Legislature(1999 - 2000)

05/10/1999 03:22 PM L&C

Audio Topic
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
txt
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.                                                                     
                                                                                                                                

Document Name Date/Time Subjects