of the MQF.
[return to top]
Dirigo Health Agency Board of Directors Meets
The Dirigo Health Agency Board of DIrectors met on Feb. 13. Among the items discussed were the following:
The figure for current annual health care spending in Maine is $6.2 billion. This will be the baseline for the global budget in the State Health Plan.
Staff reiterated that Governor Baldacci is committed to retaining the $53 million for the Dirigo Health start-up. Staff also indicated their belief that Dirigo would not be a "drain" on the MaineCare program. The earlier figure of 78,000 potential eligible MaineCare enrollees through the Dirigo Health law was a worst case scenario and is not accurate. 42,000 persons would be more accurate, with the increase in the non-parents up to 125% of the federal poverty level and for the parents up to 200%. 11,000 new enrollees are expected in the first year, anticipating a take-up rate of 30%
Staff also gave an overview of the current efforts regarding the savings offset payment relative to third-party administrators, and of the current discussions regarding the insurance product. At the previous meeting on Jan. 26th, Executive Director Tom Dunne and Gino Nalli of the Muskie School had indicated that it was likely that the Dirigo Plan would have a higher deductible and coinsurance than originally planned, because of changes in the market. It was also noted at that meeting that interest from the insurance carriers in offering the product had been mixed. [return to top]
NHIC-NE to host CMS "Medicare Resident & New Physician Guide"
On Wednesday, March 10, 2004, from 2:00pm to 3:00pm EST, National Heritage Insurance Company (NHIC), the Medicare Part B carrier for Maine, New Hampshire, Vermont and Massachusetts, will host The Medicare Learning Network satellite broadcast entitled, "Medicare Resident & New Physician Guide."
The Medicare Resident & New Physician Guide -- Welcome to the Medicare Program video, was developed to introduce finishing residents and new physicians to the Medicare program. This video provides information and tools about the Medicare program that will be helpful to anyone interested in a basic overview of Medicare and how it works.
Topics in the video include:
* Identification of Medicare's three components
* Who is eligible to receive Medicare benefits
* The benefits of becoming a participating physician
* Understanding the Medicare enrollment process
* Understanding why medical documentation is important
* Identification of the different types of claims and filing methods
* Description of methods to protect a physician's practice and ensure compliance with Medicare requirements
NHIC-NE has registered as a host site to view this broadcast. The address is 75 Sgt. Wm B. Terry Drive in Hingham, MA. Limited seating is offered by pre-registration. You may register for this location through the NHIC link--http://www.medicarenhic.com/ne_prov/updates/2004/residentvideo_0204.htm or choose another location through the CMS MEDLEARN website: http://www.cms.hhs.gov/medlearn/broadcst.asp. Should you have questions, you may contact Maria Petruziello at Maria.firstname.lastname@example.org.
[return to top]
AMA, others Continue Protesting Unfunded Mandate for Interpreter, Translator Services
Since 2000, the AMA along with the Maine Medical Association and dozens of medical societies and organizations, has objected to Office of Civil RIghts (OCR) policies that require the provision of oral and written interpretation for all patients in a physician practice who have limited English proficiency (LEP).
If a practice receives any Medicare or Medicaid funds, the policy applies and mandates the services for LEP patients, while providing no additional financial assistance for the physician. In other words, interpreter and translator charges must be absorbed by the health care provider, in those instances where an interpreter or translator is required.
In the lastest exchange, the AMA provided comments to Deeana Jang, Department of Health and Human Services, regarding additional federal "guidance" published in the Federal Register. That entry provided four factors for determining the extent of a physician's obligation to provide LEP services:
* The number or proportion of LEP persons eligible to be served or encountered
* The frequency with which LEP individuals are in contact
* The nature and importance to people's lives of the program, activity or service provided
* The resources available and their costs
While applauding the fact that smaller entities are not expected to provide the same level of language services as larger ones, the AMA re-emphasized in its response that the cost of providing these services can impose severe economic losses.
"If the cost burden is not addressed, physicians will not be able to afford to treat Medicaid and other patients who benefit from federal financial assistance," noted the AMA, "and thus the poor and medically indigent will suffer adversely."
State and specialty societies, along with the AMA, urged the DHHS to continue working with the physician community to identify and share cost-reduction strategies and resources. Development of independent federal and state initiatives for insuring interpreter and translator competency was also encouraged.
Find the latest LEP guidance at: www.hhs.gov/ocr/lep/revisedlep.html.
At the January meeting of the MMA Executive Committee, staff was requested to develop a brochure on this subject for members, with the material to include the various resources available in this area as well as discussing the law itself.
[return to top]
Profits Surge at Would-be Mates WellPoint and Anthem
Anthem, Inc. and WellPoint Health Networks, Inc., the two largest BlueCross BlueShield companies, intend to merge in 2004. Both reported significant gains in net income for the 2003 fourth quarter as well as the full year. Anthem posted a 21% increase in fourth quarter earnings of $208.8 million as revenue rose 8 percent to $4.3 billion. For the year, Anthem reported its net income increased 41% to $774 million, revenue rose 26% to $16.7 billion, and enrollment increased 8 percent to 11.9 million members. For 2004, Anthem increased its per share earnings outlook to $7.10.
WellPoint reported a 51% increase in fourth quarter earnings to $271.5 million as revenue rose 21 percent to $5.5 billion. For the year, WellPoint reported its earnings rose 33 percent to $935.2 million, revenue rose 17 percent to $20.4 billion, and enrollment increased 9% to 15 million members. (From Modern Healthcare, Jan. 29, 2004)
[return to top]
MMA Committee Meetings at MMA this Week
The MMA Payor Liaison Committee will meet Wednesday evening, Feb. 18th at the Frank O. Sred Building in Manchester. The meeting will begin at 6:30 with dinner available at 6:15pm. Guests will include representatives of Cigna HealthCare, including RIchard White, the Market Service Leader in New England and Robert Hockmuth, M.D., Medical Director.
The MMA Comittee on Membership and Member Benefits will meet on Thursday evening, Feb. 19th, also at the Frank O. Sred Building in Manchester. [return to top]