Feature

With bleak budget situations in the states, psychologists faced uphill advocacy battles this year. But in many states--even those in economic hard times--advocates trudged on to legislative victories.

"This was a very tough year financially," says Michael Sullivan, PhD, assistant executive director for state advocacy in APA's Practice Directorate. "State legislatures didn't have money to spend. So it's been a mixed picture for psychology."

Psychology leaders say a great deal of credit for the legislative victories goes to state psychological associations. "The gains during 2003 are largely a testimony to state associations' organized advocacy strategies and sheer persistence," says APA Executive Director for Professional Practice Russ Newman, PhD, JD. "These associations have continued to demonstrate the perseverance and flexibility needed to achieve important legislative goals in difficult and uncertain times."

Scope of practice

Perhaps some of the most significant action this year revolved around psychologists' scope of practice, Sullivan says. For example, developments occurred in the following states:

  • California passed a law that gives psychologists authority to discharge patients who have been involuntarily committed to hospital treatment. The "discharge" bill was introduced by state representative and psychologist Judy Chu, PhD.

California has typically been "a bellwether state for leading the nation in terms of scope of practice," including previous hospital privileges laws, says Charles Faltz, PhD, director of professional affairs for the California Psychological Association. But, in this case, psychologists' authority to discharge patients before the end of a commitment period had been in question.

"This bill is part of a compromise," says Faltz. "It requires consultation between psychologists and psychiatrists." Even though psychologists don't yet have complete decision-making autonomy concerning an involuntarily committed patient's release under this new law, it's a step in the right direction, adds Sullivan.

  • Pennsylvania also reached a compromise with the state medical association to pass legislation governing hospital privileges for psychologists. After a 15-year fight, the Pennsylvania Psychological Association (PPA) finally mounted enough pressure in the legislature to succeed, says Tom Dewall, PPA's executive director.

"We ended up with a compromise," he says. The law doesn't give admission privileges to psychologists, but psychologists can participate on treatment teams and can be voting members on hospital staffs. Also, if a psychologist's patient is admitted to or discharged from the hospital, the attending psychiatrist must alert the psychologist.

Sullivan says the passage of this law illustrates the value of persistence and underscores the importance of APA's hospital privileges agenda. Now 18 states have some type of psychologist hospital practice law.

  • Massachusetts psychologists also experienced a victory related to their scope of practice law. Eight years ago, the Massachusetts Psychological Association (MPA) worked to amend the psychology licensing law to prevent unlicensed professionals working in state institutions from using the title psychologist. Despite winning this battle, the state didn't completely end the practice. So MPA, with support from Ruth Balser, PhD, a psychologist in the Massachusetts state legislature, launched a campaign with the state's Office of Human Resources to implement the title "psychological assistant" for these nonlicensed positions--and they won.

This case, says Elena Eisman, EdD, MPA's executive director, is a perfect example of how grassroots advocacy doesn't end when legislation is passed. "Your job isn't over until the regulations are implemented," she says.

Prescriptive authority

While no new prescription privileges legislation was passed this year, more states advanced bills to hearings than ever before--perhaps gaining momentum from the implementation of New Mexico's prescription privileges law. Nine new prescription privileges bills were introduced. Of those, six went to committee hearings--in Florida, New Hampshire, Oregon, Wyoming, Hawaii and Texas.

Indeed, in Wyoming, the bill traveled a remarkable distance--it was even brought to a vote--through the legislature in its first year.

"That shows real access-to-care concerns," says Sullivan.

For many states where there is a dire need for mental health services in rural areas, the active prescription privileges agenda is encouraging, he adds.

Health-care reform

Psychologists in Maine made huge strides this year, passing a comprehensive mental health parity law as well as a universal health plan.

According to Sheila Comerford, executive director for the Maine Psychological Association (MePA), the association had been working toward full mental health parity since 1994. In fact, the bill was even vetoed by the past governor.

But in October, the new law, which improves a law that only provided coverage for certain diagnoses, finally became effective. A broad-based parity bill, it includes substance abuse treatment, eliminates separate mental health co-pays and lifetime maximums on care, and allows for medically necessary home health visits by mental health professionals.

This win pushes the number of states with full mental health parity up to 15.

Maine psychologists also testified in support of the Dirigo Health Plan--Gov. John Baldacci's universal health plan. The bill became law in June, and coverage begins in July 2004.

The new law gives approximately 180,000 uninsured Mainers access to coverage--to be fully implemented by 2009, says Comerford. To accomplish this, the law establishes a combined public and private insurance plan and expands state Medicaid coverage. The plan will also use employer and individual contributions, federal funds, recovered debts and charity funds to operate.

Other states chipped away at health-care reform in different ways. Maryland, for example, passed new managed-care accountability legislation. The new law requires managed behavioral health-care companies to disclose certain financial information publicly. Moreover, the information must be reported accurately and uniformly. That means any insurance carrier that contracts with a managed-care company must require that company to provide an annual report on its direct behavioral health-care expenses, not including administrative expenses.

The Maryland legislation reforms an old law that, according to Sullivan, wasn't specific enough. "Managed-care companies were not disclosing their costs fully--there were too many loopholes," he says.

Only Vermont has similar legislation. Sullivan notes that psychologists there are grappling with the same loopholes. The Maryland law, he says, may set a precedent the Vermont legislature--and perhaps other states--will follow.

Though Vermont psychologists did not see legislative activity, there was some action on the parity front. The Substance Abuse and Mental Health Services Administration closely examined Vermont's mental health parity law.

"This was the most exhaustive study of a parity law done so far," says Sullivan. By and large, the findings were positive. For example, following parity implementation in Vermont, more people received outpatient mental health, consumers paid a smaller share of the total amount spent on mental health services and less than one percent of Vermont employers reported that they dropped health coverage for employees.

Civil immunity

The Florida Psychological Association (FPA) was instrumental in passing a new law that provides good-faith protection for court-appointed psychologists in child-custody cases. According to FPA, 80 percent of all administrative complaints filed with the state board of psychology came from people involved in child-custody evaluations. The problem was so pervasive some psychologists in Florida stopped doing child-custody evaluations altogether.

The new law says that complaints made to the board can no longer be anonymous and complainants must petition the appointing judge to determine whether the psychologist has violated set standards. If the psychologist is exonerated, the complainant must bear the cost. Conversely, psychologists must pay if they are found at fault.

"This is nice protection and is a way of keeping psychologists involved when the threat of litigation is high," says Sullivan.

"In a year where very few bills were passing in general...FPA made out like a seasoned winner," says Michael Brawer, FPA's executive director. "We expect this law to significantly reduce the instances of complaint in this arena of practice."

Medicaid issues

Health-care funding cuts were rampant in many states this year. Some states fared well, but others lost important Medicaid funding for services. Indeed, three states--Connecticut, Texas and Ohio--lost Medicaid coverage for adult outpatient psychotherapy.

In New York, however, psychologists won increased funding for patients who are eligible for both Medicaid and Medicare. According to Eric Garfinkel, PhD, chair of the New York State Psychological Association (NYSPA) Managed Care Committee, approximately 80 percent of nursing home residents in New York are dually eligible.

NYSPA members testified to the state legislature and were successful in blocking proposed cuts to crossover care. So when psychologists provide psychotherapy services to this population, Medicaid picks up what Medicare doesn't pay. "The legislature really made an exception for psychology," adds Garfinkel.

"State associations are really out in the forefront fighting cuts to mental health services," says Sullivan, who admits, "Next year will be tough too." But like this year, psychologists in the states will persevere.