Legislature(1999 - 2000)
05/10/1999 03:22 PM L&C
* first hearing in first committee of referral
= bill was previously heard/scheduled
= bill was previously heard/scheduled
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.