Feature

This year, state psychological associations continued to broaden resources for psychological services to patients by working with legislators for action on prescriptive authority, mental health parity, hospital practice and other professional regulations.

"Guided by the strategic efforts of our state association leaders, a number of important initiatives for professional psychology are gaining ground throughout the country," said Russ Newman, PhD, JD, APA's executive director for professional practice. "While expanding the availability of psychological services continues to be a challenge in the current climate, the work of many state psychological associations continues to succeed in moving the agenda forward."

Here are some of the issues that made significant headway in 2005.

Prescriptive authority

In recent years, New Mexico and Louisiana made history as the first two states to pass legislation allowing qualified psychologists to write prescriptions. This year, they made history by implementing the legislation.

The training requirements are different in each state. In New Mexico, after psychologists have completed all coursework and other training requirements, they are eligible for a two-year conditional prescription certificate, which allows them to prescribe under the supervision of a physician. If they successfully complete the two-year supervision process, psychologists will then be allowed to independently prescribe, but will still work closely with the patient's physician.

In Louisiana, after psychologists have completed their training, they may independently prescribe medication, but are required to consult the patient's physician. According to James Quillin, PhD, president of the Louisiana Academy of Medical Psychologists, 25 psychologists are currently prescribing in Louisiana, with more on the way. Quillin says the system is working well for all parties.

"It's well accepted by patients," he says. "It's quite a benefit to them because it's based on a collaborative-care model that ensures optimal treatment," he says.

Other states are working on prescriptive authority bills. Hawaii, which has been working on this issue since 1984, pushed a bill all the way to the Senate floor this year-the farthest such legislation has ever advanced. The bill died on a tie vote, but a task force has been set up to study the need for prescriptive authority in the state. Tennessee has also been making progress in moving a bill through the legislature, and several other states have held hearings.

"More prescriptive-authority bills got hearings this year than any other year-it's an indication of the growth of the movement," says Michael Sullivan, PhD, assistant executive director for state advocacy in APA's Practice Directorate.

APA's Committee for the Advancement of Professional Practice (CAPP) provided funding for most of the state prescriptive initiatives.

Mental health parity

Also bringing benefits to patients are mental health parity laws passed this year by Washington, Oregon, Iowa and South Carolina-bringing the number of states with some form of mental health parity to 41. Hawaii, Illinois and Maryland expanded their existing mental health parity laws, and psychological associations in other states continue to push to get laws passed.

"Persistence and creativity are key to passing legislation, and the successful parity effort in Washington state is a great example of that," says Marilyn Richmond, assistant executive director for government relations in the APA Practice Directorate. For eight years, Washington's parity advocates fought hard to enact a comprehensive parity law, she explains: "They broke the legislative logjam not

by compromising on what mental health disorders would be included, but by taking an innovative approach that will phase in parity for all diagnoses."

As a result of this effort, Washington passed a comprehensive parity law that mandates that all mental illnesses-excluding substance abuse-be covered by health insurance at the same level as physical illnesses. The legislation will be implemented over an six-year period beginning Jan. 1. Parity will be phased in for co-payments and co-insurance in 2006, for maximum out-of-pocket expenses in 2008 and for deductibles in 2010.

Randy Revelle, vice-president of the Washington Hospital Association and chairman of the 126-organization Washington Coalition for Mental Health Parity, says the coalition plans to go back to the legislature in two years to fight for inclusion of small-businesses and individual policies under the new law. However, neither Washington nor any other state can currently mandate coverage for those in employer-insured plans. The federal Employee Retirement Income Security Act of 1974 (ERISA) exempts self-insured plans from state-level regulation. However, Revelle says he's noticed an interesting trend-since the legislation passed, a number of Washington's big self-insured employers have begun offering parity on their own.

Oregon also enacted a comprehensive parity law. Advocates went one step further by securing inclusion of substance abuse services in their legislation. The Oregon law also applies to individual and small-business plans.

The South Carolina and Iowa legislatures passed "diagnosis-specific" bills. These bills require patients to receive a diagnosis for a specific mental illness-such as major depression, bipolar disorder or schizophrenia-to receive parity coverage for their mental health care. South Carolina, however, provided full parity to its state employees in 2002.

Other states made progress as well. Illinois added post-traumatic stress disorder to its list of covered diagnoses. Hawaii added delusional disorder, major depression, obsessive-compulsive disorder and dissociative disorder to its current parity law. Meanwhile, Maryland removed from its parity law a provision that allowed the exclusion of psychological and neuropsychological testing from coverage.

Testing and evaluation advances

Psychology professionals expanded their practice authority in Colorado and Arkansas. Colorado passed a law recognizing psychologists' ability to perform competency-to-stand-trial evaluations in juvenile cases. And Arkansas passed a law allowing the use of technicians by neuropsychologists. CAPP provided funding for these initiatives.

Medicaid

Funding is frequently a challenge when it comes to psychological services, explains Sullivan. Medicaid is a particular problem because it is the largest item in a state's budget. As a result, it's common for states to try and trim Medicaid budgets, by eliminating "optional" services such as psychological treatment. This means that state associations have to fight to get them reinstated, Sullivan notes.

Once again, after sustained grassroots action by the New York State Psychological Association, the legislature reversed the governor's budget proposal and kept psychology in its Medicaid program. And this year, overcoming significant obstacles, Texas succeeded in having its psychological services restored.

Hospital practice regulations

Finally, California's Department of Health Services (DHS) granted psychologists most of the same privileges in acute care state hospital facilities that psychiatrists have, including the ability to admit, diagnose and discharge patients. These regulations are the result of advocacy by Psychology Shield, a nonprofit organization-supported by the APA Practice Organization and others-devoted to improving patient care in California's state-operated mental hospitals, and the California Psychological Association (CPA).

However, the state psychiatric association and psychiatric union have filed a lawsuit against DHS challenging the regulations-attempting to block psychologists from exercising these privileges.

The APA Practice Organization will provide Psychology Shield and CPA with any necessary assistance in helping DHS defend against the psychiatrists' lawsuit, notes Alan Nessman, special counsel for the APA Practice Directorate's Office of Legal and Regulatory Affairs.

Further Reading

Look for an update on California's practice regulations in future issues of the Monitor and see the July/August 2005 issue for more details on the new regulations.