Legislature(1999 - 2000)
05/10/1999 03:22 PM House L&C
| Audio | Topic |
|---|
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HOUSE LABOR AND COMMERCE STANDING COMMITTEE
May 10, 1999
3:22 p.m.
MEMBERS PRESENT
Representative Norman Rokeberg, Chairman
Representative Andrew Halcro, Vice Chairman
Representative Jerry Sanders
Representative Lisa Murkowski
Representative John Harris
Representative Tom Brice
Representative Sharon Cissna
MEMBERS ABSENT
All members present
OTHER MEMBERS PRESENT
Representative Mary Kapsner
COMMITTEE CALENDAR
HOUSE BILL NO. 183
"An Act relating to the powers and duties of the chair of the
Alaska Public Utilities Commission; relating to membership on the
Alaska Public Utilities Commission; and relating to the annual
report of the Alaska Public Utilities Commission."
- MOVED CSHB 183(L&C) OUT OF COMMITTEE
* SPONSOR SUBSTITUTE FOR HOUSE BILL NO. 139
"An Act authorizing certain psychologists to prescribe and dispense
certain psychotropic medications and their adjuncts within the
practice of psychology."
- HEARD AND HELD
* HOUSE BILL NO. 211
"An Act relating to liability for providing managed care services,
to regulation of managed care insurance plans, and to patient
rights and prohibited practices under health insurance; and
providing for an effective date."
- HEARD AND HELD
CS FOR SENATE BILL NO. 29(RLS)
"An Act relating to licensure of physicians; and providing for an
effective date."
- SCHEDULED BUT NOT HEARD
(* First public hearing)
PREVIOUS ACTION
BILL: HB 183
SHORT TITLE: ALASKA PUBLIC UTILITIES COMMISSION
SPONSOR(S): SPECIAL COMMITTEE ON UTIL RESTRUCTURING
Jrn-Date Jrn-Page Action
4/09/99 702 (H) READ THE FIRST TIME - REFERRAL(S)
4/09/99 702 (H) URS, L&C
4/14/99 (H) URS AT 8:00 AM BUTROVICH ROOM 205
4/14/99 (H) SCHEDULED BUT NOT HEARD
4/16/99 (H) URS AT 2:00 PM CAPITOL 120
4/16/99 (H) MOVED CSHB 183(URS) OUT OF COMMITTEE
4/16/99 (H) MINUTE(URS)
4/20/99 880 (H) URS RPT CS(URS) NT 6DP
4/20/99 880 (H) DP: PORTER, KOTT, COWDERY, HUDSON,
4/20/99 880 (H) GREEN, ROKEBERG
4/20/99 880 (H) ZERO FISCAL NOTE (DCED)
4/20/99 880 (H) REFERRED TO L&C
4/23/99 (H) L&C AT 3:15 PM CAPITOL 17
4/23/99 (H) HEARD AND HELD
4/23/99 (H) MINUTE(L&C)
4/26/99 (H) L&C AT 3:15 PM CAPITOL 17
4/26/99 (H) HEARD AND HELD
4/26/99 (H) MINUTE(L&C)
4/28/99 (H) L&C AT 3:15 PM CAPITOL 17
4/28/99 (H) HEARD AND HELD
4/28/99 (H) MINUTE(L&C)
4/30/99 (H) L&C AT 3:15 PM CAPITOL 17
4/30/99 (H) HEARD AND HELD
4/30/99 (H) MINUTE(L&C)
5/03/99 (H) L&C AT 3:15 PM CAPITOL 17
5/03/99 (H) HEARD AND HELD
5/03/99 (H) MINUTE(L&C)
5/04/99 1168 (H) FINANCE REFERRAL ADDED
5/05/99 (H) L&C AT 3:15 PM CAPITOL 17
5/05/99 (H) SCHEDULED BUT NOT HEARD
5/07/99 (H) L&C AT 3:15 PM CAPITOL 17
5/07/99 (H) SCHEDULED BUT NOT HEARD
5/08/99 (H) L&C AT 2:00 PM CAPITOL 17
5/08/99 (H) <CANCELLED MEETING>
5/10/99 (H) L&C AT 3:15 PM CAPITOL 17
BILL: HB 139
SHORT TITLE: PRESCRIPTIONS BY PSYCHOLOGISTS
SPONSOR(S): REPRESENTATIVES(S) JAMES
Jrn-Date Jrn-Page Action
3/16/99 479 (H) READ THE FIRST TIME - REFERRAL(S)
3/16/99 479 (H) L&C, FIN
4/13/99 794 (H) SPONSOR SUBSTITUTE INTRODUCED
4/13/99 794 (H) READ THE FIRST TIME - REFERRAL(S)
4/13/99 794 (H) L&C, FIN
4/16/99 851 (H) ADDITIONAL REFERRAL TO HES
4/16/99 852 (H) COSPONSOR(S): KAPSNER
5/10/99 (H) L&C AT 3:15 PM CAPITOL 17
BILL: HB 211
SHORT TITLE: MANAGED HEALTH CARE INSURANCE
SPONSOR(S): REPRESENTATIVES(S) ROKEBERG BY REQUEST
Jrn-Date Jrn-Page Action
4/22/99 914 (H) READ THE FIRST TIME - REFERRAL(S)
4/22/99 914 (H) L&C, JUD, FIN
5/10/99 (H) L&C AT 3:15 PM CAPITOL 17
WITNESS REGISTER
REPRESENTATIVE JAMES
Alaska State Legislature
Capitol Building, Room 102
Juneau, Alaska 99801
Telephone: (907) 465-3743
POSITION STATEMENT: Testified as sponsor of SSHB 139.
ROBERT LANE, President
Alaska Psychological Association
4050 Lake Otis Parkway, Suite 111
Anchorage, Alaska 99508
Telephone: (907) 561-4535
POSITION STATEMENT: Testified on HB 139.
DR. TIM DUKE, licensed Psychologist;
Graduate, Psychopharmacology Demonstration Project
12490 Quivira Road, Apt. 2214
Overland Park, Kansas 66213
Telephone: Not provided.
POSITION STATEMENT: Discussed the Psychopharmacology Demonstration
Project and reasons supporting the need for HB 139.
DR. LAWRENCE KLUSMAN, Psychologist
The Psychology Group
701 South Acadian Thruway
Baton Rouge, Louisiana 70806
Telephone: (225) 757-9534
POSITION STATEMENT: Discussed the Psychopharmacology Demonstration
Project.
DR. MONTY MILLER, Internist
Specially Board Certified in Internal Medicine;
Former Air Force Surgeon General
Address not provided.
Tennessee
Telephone: (907) 967-8717
POSITION STATEMENT: Discussed the Psychopharmacology Demonstration
Project and his concerns with psychologists prescribers.
DR. DWIGHT STALLMAN, Board Certified Psychiatrist;
Medical Director, Life Quest
19231 Monastery Drive
Eagle River, Alaska 99577
Telephone: (907) 696-1441
POSITION STATEMENT: Testified that psychologist prescribers pose
risks to patients.
BARRY CHRISTENSEN, Pharmacist
Chair, Alaska Pharmaceutical Association
3526 Tongass Avenue
Ketchikan, Alaska 99901
Telephone: (907) 225-6186
POSITION STATEMENT: Opposed HB 139.
DR. IRVIN ROTHROCK, Psychiatrist
Fairbanks Psychiatric Neurological Clinic
1919 Lathrop Street
Fairbanks, Alaska 99701
Telephone: (907) 452-1239
POSITION STATEMENT: Urged the committee to vote against HB 139.
DR. CAROLYN RADER, Psychiatrist
Langdon Clinic
4001 Dale Street
Anchorage, Alaska 99508
Telephone: (907) 561-1361
POSITION STATEMENT: Urged the committee not to pass HB 139.
TORIL STARK
10329 Chickaloon Street
Eagle River, Alaska 99577
Telephone: (907) 696-7158
POSITION STATEMENT: Supported HB 139.
DR. WANDAL WINN, Physician and Board Certified Psychiatrist
4300 B Street, Suite 202
Anchorage, Alaska 99503
Telephone: (907) 562-0794
POSITION STATEMENT: Urged the committee to defeat HB 139.
DR. RAMZI NASSAR, Board Certified Psychiatrist
Providence Behavioral Medicine Group
2401 East 42nd Avenue
Anchorage, Alaska 99508
Telephone: (907) 561-6611
POSITION STATEMENT: Discussed concerns with HB 139.
DR. ROGER SHAFER, Psychiatric Physician
Veterans Administration
2925 DeBarr Road
Anchorage, Alaska 99508
Telephone: (907) 257-4857
POSITION STATEMENT: Urged the committee not to pass HB 139 from
committee.
DR. MERIJEANNE MOORE, President
Alaska State Psychiatric Association
Private Practice Psychiatrist
110 West 15th Avenue, Suite A
Anchorage, Alaska 99501
Telephone: (907) 272-1892
POSITION STATEMENT: Viewed allowing psychologist prescribers as a
quality of care issue.
DR. JEROME LIST, DDS, MD; President
Alaska State Medical Association
4107 Laurel Street
Anchorage, Alaska 99508
Telephone: (907) 562-0304
POSITION STATEMENT: With regard to HB 139, discussed need for
cooperation and collaboration between psychologists and
psychiatrists. Urged the committee to favorably consider HB 211.
DR. CHARLES BURGESS, Chairman
Department of Psychiatry;
Providence Behavioral Medicine Group,
Providence Hospital;
Board of the Help Alaska Network
4001 Dale Street, Number 101
Anchorage, Alaska 99508
Telephone: (907) 561-1361
POSITION STATEMENT: Discussed need for holistic integrated care
which HB 139 goes against.
DR. DAVID RICHARD SAMSON, Psychiatric Physician
2600 Denali, Number 606
Anchorage, Alaska 99503
Telephone: (907) 276-2978
POSITION STATEMENT: Encouraged the committee not to endorse
HB 139.
DR. ROBINSON, M.D.
8800 Glacier Highway, Suite 216
Juneau, Alaska 99801
Telephone: (907) 789-3800
POSITION STATEMENT: Declined to testify.
DR. CHUCK ELLIS, M.D.
733 West 4th, Number 668
Anchorage, Alaska 99501
No telephone provided.
POSITION STATEMENT: Declined to testify.
DR. GILBERT SANDERS, Psychologist
2622 Easthaven Circle
Anchorage, Alaska
Telephone: (907) 338-0518
POSITION STATEMENT: Discussed the GAO report, and the issues of
training and access.
CATHERINE REARDON, Director
Division of Occupational Licensing
Department of Commerce & Economic Development
PO Box 110806
Juneau, Alaska 99801
Telephone: (907) 465-2538
POSITION STATEMENT: Testified that the department has not taken a
position on HB 139.
DR. JIM JORDAN, Executive Director
Alaska State Medical Association
4107 Laurel Street
Anchorage, Alaska 99508
Telephone: (907) 562-0304
POSITION STATEMENT: Offered to answer any questions.
MARCI BURTON, Regional Director
Managed Health & Physician Integration
Providence Health System
7701 Evander Drive
Anchorage, Alaska 99518
Telephone: (907) 261-3105
POSITION STATEMENT: Discussed areas needing clarification as well
as areas of concern.
MARY VEALE, Physical Therapist
Alaska Chapter
American Physical Therapy Association
PO Box 240286
Douglas, Alaska 99824
Telephone: (907) 364-2164
POSITION STATEMENT: Supported HB 211.
ACTION NARRATIVE
TAPE 99-56, SIDE A
Number 0001
VICE-CHAIRMAN ANDREW HALCRO called the House Labor and Commerce
Standing Committee meeting to order at 3:22 p.m. Members present
at the call to order were Representatives Halcro, Harris, Brice and
Cissna. Representatives Sanders, Murkowski and Rokeberg arrived at
3:25 p.m., 3:39 p.m. and 3:48 p.m., respectively.
HB 183-ALASKA PUBLIC UTILITIES COMMISSION
VICE-CHAIRMAN ANDREW HALCRO announced that the first order of
business is HB 183, "An Act relating to the powers and duties of
the chair of the Alaska Public Utilities Commission; relating to
membership on the Alaska Public Utilities Commission; and relating
to the annual report of the Alaska Public Utilities Commission."
At the request of the chair, Vice-Chairman Halcro said he would
entertain a motion to report HB 183 from committee.
REPRESENTATIVE BRICE asked if the committee had a copy of the
version of the bill that would incorporate all the amendments.
VICE-CHAIRMAN HALCRO understood that Version K incorporates all the
amendments and that the committee would need to adopt Version K as
the workdraft.
REPRESENTATIVE CISSNA asked if the committee had passed all of the
amendments.
VICE-CHAIRMAN HALCRO indicated that all the amendments were passed
and incorporated in Version K.
REPRESENTATIVE HARRIS moved to adopt the committee substitute (CS)
labeled LS0764\K, Cramer, 5/4/99, as the working document before
the committee. There being no objection, it was so ordered.
VICE-CHAIRMAN HALCRO called an at-ease at 3:25 p.m. The committee
returned to order at 3:26 p.m., upon which he inquired as to the
wish of the committee.
Number 0151
REPRESENTATIVE HARRIS moved to report CSHB 183, LS0764\K, Cramer,
5/4/99, out of committee with individual recommendations and the
accompanying fiscal notes. There being no objection, it was so
ordered.
SSHB 139-PRESCRIPTIONS BY PSYCHOLOGISTS
VICE-CHAIRMAN HALCRO announced that the next order of business
before the committee is HB 139, "An Act authorizing certain
psychologists to prescribe and use controlled substances within
their practice of psychology."
The committee took an at-ease at 3:27 p.m. and returned at an
unspecified time.
REPRESENTATIVE JAMES, Alaska State Legislature, testified as the
sponsor of HB 139. She read the following sponsor statement into
the record:
I have introduced HB 139 to open the discussion of an
important public policy issue. This bill, similar to
proposals currently under review in several states, would
authorize qualified psychologists with appropriate
pharmacological training to prescribe medications within
the scope of their professional practice.
In addition to the substantial education and training
psychologists already have in the diagnosis and treatment
of mental health and emotional disorders, this bill would
require completion of rigorous additional training as
determined by the Board of Psychology prior to being
authorized to prescribe medication.
Alaska has a large, under-served population with mental
health problems. Prescription privileges for
psychologists will help increase access to appropriate,
comprehensive treatment for many of these Alaskans. It
will also streamline patient care, give consumers more
choices, and reduce costs.
REPRESENTATIVE HARRIS inquired as to the difference between a
psychiatrist and a psychologist.
REPRESENTATIVE JAMES specified that one has medical school [a
medical school degree] and the other one does not.
VICE-CHAIRMAN HALCRO announced that testimony would be limited to
three minutes.
Number 00415
ROBERT LANE, President, Alaska Psychological Association, thanked
the committee for the opportunity to begin this education process
which he hoped would lead to the passage of HB 139. This
legislation would permit appropriately trained psychologists to
prescribe medications within the scope of their practice. He
believed that HB 139 would be good for Alaskans because it would
increase access to mental health services, provide for better
continuity of care for mental health patients, and there will
eventually be a cost savings due to the elimination of duplication
of services.
MR. LANE informed the committee that psychologists have a doctoral
degree which is typically six to eight years beyond a bachelor's
degree. This legislation is an education beyond the doctoral
degree which prepares one to perform psychotherapeutic
interventions along a broad range of mental health issues.
Psychologists view prescribing as a tool which would be useful in
providing the continuity of care so that patients are not forced to
go to various providers. Currently, those with expertise in
psychotropic medications have long waiting lists and full case
loads. Therefore, finding someone with the appropriate amount of
education to prescribe such medication is limited. Studies
indicate that the bulk of psychotropic medications are prescribed
by family practitioners and internists who have less specific
training in mental health than do psychiatrists. Mr. Lane believed
that with the amount of training psychologists receive through
their doctoral degree plus the specific training on prescribing,
another masters degree, would allow psychologists to provide
greater access for people in need of such services.
MR. LANE explained that the training program was developed, in
part, from a number of Blue Ribbon panels with nationally
recognized experts in medicine, psychiatry, nursing, pharmacy,
neurosciences, and psychology. Additionally, the training program
was developed from the Department of Defense's Psychopharmacology
Demonstration Project (PDP) in which psychologists were educated to
prescribe in military settings. Therefore, Mr. Lane believed that
a good training model had been developed which ensures safety to
the public. He noted that Dr. Lawrence Klusman would inform the
committee later of the process that led to the training program.
With regard to public safety, he pointed out that across the nation
there are nonphysician prescribers which include physician's
assistants, nurse practitioners, optometrists, dentists, midwives,
and in some states pharmacists. In the early 1990s the Drug
Enforcement Agency passed a rule adopting a provision that would
allow nonphysician providers to be able to prescribe. He noted
that Dr. Tim Duke, a Department of Defense graduate, is on-line to
speak to the committee about safety and consumer satisfaction as
related to psychologists prescribing. In conclusion, Mr. Lane
reiterated his reasons why HB 139 would be good for Alaskan
consumers.
VICE-CHAIRMAN HALCRO inquired as to how many other states allow
psychologists to dispense psychotropic drugs.
MR. LANE informed the committee that currently, the Territory of
Guam is the only territory that allows prescribing. However,
Guam's prescription bill is done in collusion with a physician as
part of the statute. Indiana has passed legislation allowing
psychologists who have completed the Department of Defense's
training to prescribe within Indiana. Mr. Lane noted that many
states have legislation on this subject pending. In further
response to Vice-Chairman Halcro, Mr. Lane said that there have
been attempts in other states to pass model legislation similar to
HB 139. Those attempts have yet to pass.
REPRESENTATIVE KAPSNER referred to Mr. Lane's comment that HB 139
would allow greater access to services. She inquired as to where
there is a lack of access.
MR. LANE pointed out that even in Anchorage, one would expect a
four to six week wait for an appointment with a psychiatrist.
Furthermore, some psychiatrists have a full case load and are not
taking more patients. Therefore, even in Anchorage more providers
would offer greater access. In rural areas, there is even less
access to qualified competent providers than there would be in
urban areas such as Anchorage. In further response to
Representative Kapsner, Mr. Lane was not sure how many
psychologists would administer psychotropic drugs. He pointed out
that the legislation includes language which makes it "incumbent
upon the psychologist themselves to decide if they want to do the
extra training ... beyond a doctoral degree to qualify to
prescribe."
Number 0987
DR. TIM DUKE, a licensed psychologist in Missouri and a graduate of
the Psychopharmacology Demonstration Project (PDP), testified via
teleconference from Kansas. He informed the committee that his
testimony is based on real life experience. Upon completion of the
demonstration project, Dr. Duke practiced as a military prescribing
psychologist under a Psychiatry Consultant to the U.S. Army Surgeon
General from July 1997 to July 1998. After that year, he stayed
three more months as an independent civilian prescribing
psychologist. He noted that the majority of his patients were
referred by family care physicians. Those family care physicians
advocated, to the Commander of the Hospital, for Dr. Duke to stay
on at the hospital at Fort Hood. Dr. Duke believed that
demonstrates the collaborative interaction he achieved with other
physician groups who had a choice to whom to send their patients.
DR. DUKE informed the committee that as a prescribing psychologist,
he saw approximately 1,500 patients of which he did not place all
on medication. These patients included active duty soldiers, their
dependents, and retirees. Furthermore, the patients varied with
respect to race and rank. He noted that he also saw many with
complicated medical conditions who were often on multiple
medications. His formulary consisted of all medications used for
the treatment of mental disorders some of which required persistent
follow-up. Dr. Duke explained that he has provided all this
information in order that the committee can make an informed
decision as to whether psychologists can prescribe confidently. He
predicted that the opposition would undoubtedly, testify that HB
139 will place the already vulnerable mental health patient at
serious risk. He further predicted that the opposition will
attempt to provide evidence of his incompetence based upon lack of
medical school training and attempt to persuade the committee that
only a medical doctor can prescribe psychotropic medication.
However, the opposition will not provide any evidence that Dr.
Duke's patients were ever in danger or mismanaged. Nor will the
opposition provide any study that other nonphysician clinicians
endanger their patients. Dr. Duke said that his claims of safety
are based on his training experience which included course work at
the Uniform School of Health Science University in which Dr. Duke
was placed in classes with nurse anesthetists and nurse
practitioners who can, in some states prescribe. His second year
was predominantly clinical work at the Walter Reed Army Medical
Center.
DR. DUKE stated that HB 139 would provide rural area patients much
needed competent follow-up while on psychotropic medication.
However, the continuity of care is a more important reason for
psychologists to be allowed to provide. "As a prescribing
psychologist, I did not need to redo my treatment plan or tell a
patient who needed medications that they had to wait three to four
weeks before they could see a psychiatrist." He pointed out that
he was able to provide a complete mental health service. In
conclusion, Dr. Duke said that HB 139 is not requesting anything
that would endanger patient welfare nor is it requesting anything
less than that afforded to other nonphysician groups.
Number 1237
REPRESENTATIVE MURKOWSKI understood from Dr. Duke's resume that he
is the Clinical Director at Cass County Psychological Services.
She asked if he was able to prescribe in his capacity in Missouri.
DR. DUKE replied no and noted that it is a frustrating situation.
He explained that he was in area in which there are problems with
rural area clinicians. Since he cannot prescribe in Missouri, he
does collaborative work with few general physicians in the area.
In further response to Representative Murkowski, Dr. Duke specified
that he was a prescribing psychologist for one year as an active
duty psychologist and three months as a civilian prescriber. With
regard to the PDP, he noted that there are nine prescribing
psychologists of which four are in the U.S. Air Force, three in the
U.S. Navy, and two in the U.S. Army.
REPRESENTATIVE HARRIS asked if there have been attempts by the
legislatures in Kansas or Missouri to institute legislation
allowing prescribing psychologists.
DR. DUKE was not aware of any such legislation in Kansas, but
Missouri has legislation in a House subcommittee. In further
response to Representative Harris, Dr. Duke indicated that the
issues are nationwide. Psychologists are being portrayed as not
being independent providers. He explained that currently,
psychologists receive referrals from the patient or other
physicians. Psychologists are independent practitioners. He
emphasized that the extra training, two to three years, being
proposed for psychologists is very similar to that already provided
for nurse anesthetists and nurse practitioners. This would create
a more competent clinician similar to nurse anesthetists and nurse
practitioners of which some have great prescribing capability in
some states.
VICE-CHAIRMAN HALCRO inquired as to why Dr. Duke felt such
legislation has failed in other states.
DR. DUKE said he believed that psychiatrists are fearful that if
psychologists obtained prescribing authority, the definition
between a psychiatrist and a psychologist would be diminished. At
some level, psychiatrists fear their existence.
DR. DUKE, in response to Representative Murkowski, clarified that
in order for psychologists to prescribe, two to three years of
post-doctoral training would be required.
REPRESENTATIVE MURKOWSKI referred to a letter from an Alaskan
doctor who stated that HB 139 proposes 300 hours or 10 weeks of
medical training. In comparison, a psychiatrist receives eight
years of intensive medical training.
DR. DUKE pointed out that medical school is four years, after which
the individual enters into a residency program which is referred to
as an internship for psychiatrists. Upon the entrance to the first
year of the internship, the individual is allowed to prescribe
medication. He clarified that is the procedure in the U.S.
military. With regard to the time frame, Dr. Duke pointed out that
nurse anesthetists and nurse practitioners simply have a B.S.N. on
top of a master's degree which amounts to about six years total.
REPRESENTATIVE MURKOWSKI asked if it is correct to say that
psychologists are not able to prescribe without the supervision of
a medical doctor for a period of time, similar to an internship.
DR. DUKE explained that upon completion of the two year
demonstration project, he had to proceed to a proctorship with the
consultant to the U.S. Army Surgeon General for a year. At that
point, Dr. Duke could prescribe independently. He agreed that
would be after the three year period.
VICE-CHAIRMAN HALCRO returned the gavel to Chairman Rokeberg.
Number 1624
DR. LAWRENCE KLUSMAN, Psychologist, The Psychology Group, testified
via teleconference from Baton Rouge, Louisiana. He informed the
committee that he is a former Chief, Department of Psychology,
Walter Reed Army Medical Center. During his time at the Walter
Reed Army Medical Center, Dr. Klusman was the Executive Director of
PDP. Dr. Klusman said he would discuss how the training curriculum
for the project was developed. The original model for teaching
psychologists to prescribe was a physician's assistant model.
Early on, it was discovered that model was not adequate.
Therefore, the U.S. Army Surgeon General called a commission of
physicians, psychologists and psychiatrists in order to develop a
better model. The commission first determined that psychologists
should complete the first two years of medical school which some of
the PDP graduates completed. The thinking was that the first two
years of medical school include the basic course work for a
physician. After that time, a military medical school in Bethesda,
Maryland, reviewed the program as did outside consultants from the
American College of Neuropsychopharmacology. The program was
reviewed in order to determine what was necessary for a
psychologist to prescribe medication while recognizing that
psychologists are trained at the doctoral level, practice
independently, and have been performing diagnosis and assessments
for years. That review lead to the program as Dr. Duke described
in which the psychologist must complete one year of medical
training at Bethesda and one year supervised practicum at Walter
Reed Army Medical Center. Dr. Klusman believed that program worked
and ten graduated from PDP before its end in 1997. Nine of those
ten, remain on active duty and are prescribing. Their activities
have been overseen by an external consultant, the American College
of Neuropsychopharmacology, who have found their practices to be
safe, competent and effective. Dr. Klusman pointed out that one of
the PDP graduates is now the Chief of Inpatient Mental Health
Services which is essentially, inpatient psychiatry, at Keesler Air
Force Base. With regard to whether this program is a good training
program for psychologists to prescribe, Dr. Klusman believed that
had been answered by the experiences of the graduates.
VICE-CHAIRMAN HALCRO noted that the U.S. General Accounting Office
(GAO) report entitled, "Need for More Prescribing Psychologists Is
Not Adequately Justified," was not very flattering of the
Department of Defense program. In fact, one report in 1995
suggested the program be ended.
DR. KLUSMAN said that he believed the suggestion to end the program
was essentially a business decision. The GAO felt that the cost of
the program was very high and that report occurred during a time of
great concern for the federal budget. The report also "took the
Department of Defense to task for not justifying in advance why the
Department of Defense needed prescribing psychologists in uniform."
Dr. Klusman pointed out that the body of the report does not
indicate that these trained psychologists were inadequate or
incompetent practitioners. He believed the report recognized that
those psychologists were doing a good job.
Number 1873
DR. MONTY MILLER, Internist, Specially Board Certified in Internal
Medicine testified via teleconference from Tennessee. He informed
the committee that he was the Air Force Surgeon General at the
inception of PDP. Dr. Miller believed that the demonstration
project is somewhat misunderstood and misrepresented. He explained
that the project was developed in order to determine the
feasibility of training non-medical doctor psychologists to
prescribe. "Each of the three services was levied to provide two
psychologists to the program each year." He noted that the project
was not popular and the recruiting goal was not met, three dropped
out, and two entered medical school. As was mentioned, only 10
completed the program. Dr. Miller informed the committee that at
first the students were placed in the military medical school which
proved to be too difficult. Therefore, the students were switched
to the university nursing school curriculum for the basic sciences,
physical assessments and so forth. Initially, the program required
two years' course work at the military medical school followed by
a one year internship at Walter Reed which was followed by one year
proctored, a supervised patient care assignment. It took four
years for the first class to complete the program. Subsequent
classes received one year in the classroom, one year full-time
clinical training which was followed by a year of proctored
practice in a hospital environment. After evaluation of the
program, the National Defense Authorization bill mandated
termination of the program no later than June 1997 and required a
GAO report regarding the program's cost benefit and recommendations
concerning the continuation of the project. He quoted the GAO
report as saying, "Psychologists could not be substituted for
psychiatrists." The GAO report concluded that although the
Department of Defense had illustrated it could train psychologists
to prescribe, the training was not justified due to insufficient
need, increased costs, and "the benefits were uncertain and
questionable." He noted that PDP was featured on NBC as an example
of the fleecing of America.
DR. MILLER informed the committee that the American College of
Neuropsychopharmacology, some 600 scientists including
psychologists was contracted to make recommendations as to how the
psychologists should be utilized. The American College of
Neuropsychopharmacology (ACNB) recommended that the advisory
council develop the procedures and criteria for using the trainees.
The advisory council reviewed the scope of practice for the PDP
graduates and decided that the psychologists' scope of practice
should be similar to that of the physician assistants or nurse
practitioners rather than an independent practice. He explained
that the scope of practice was to be under physician supervision,
according to a treatment protocol, and a limited formulary.
Furthermore, the psychologists were restricted from treating
children under 18 years of age and those over 65 years of age in
order to protect these more fragile groups. Consequently, the
psychologists were credentialed as psychologist prescribers based
on a nurse practitioner's template. He specified that the
psychologists could practice psychology as independent
practitioners, but could only prescribe under a specifically
designated physician and from a specific limited list of drugs
which remains the Department of Defense's policy.
DR. MILLER turned to the performance of the graduates. He
acknowledged that some of the graduates developed a symbiotic
relationship with their supervisors which was to the benefit of
patients. In other instances, the relationship was not as
harmonious. The ACNB performed follow-up evaluations of the
graduates and reported that generally, the graduates surveyed were
prescribing safely and effectively given the restricted formulary,
proctoring, and the absence of inpatient seriously ill psychiatric
patients. Furthermore, the ACNB reported that the graduates'
patients had received a good medical evaluation before being seen
by the psychologist, the patients did not have complex or severe
mental disorders, and the bulk of the patients treated had
uncomplicated depressions. Of particular significance, the ACNB
reported that most of the graduates interviewed felt weak in
general medical knowledge, physical diagnosis, and use of the
laboratory; all after three to four years of training.
DR. MILLER expressed his chief concerns. He reiterated the
psychologists' deficiencies in basic science which precluded their
ability to participate at the medical school curriculum level.
Additionally, at the graduate level the PhD focus in psychology is
human behavior not medical science or medical illness. He pointed
out that one can receive a PhD in psychology with only one course
in the biological basis of behavior in comparison to the
approximately 4,000 hours of medical science in medical school. He
further noted that at the post doctoral level, primary care medical
doctors, internal medicine, family practitioners, pediatricians,
and psychiatrists undergo 10,000 to 12,000 hours of supervised
clinical, hospital based experience. Dr. Miller questioned the
severity of the impact of no resident psychiatrists in isolated
areas given society's mobility. Furthermore, he was concerned with
the timely detection and diagnosis of organic medical causes of
mental and/or behavioral abnormalities, especially in light of the
admitted weaknesses of the graduates. He expressed further
concerns with the timely detection of side effects from
psychotropic medications and/or their reactions with other
medications being taken by a patient.
Number 2252
DR. DWIGHT STALLMAN, Board Certified Psychiatrist; Medical
Director, Life Quest, testified via teleconference from the Mat-Su
Valley. He felt the risk to patients in allowing psychologists to
prescribe would be too great, even with two to three years
training. However, it would be reasonable for a psychologist to
enter a nursing program or a physician assistant program working
under a physician or psychiatrist. Furthermore, there is not a
great need for this. Although he acknowledged that there may be
some cost savings in managed care, he indicated that it would be
moving in the wrong direction for quality care and safety.
BARRY CHRISTENSEN, Pharmacist; Chair, Alaska Pharmaceutical
Association, testified via teleconference from Ketchikan. The
Alaska Pharmaceutical Association's Board of Directors and its
legislative committee oppose HB 139. He expressed concern
regarding the establishment of two tiers of licenses. Pharmacists
would be left to confirm endorsements of practitioners. While the
language saying that the Board of Psychology would transmit a list
of psychologists with endorsements to the Board of Pharmacy,
historically such a process is slow. Currently, the Board of
Pharmacy only meets three times a year and the list would probably
be outdated by the time of its receipt. Mr. Christensen referred
to Section 3 (d) which allows a psychologist to house a supply of
pharmaceuticals at their office. That is of concern in that there
is not a third check with regards to the pharmacist being able to
check dosage and drug interactions. He was baffled that the
legislation only speaks to controlled substances because there are
many medications being used as anti-depressants that are not
controlled substances.
REPRESENTATIVE MURKOWSKI inquired as to the process of how the
Board of Pharmacy would monitor these endorsements. Would the
board simply receive a list of those psychologist prescribers which
would be forwarded to any pharmacy in the state?
MR. CHRISTENSEN understood, by the legislation, that the Board of
Psychology would provide the list to the Board of Pharmacy. Then
the Board of Pharmacy, through the Division of Occupational
Licensing, would have to forward the list to the individual
pharmacies and pharmacists. The concern is that the process is
slow. He noted that this is of concern for pending legislation
regarding optometrists having potentially three types of licenses.
TAPE 99-56, SIDE B
REPRESENTATIVE MURKOWSKI posed a situation in which the Board of
Pharmacy was not on top of who is a licensed prescribing
psychologist, and someone not licensed as a prescribing
psychologist obtained a prescription. She asked if there would be
some fall-out to the pharmacy.
MR. CHRISTENSEN said he believed that is exactly the point. He
clarified that he is a member of the Alaska Pharmaceutical
Association, not actually a member of the Board of Pharmacy. In
theory, he agreed that the situation she described could result in
the pharmacy/pharmacist being reprimanded.
REPRESENTATIVE CISSNA referred to Mr. Christensen's comments
regarding not receiving the list in a timely manner. She pointed
out that HB 139 includes language requiring the information to be
provided in a timely manner. Representative Cissna inquired as to
how that receipt of information works with prescribing physicians;
do similar problems occur?
Number 0084
MR. CHRISTENSEN explained that physicians have prescribing rights
upon graduation from medical school. The only way that physicians
do not have prescribing rights is if their license is taken from
them. The pharmacies do not necessarily have lists of every
practicing physician in the state, although on occasion lists of
those physicians who have lost their license or those who are not
able to prescribe in total or certain classes of medications are
issued. He recalled that HB 139, as written, says that the Board
of Psychology will notify the Board of Pharmacy upon termination,
suspension, or reinstatement of an endorsement. The concern is
with regard to the time lag between the two boards and the
pharmacist. Currently, there is not a two tiered system within the
prescribing groups.
REPRESENTATIVE CISSNA asked how long after graduation would it be
before a pharmacist would receive knowledge that someone had
received their medical degree and can prescribe. Are there
problems in that arena?
MR. CHRISTENSEN answered that typically, there are not problems in
that area.
REPRESENTATIVE CISSNA questioned what constitutes a timely manner.
MR. CHRISTENSEN said he believed that a timely manner would be a
month or so after someone is endorsed to prescribe.
Number 0188
DR. IRVIN ROTHROCK, Psychiatrist, Fairbanks Psychiatric
Neurological Clinic, testified via teleconference from Fairbanks.
He informed the committee that he has been in practice in Fairbanks
since 1977. He noted that he is a current member of the Alaska
State Medical Board, but specified that his remarks did not
represent the board's position. He said that his objections to HB
139 were covered by Dr. Miller. The major objection is that there
is no way to adequately cover neuroscience, pharmacology,
psychopharmacology, physiology, et cetera in only 300 contact hours
of training. Dr. Rothrock read SSHB 139 to require supervised
treatment of 100 patients, after which there would be no further
supervision. Furthermore, the legislation does not reference any
continuing education to assure that the person is keeping abreast
of this field. He compared this with the physician's assistant who
always works with a supervising physician, and has completed two
years of schooling. Therefore, Dr. Duke's comparison of
psychologist prescribers to physician's assistants and nurse
practitioners is not helpful. In conclusion, Dr. Rothrock urged
the committee to vote against HB 139.
REPRESENTATIVE HALCRO asked if the Alaska State Medical Board has
taken a position on HB 139.
DR. ROTHROCK replied no.
Number 0364
DR. CAROLYN RADER, Psychiatrist, testified via teleconference from
Anchorage. She seconded Dr. Rothrock's point regarading the
comparison of psychologist training to that of physician's
assistant and nurse practitioner training. Dr. Rader noted that
she had talked with Faye Riley (ph) who ran, at one time, the
advanced nurse practitioner in mental health program at the
University of Alaska - Anchorage. That program included 1,700
hours of supervised clinical work with patients and 1,500 didactic
hours. With regard to the argument that psychologist prescribers
could provide services to rural areas that are not served by
psychiatrists, psychologists are already in an over abundance in
urban Alaska while scarce in rural areas just as psychiatrists.
She pointed out that psychiatrists travel throughout the state
providing services to rural areas. Furthermore, when telemedicine
comes on-line it will be less of an issue. For the safety of
Alaskans, Dr. Rader believed that properly trained mental health
care practitioners should be utilized. Dr. Rader urged the
committee not to pass HB 139.
TORIL STARK, a patient of a clinical psychologist and a
psychiatrist, testified via teleconference from Anchorage. Ms.
Stark supported HB 139 and commented that Dr. Lane's testimony
covered many of her points. However, she informed the committee of
the difficulties she had with seeking the appropriate treatment of
her bipolar and depression. She noted that she was diagnosed by
her psychologist, but due to medical protocol she had to visit more
than one psychiatric establishment in order to find a psychiatrist
that would work one-on-one with her to manage her medication. That
entire process took 18 months and she just returned to work. She
reiterated her support of HB 139.
Number 0575
DR. WANDAL WINN, Physician and Board Certified Psychiatrist,
testified via teleconference from Anchorage. He informed the
committee that he has a practice in Anchorage, but the emphasis is
on rural consultation. Dr. Winn noted that he holds degrees in
psychology and medicine. Dr. Winn reinforced Dr. Rader's comments
regarding rural access to care and noted that he has been traveling
to rural areas for over 20 years. Rural residents are entitled to
medical care and would be poorly served by a nonmedical person
prescribing such potent and potentially dangerous medications.
Furthermore, Dr. Winn echoed comments regarding the use of
telemedicine for rural areas.
DR. WINN emphasized that HB 139 is a radical proposition which
attempts to convert, through statute, a doctor of philosophy into
a doctor of medicine. Prescriptive practices cannot be segregated
from medical practice. Medications are integrated into a medical
model with many complex medical issues. Dr. Winn posed the issue
of side effects and asked how a psychologist prescriber would start
an IV or admit a patient to a hospital for a drug reaction, et
cetera. He also pointed out the issue of co-morbid conditions,
explaining that medications interact with hormonal systems and
other systems in the body. Most nonpsychiatric medications,
including antibiotics, cardiac medications, and anti-seizure
medications all have effects and interactions with psychotropic
agents. In closing, Dr. Winn said that an education in psychology
does not provide a foundation to practice medicine. Medical care
should be provided by physicians. Dr. Winn urged the committee to
defeat HB 139.
REPRESENTATIVE MURKOWSKI appreciated Dr. Winn's comments regarding
telemedicine and access for rural areas. She inquired as to the
importance, in the psychiatric field, for patients to have access
to laboratories such as those in urban centers.
DR. WINN stated that access to laboratory data and support is
important in psychiatric practice, although it would vary with the
case. There are complex protocols which differentiate between a
simple case and a complex polypharmacy case in which a physician
may need real time access to blood levels or medical laboratory
procedures. He agreed with Representative Murkowski that
utilization of a laboratory would also require the ability to read
and understand those reports. Furthermore, the information
provided by those reports must be considered in the context of how
it effects the rest of the medical care and management of the
patient holistically.
Number 0874
DR. RAMZI NASSAR, Board Certified Psychiatrist, Providence
Behavioral Medicine Group, testified via teleconference from
Anchorage. Three of the past four years, Dr. Nassar has worked out
of Nome, Alaska which further illustrates that there are
psychiatrists in Bush Alaska who travel to remote areas. With
regard to the earlier comment about long waiting lists for
psychiatrists, psychologists also have long waiting lists.
Therefore, he was not convinced that to be an issue. Dr. Nassar
explained that he and his colleagues practiced in a manner in which
someone with an appropriate referral will be seen in a timely
manner regardless of the waiting list. He believed that to be the
practice of many physicians.
DR. NASSAR turned to the issue of seamless care. The notion that
patients have to see a psychologist, then a psychiatrist, and,
perhaps, cycle through a social worker is a real scenario.
Although many psychiatrists are good at and enjoy providing
psychiatric care, the system is limited by the insurance companies.
He hoped that any legislation proposed would be such that it would
limit the way insurance companies limit the practice of this field.
DR. NASSAR continued with the issue of psychiatric training. More
often, the goal of psychiatric treatment is no longer to correct
chemical imbalances. Currently, more medications are being created
which go into the cells and neurons in the brain and throughout the
body. The lines between biochemistry, physiology, and anatomy are
becoming blurred. He echoed earlier comments regarding the
importance of those areas in prescribing medications. He also
believed that the lines between mental illness, neurological
illness, and physiological illness are becoming blurred.
Therefore, the comprehensive knowledge that medical training
provides for a psychiatrist is crucial in being able to practice
and continue to practice into the future.
Number 1067
DR. ROGER SHAFER, Psychiatric Physician, Veterans Administration,
testified via teleconference from Anchorage. He specified that his
testimony would speak to his own opinions. With regard to the
access issue, Dr. Shafer informed the committee that for the last
seven years he has been a psychiatric consultant to Nenana, Healy,
and the Railbelt. He noted that he has also be involved with the
telemedicine activity in Alaska. The access issue is a bit bogus.
Dr. Shafer turned to the issue of training and informed the
committee that he had been trained in sociology, psychology, and
then medicine. He had to take a great deal of training before
entering medical school, then four years of medical education with
a year of rotating internship and then three years of psychiatric
residency. Dr. Shafer said that combination was critical for him
to be able to practice medicine and psychiatry. Therefore, he
emphasized the need to know all organ systems in order to
effectively prescribe medication. Although psychologist training
ranges the spectrum, almost all of them are academic rather than
medical in nature. Dr. Shafer said that most psychologists he has
contact with are against legislation such as this because they
feel it would move beyond the scope of their practice and that a
training course would not allow them to effectively practice in
this area. Dr. Shafer stated, "It is impossible to prescribe
without engaging in the practice of medicine." In conclusion, he
urged the committee not to pass HB 139 out of committee.
REPRESENTATIVE MURKOWSKI recalled the argument that there are not
enough psychiatrists for the rural areas. Therefore, she asked if
Dr. Shafer maintained ongoing relationships with the nurse
practitioners or physician's assistants in some of the rural
communities in order to allow for contact and advice from
psychiatrists.
DR. SHAFER said that he has worked with many nurse practitioners
and found that to be a positive working relationship.
REPRESENTATIVE HALCRO commented that the access argument made him
curious as to how many psychiatrists there are today as compared to
10 years ago. According the State Medical Board, there are twice
as many licensed psychiatrists in Alaska as there were in 1989.
Number 1346
DR. MERIJEANNE MOORE, President, Alaska State Psychiatric
Association; Private Practice Psychiatrist, reiterated the point
that Alaska does have more psychiatrists and access is not such a
problem. Furthermore, psychiatrists work well with nurse
practitioners, physician's assistants, and other paramedical
people. The training psychology is proposing, 300 hours of
training and 100 patients, does not equal the training of a
psychiatrist, nurse practitioner, physician's assistant, or anyone
else practicing in this field. Dr. Moore emphasized that this is
viewed as a quality of care issue, not an economic or turf problem.
REPRESENTATIVE SANDERS identified the 300 hours as a common
concern. He asked if there is an amount of hours that would be
more appropriate.
DR. MOORE stressed that medical school is required. Furthermore,
there is a medical school in Alaska, the WAMI program, while there
is not a PhD psychology program here or a psychology prescribing
program. There are also nurse practitioner programs in Alaska.
REPRESENTATIVE CISSNA understood that psychiatrists cost a great
deal more than psychologists.
DR. MOORE replied no. She said that upon review of the
reimbursement schedules for Medicare codes, the overlapping codes
were the same. She noted that in Alaska Medicaid does not pay for
free-standing psychologists, but does pay for those psychologists
working in community mental health or physician directed clinics.
However, psychiatrists tend to work more hours.
REPRESENTATIVE CISSNA commented that there would be situations in
which the majority of the treatment would be behavioral with a
small portion being medication. Therefore, she asked if Dr. Moore
could see the need for both areas of expertise and possibly having
more charge over the pharmacological answers by both.
DR. MOORE answered no because she viewed the pharmacology portion
as difficult and complex. She agreed that there can be various
combinations of physical and mental problems. However, one would
not seek treatment from a behavioral specialist for diabetes just
because diabetes effects the person's behavior. Therefore, she did
not believe that one would seek treatment from a behavioral
specialist to treat medically based depression because that impacts
the person's behavior. Although there is overlap, these are two
separate fields. She indicated the need for more holistic care.
Number 1694
REPRESENTATIVE HALCRO reiterated his comment regarding the increase
in psychiatrists in Alaska. He also noted that in that
conversation with the Alaska State Medical Board, there was
discussion regarding the wider dispersement of psychiatrists in
rural communities. Representative Halcro requested that Dr. Moore
discuss the delivery of care in rural Alaska.
DR. MOORE confirmed that there are more psychiatrists living in
rural communities. However, there are also communities with small
population bases that cannot support a given specialist. She
commented, from personal experience, that in smaller communities
people treat you differently if you are a psychologist or a
psychiatrist. Dr. Moore pointed out that psychiatrists do circuits
in that they cover rural areas. In response to Chairman Rokeberg,
Dr. Moore recalled that there are 79 psychiatrists on the mailing
list, but deferred to Representative Halcro.
REPRESENTATIVE HALCRO noted that his information said that there
are 95 psychiatrists in Alaska.
Number 1907
DR. JEROME LIST, President, Alaska State Medical Association,
clarified that he is not a psychiatrist but a otorhinolaryngology
surgeon. He wanted to reinforce the notion that this is not a
business competition decision. Those at the association are
concerned about those who are not trained in the medical field
utilizing medications with significant impact on the body. Dr.
List commented that there is a well-publicized lawsuit in which a
well-trained physician in this community misprescribed some
medications, even through the scrutiny of the nurses, and the
patient died. Therefore, the potential for mistakes can happen
even in the hands of an experienced physician. He noted the
liability issues such a situation would bring on psychologists.
Dr. List proposed a tighter relationship between practitioners,
working as a team to deliver the health care system in a more
organized, coordinated fashion. He believed that telemedicine,
telehealth, and telepsychiatry will help eliminate some of these
barriers in the future.
REPRESENTATIVE MURKOWSKI appreciated Dr. List's comments regarding
the need for cooperation and asked if there is too much turf
between psychology and psychiatry. She referred to those who say
that they had to go to a psychiatrist and explain their situation
in order to receive the medication that the psychologist could not
prescribe. She asked if there is a way to marry the situation
short of giving psychologists prescribing authority.
DR. LIST pointed out that there are some large clinics in Anchorage
which have integrated clinical psychologists along with a
psychiatrist. He reiterated his belief that the professions can
compliment each other. Personally, he viewed modern medicine as
prescribing too many medications. Dr. List recognized that there
is an overlapping of duties which has lead to an unwillingness to
work together, as has also happened between optometrists and
ophthalmologists. Working together offers a better situation for
everyone, providing better health care for Alaska's communities.
REPRESENTATIVE HALCRO inquired as to whether malpractice insurance
would increase for prescribing psychologists.
Number 2272
DR. LIST said he was sure prescribing psychologists would incur an
increase in malpractice insurance. He was not sure that cost
savings would be realized in view of the overall cost of delivering
medicine. He informed the committee that his malpractice insurance
premiums are over $30,000 per year, those are health care dollars.
REPRESENTATIVE MURKOWSKI recalled Representative Sander's question
regarding how many hours of training would be appropriate for a
psychologist to be able to prescribe. In that vein, she noted that
this committee recently heard legislation requiring manicurists to
receive 250 hours of health, safety training. She inquired as to
Dr. List's opinion on the appropriate amount of training.
DR. LIST commented that he was not sure he could provide a specific
number of hours. He turned to the "health aides" in Alaska who
have done a great job of providing health care in rural communities
and have the availability of certain medications. Those "health
aides" can deal with certain medications in 95 percent of the
cases, but the difficult part is dealing with the remaining five
percent.
TAPE 99-57, SIDE A
DR. LIST reiterated his inability and uncomfortableness with
specifying a number of hours. Often, the issues surrounding the
hours come into the turf battle. The difference with the medical
training is that education makes one better prepared, although that
is not an absolute.
REPRESENTATIVE CISSNA recognized that there are cases that require
combination approaches, but she noted that there are cases with
predominantly behavioral problems with a minor need for medication.
She seemed to view this as having two sides. Representative Cissna
asked if Dr. List saw a way to reach the point at which one could
recognize a situation as beyond his/her professional ability which
would lead to a referral to a specialist.
DR. LIST acknowledged the complaint that the medical community is
not sufficiently holistic. He informed the committee that although
he deals with mental illness day in and day out and has the
training to prescribe prozac, he does not do so because he believed
there is someone better trained to prescribe it. He also noted
that he refers many patients to psychologists when he feels
patients would be better served by them. Dr. List stated that he
would not want to see people without training prescribing
psychotropic medications. Furthermore, he said that he would not
send a family member to a psychologist for medication.
Number 0460
DR. CHARLES BURGESS, Chairman, Department of Psychiatry, Providence
Hospital, testified via teleconference from Anchorage. He informed
the committee that he is a social worker that attended medical
school. Dr. Burgess heads the Providence Behavioral Medicine Group
which consists of four PhD psychologists, one master's level
psychologist and five social workers. Dr. Burgess noted that he
also sits, as the only psychiatrist, on the Board of the Help
Alaska Network which is the primary care physicians group. That
group intends to plan integrated mental health services with
primary care physicians. Dr. Burgess said that originally, he was
going to testify to the effect that if it is not broken then there
is no need to fix it. Currently, the system is working well.
DR. BURGESS informed the committee that approximately 60 percent of
prescribed psychotropic medications come through the primary care
community, primary care physicians. The family practice residency
is adequate and strong in the training of diagnosis and treatment
of mental illness. Still, primary care physicians rely on
psychiatrists as specialist backups. Dr. Burgess informed the
committee that about 30-40 percent of communities are provided
psychiatric services as well as psychological services from the
Langdon Psychiatric Clinic. He noted that psychiatrists prescribe
less than 40 percent of all medications and nurse practitioners and
physician's assistants prescribe some percentage in that.
DR. BURGESS pointed out that there is already a provision allowing
psychologists to prescribe if that psychologist attends medical
school, nurse practitioner training, or physician's assistant
training. Creating another group of prescribers would be in
opposition to the goal of holistic care. The goal is to support
the primary care physicians in rural communities in bringing mental
health care into a more integrated holistic setting. He mentioned
the consideration of psychiatrists and psychologists rotating into
the primary care practices in order to promote communication with
physicians.
CHAIRMAN ROKEBERG requested that Dr. Burgess expand upon his
comments regarding the lack of coordination.
DR. BURGESS commented that with regard to having psychologist
prescribers, most psychologists are solo practitioners that are
disconnected from the medical community. Therefore, there is angst
among physicians regarding the possibility of moving in this
direction. He reiterated the need for medical training in order to
have a more holistic product. Dr. Burgess stressed that
psychologists don't often relate well with physicians which can be
in part related to the psychologists treatment of a particular
portion of the patient, not the entire patient. In that regard,
psychologists serve as a bridge. Dr. Burgess pointed out that
probably 30 percent of his patients have diagnoses that must be
differentiated between such as depression and thyroid problems. In
addition, Dr. Burgess informed the committee that the Providence
Hospital Board is opposed to HB 139.
Number 0869
DR. DAVID RICHARD SAMSON, Psychiatric Physician, testified via
teleconference from Anchorage. Although he is currently the
Medical Director of the Anchorage Community Mental Health Center,
Dr. Samson emphasized that his testimony only reflects his
thoughts. He noted that his concerns have been addressed in a
letter to the committee. He informed the committee that he would
discuss his experiences with the process of becoming a clinician.
Dr. Samson said that he has seen and probably supervised directly
the clinical services provided by at least 150 allied mental health
professionals. Furthermore, any physician seeking his consultation
has had a certain standard of training which would not be true of
those who are not from a medical doctor background or an osteopathy
background. With regard to the nurse practitioners, he pointed out
that they have standardized schooling throughout the nation and are
more able to move into a prescribing role. While psychologists
tend to come from a PhD, science background with a variety of
disciplines that don't have any standardization. In the process of
his supervision of 150 or more different clinicians, not one of
those would want to be able to prescribe without going through the
nurse practitioner or medical doctor process. With regard to the
question of prescribing from a limited formulary, the floor often
becomes the ceiling. Dr. Samson encouraged the committee not to
endorse HB 139.
DR. ROBINSON, M.D., announced that he would withhold his comments
and would be available to answer questions.
DR. CHUCK ELLIS, M.D., also declined to testify.
Number 1115
DR. GILBERT SANDERS, Psychologist, informed the committee that he
has a private practice and also works for the Alaska Native Medical
Center. He noted that his opinions are his own. Dr. Sanders
turned to the GAO report and noted that he has had intimate contact
with PDP. Colonel Gill(ph), a psychologist at the Academy of
Health Sciences, specified in testimony before Congress that the
first group of individuals to go through PDP were required to
compress the first two years of medical school into one year.
Therefore, some of the problems mentioned were the result of the
compression of medical school. According to Colonel Gill(ph), the
administration of the school determined it best to pull the
training down to a manageable level which specifically addresses
those topics relevant while excluding those areas not required to
prescribe safely. With regard to the report's comments on the
excessive cost with PDP, Dr. Sanders didn't believe that point to
be relevant. However, he indicated the need to question the
report's overall integrity since the cost of training the
psychologists included the cost of the report considering the
training.
DR. SANDERS turned to the issue of training. There seems to be a
misunderstanding of the 300 hours/100 patients. The 300 hours is
designed as the didactic portion and does not include the various
studying or passage of intermediate tests. Dr. Sanders said,
"Basically, if one were to look at that training as it were
pertained to academic study, ... it would break down to some 21
plus semester hours of training which would be post-doctoral.
There are several colleges and universities around the United
States today that are offering the training. Basically, what they
have done is they've expanded those particular programs and
basically are, now with the practicum included, offering a master's
degree post-doctoral in psychopharmacology."
DR. SANDERS addressed the question of why bills such as this have
failed in the past. To this point, no bill has made it to any
floor of the Senate or House of any state for a vote other than in
Indiana. The bill passed in Indiana specifically provided the
graduates of the Department of Defense's PDP unlimited ability to
prescribe psychotropic medications and their allied agents. Bills
have been introduced in Georgia, Louisiana, Missouri, California,
Hawaii, New Jersey, and Oklahoma.
DR. SANDERS acknowledged the concerns with telehealth. He informed
the committee that he had spoken with Senators Murkowski and
Stevens regarding bringing funds to Alaska specifically for
telehealth. Furthermore, he has been involved in various meetings
to sponsor telehealth. He stated that psychology is involved in
the telehealth project. With regard to comments about the lack of
a medical program for psychologists and the availability of the
WAMI program, Dr. Sanders noted that he is a faculty member of the
WAMI program. As a psychologist, Dr. Sanders, helped train
physicians who will be able to prescribe. Part of his teaching
involves how a physician can perform effective psychological
assessments for the programs the physician will eventually be
trained to prescribe. Therefore, Dr. Sanders is training the
prescriber, although he is unable to prescribe.
CHAIRMAN ROKEBERG inquired as to the relative split in the
psychological community with regard to this issue.
DR. SANDERS informed the committee that the Alaska Psychological
Association has done research which has found that 75-80 percent of
all licensed Alaskan psychologists support the opportunity of
obtaining the appropriate training and knowledge to be granted
prescriptive authority. Furthermore, he didn't believe that there
is uniform opposition to this from the medical community.
Number 1536
REPRESENTATIVE MURKOWSKI recalled that Dr. Sanders testified that
there are medical schools in Georgia and California that had
developed programs to train psychologists for prescribing. She
inquired as to how long those programs last and if no state allows
psychologists to prescribe, why are programs in place.
DR. SANDERS pointed out that psychology is bio-psycho-social in
nature. The significant component of all psychological programs is
the biological basis of behavior. Therefore, the expansion of
these programs is two-fold. Merely understanding more makes the
psychologist a better provider. The mere existence of these
programs speaks to the direction of psychology itself. With regard
to the number of hours of the programs, he believed that the
combined program of Georgia State and the University of Georgia
called for 342 hours. That is basically a 2.5 year post doctoral
masters program. He recalled the mention of 12,000 hours to which
he pointed out that from the time he began a doctoral program to
the time of licensure eligibility he accrued in excess of 16,000
hours. Furthermore, his internship both the one year pre-doctoral
and post-doctoral were performed at a major mental health facility
in Oklahoma. As an intern, he worked side by side with a
psychiatric resident in his second year of residency. Therefore,
care must be taken in review of this.
REPRESENTATIVE SANDERS inquired as to how many psychologists are in
Alaska.
DR. SANDERS said he believed there are approximately 140
psychologists in the state, many of which live in remote areas. In
response to Representative Halcro, Dr. Sanders said there would
certainly be a significant increase in malpractice insurance.
Although Coopers & Lybrand [currently, Price Waterhouse Coopers]
have done studies, a specific figure is not available. He
predicted that those completing the proposed training would
probably face a several fold increase in malpractice insurance.
REPRESENTATIVE HALCRO pointed out that according to the sponsor's
documentation, psychologists are generally less expensive than
psychiatrists/medical doctors. There is further documentation that
the elderly and poor are particularly hard hit by those costs.
Therefore, Representative Halcro predicted that an increase in
malpractice costs would be passed along to the patients which would
place psychologists on the same plane as psychiatrists.
DR. SANDERS replied, not necessarily. He pointed out that the
liability insurance for an advanced nurse practitioner is not at
the same level as a psychiatrist or physician. Although there will
be increased costs, the overall costs will probably remain
significantly lower. He informed the committee that several of the
individuals at his work have just completed their boards and
several others have completed three years post boards, those
individuals are making about $60,000 more than himself who
completed his doctoral training program 25 years ago.
REPRESENTATIVE CISSNA noted the previous testimony of psychiatrists
with regard to the need for medical training. She inquired as to
why the training is not good enough.
DR. SANDERS answered that the system is not working well as it is,
he noted Alaska's problems with access. For example, when an
individual makes a decision to seek treatment for mental health
issues the window is open. If the individual can be seen at that
time, significant progress can usually be made. Currently,
psychiatrists have extended waiting lists of four to six weeks for
those that aren't life-threatening or suicidal. If that window is
not utilized, those individuals tend not to seek treatment. If an
individual obtains an appointment within one week, there is a high
probability, 90 percent, that individual will make that
appointment. Every day outside that one week, the probability that
individual will not make that appointment increases. From a mental
standpoint, those unmet mental problems show up as physiological
problems. Data says that 70 percent of all medical problems have
a significant mental health or psychological basis.
Number 2013
CATHERINE REARDON, Director, Division of Occupational Licensing,
Department of Commerce & Economic Development, stated that the
department has not taken a position on HB 139. Furthermore, the
Medical Board, the Board of Pharmacy, and the Board of Psychology
have not taken a position on HB 139 either. Ms. Reardon informed
the committee that Alaska doesn't license physicians in
specialities, therefore, psychiatrists aren't actually licensed.
A physician's license is issued, and legally the gamut from surgery
to general practice could be performed, although a specialty can be
listed. Therefore, the statistics as to how many individuals
comprise a specialty would not necessarily be accurate. Ms.
Reardon also clarified that in Alaska advanced nurse practitioners
don't have to have collaborative agreements with physicians while
physician's assistants do. Ms. Reardon noted that there are other
professions that are able to prescribe, not psychotropic or mental
health drugs, with an endorsement. For example, some optometrists
have an endorsement which allows them to prescribe from a limited
formulary which illustrates that there is some experience in
running a program in which some licenses would have endorsements.
In such cases, the pharmacists would need to be aware of who can or
cannot prescribe.
MS. REARDON turned to the appropriate training background. She
suspected that the more similar the training to the volume and
quality of training of physicians, fewer psychologists would seek
to obtain the endorsement. She explained that one of the arguments
for psychologist prescribers is the notion of greater access,
greater rural access. She suggested that perhaps, there would only
be 10 more people. At that point, one may need to determine
whether the improved access is worth it. With regard to
malpractice insurance, it is not required in Alaska for physicians
or psychologists.
MS. REARDON recalled the comment regarding the delay in the
potential window of interest in treatment. If a potential patient
needs to see someone who can prescribe within a week or so of
indicating interest in treatment, the patient would need to be able
to distinguish between their need to choose a psychologist who can
prescribe versus a psychologist without prescriptive authority.
Without the ability to distinguish between those groups, the
patient would be in the same situation as today. Therefore, the
patient would have to be a fairly educated person or there would
need to be good screening techniques in the psychologist's office
in order to determine whether to direct the patient to a
psychologist prescriber.
CHAIRMAN ROKEBERG announced that HB 139 would be held over.
HB 211-MANAGED HEALTH CARE INSURANCE
CHAIRMAN ROKEBERG announced that the last order of business before
the committee is HB 211, "An Act relating to liability for
providing managed care services, to regulation of managed care
insurance plans, and to patient rights and prohibited practices
under health insurance; and providing for an effective date."
CHAIRMAN ROKEBERG informed the committee that, as the sponsor of HB
211, he would forego any comments and take testimony from those
present. He announced that HB 211 would be carried over as an
interim project.
Number 2337
DR. JIM JORDAN, Executive Director, Alaska State Medical
Association (ASMA), noted that the committee has been provided with
testimony as well as much background material. Therefore, he said
that he would not present testimony, but would be available for
questions.
DR. JEROME LIST, DDS, MD, Alaska State Medical Association, echoed
Dr. Jordan's comments regarding the information the committee
should have. He also noted that he could provide the committee
with a written copy of his oral testimony given today. Dr. List
began saying, the practice of medicine takes place in the context
of a complex series of relationships between patients and treating
physicians. The doctor's sole responsibility is the obligation
towards the patient. Therefore, any inappropriate intrusion into
that relationship would adversely impact the outcome of what
doctors are trying to accomplish which is to treat patients. Dr.
List pointed out that insurance companies have been involved in
selling managed care policies which have increasingly encroached on
the aforementioned relationship. This situation has flourished in
the Lower 48. He indicated that one of the ideas behind HB 211 is
to learn from some of the errors and problems that have been
experienced with managed care in the Lower 48 in order to prevent
such from happening in the State of Alaska.
DR. LIST commented that the patient and the physician have a
diminishing ability to bargain with insurance companies.
Furthermore, health insurance market shares are being concentrated
over a decreasing number of insurance companies. Alaska has had,
perhaps, three major insurance companies. He predicted that there
will be more mergers like those with the oil companies. He said,
"I think that what that boils down to is that small practices,
physician practices, solo practitioners don't stand a chance in an
adversarial situation with these monster companies." This
legislation, HB 211, would help introduce some provisions allowing
physicians to play on a more level playing field.
DR. LIST recognized that most health care insurance coverage comes
from the workplace. Most patients, unless they own their own
company, do not have much choice in their health care coverage.
Still, the employers with such authority face a gross imbalance in
bargaining with health insurers.
TAPE 99-57, SIDE B
Number 0005
DR. LIST emphasized the hope that HB 211 will help resolve some of
those issues. He pointed out that typically, physicians practices
in Alaska are solo or small group practices which may be
accentuated by Alaska's rural nature. "A sole practicing physician
is not an equal contracting party compared to a large insurance
company." He specified, "The key to HB 211 is the underlying
concept that physicians are the appropriate ones to determine the
most appropriate care for a specific patient." This concept can be
found in the definition of "medical necessity" on page 10, lines
15-23 of the bill. Medical necessity has been inappropriately
intertwined with what is covered by a certain health insurance
policy. Dr. List felt it important to separate that out.
Furthermore, the physician should be the sole individual making the
determination of what is medically necessary. Medical insurers
should review claims in order to determine if the health care
provided is medically necessary. He stressed that "we" are not
adverse to such review by insurance companies. Physicians feel
that the definitional standard needs to be established. The
definition in HB 211 has been developed by the American Medical
Association (AMA).
Number 0095
DR. LIST informed the committee that it has been provided with the
"white paper" which was presented to Congress earlier this year by
the Health Insurance Association of America (HIAA). In this paper,
the HIAA states that approximately 97 percent of the cases reviewed
for proper utilization found the course of treatment recommended by
physicians to be well within HIAA's recommended guidelines.
Perhaps, 3 percent of the cases were determined to be inappropriate
in eight different categories. The HIAA further stated that if the
current standard, which is comparable to HB 211's definition of
medical necessity, is adopted "the result would '...Raise health
care costs, reduce quality, and lead to increases in health care
fraud'." Dr. List was aware of the arguments against this however,
the definition of medical necessity should be in the physician's
hands rather than an insurance company's hands.
Number 0157
DR. LIST pointed out that the language in Section 2 of HB 211 is
patterned after language in Texas which has been adopted in
Missouri and Georgia. This language "is intended to eliminate the
'hiding place' behind ERISA [Employee Retirement and Income
Security Act] preemption." He informed the committee that the
Texas law has been challenged, but has been upheld thus far in
federal district court. Dr. List predicted that there would be
testimony opposed to the accountability section of HB 211 based
mainly on the argument of increased costs. With respect to that
argument, he urged the committee to review the cost analysis
provided by the ASMA's written testimony. In conclusion, Dr. List
requested that the committee favorably consider HB 211 in order to
provide better health care.
Number 0236
MARCI BURTON, Regional Director, Managed Health & Physician
Integration, Providence Health System, testified via teleconference
from Anchorage. Ms. Burton informed the committee that the
Providence Health System did not have an official position on this
at this time. However, there are some recommendations and
questions regarding intent. In response to Chairman Rokeberg, she
said that she would provide written comments.
MS. BURTON commented that HB 211 includes many beneficial sections
to providers as well as to the relationship between the provider
and the patient. Ms. Burton directed the committee to page 3, line
22 and requested that there be clarification regarding whether the
language references calendar days versus business days. She
suggested 10 business days in order to promote the ability to
comply with this. She turned to page 4, line 19 which promotes
effective communication between the physician and the patient.
However, the definition of "advocate" could be open to
interpretation. She requested clarification of the intent on page
4, line 31 because she has not seen a contract requiring a
physician to match a lowest rate. Ms. Burton moved to page 5, line
9 and inquired, "Are you requesting that a model contract that's
being used be given to the director or should every contract that's
negotiated be given to the director?" On page 5, line 19 which
provides that the covered services be reasonably available in the
community where the covered person resides. She indicated it could
be difficult to implement this because what is the definition of
"reasonably available." Furthermore, how will rural areas be
addressed? She commented that page 5, line 12 is great for
providers, but will probably be an issue for insurance companies.
Although the language on page 6, line 30 is great for a point of
service plan, how will that be implemented?
MS. BURTON referred to page 7, line 17 and commented that typically
transitioning a covered person to another provider is a 90 calendar
day period rather than six months which is what she has seen in
contracts. She noted that her comments do not speak to if this is
good or bad. With regard to page 8, line 16, she noted that
nationally, it is becoming more popular for insurance companies to
attempt to be a friendlier entity. She believed that AETNA and
Blue Cross, in other markets, have an external appeal process for
patients. She has heard that it is working well for both the
patient and the insurance company. Perhaps, the committee should
obtain information regarding if those truly work and are
successful. She noted that the language on page 11, line 8 is
similar to some of the "any willing provider" legislation.
Although she acknowledged the importance of choice, Ms. Burton
pointed out that this potentially limits the choice of the
employer. The employer needs to be able to have the right of
choice in order to control health care expenditures. Therefore,
she requested that this section be tied to Section 21.07.030 of HB
211. She also recommended that page 11, line 13 be tied to page 2,
line 7 in order to prevent misuse. She surmised the intent to be
peer review which is good.
MS. BURTON commented, in conclusion, that HB 211 does overall
include things that protect providers to which she was
appreciative. She reiterated that she would provide the committee
with her comments in writing.
CHAIRMAN ROKEBERG noted that Mr. Barry Christensen, Alaska Pharmacy
Association, would provide the committee with written testimony.
Number 0567
MARY VEALE, Physical Therapist, Alaska Chapter, American Physical
Therapy Association, stated support for HB 211 which really
protects patients overall. She was pleased that the issues of
accountability, access to health care professionals, open
communication between patients and health care professionals, peer
review, and point of service were covered in the legislation. Ms.
Veale noted that she would fax the committee her written statement.
She also offered to provide help over the summer with this issue.
CHAIRMAN ROKEBERG expressed his appreciation in working with Gordan
Evans, lobbyist for HIAA. He reiterated that this is an interim
project and would like to have any input from Mr. Evans, Reed
Stoops (Lobbyist, AETNA Life & Casualty), and Jerry Reinwand
(Lobbyist, Alaska Timber Insurance Exchange and Blue Cross of
Washington & Alaska). He informed the committee that it is his
intention to make health insurance available to the most people at
the most affordable rate. However, there are other concerns
regarding how the health insurance industry is designed in Alaska.
He acknowledged the concerns of the medical professions, although
he did not share those concerns, regarding the entry of managed
care type organizations in Alaska. Chairman Rokeberg said that he
wanted to foster an attitude and legal structure which would be
inviting to such types of organizations which he believed could
lower the cost and provide more service. Still, the patient's
rights are of most paramount. He noted that there are several
bills at the national level addressing some of these issues.
Chairman Rokeberg believed that the prerogatives of the state in
regulating insurance should be maintained. He indicated that the
legislature can design things that work best for Alaska which is
one of his intentions with HB 211.
ADJOURNMENT
Number 0737
There being no further business before the committee, the House
Labor & Commerce Standing Committee meeting was adjourned at 6:05
p.m.
| Document Name | Date/Time | Subjects |
|---|