Law opens hospital doors for California psychologists

Psychologists are hopeful that the language will be adopted by other states.

By Lisa Rabasca
Monitor staff

A new California law clears the way for more psychologists in that state to obtain medical staff membership and full independent clinical privileges at state-owned and state-operated health facilities.

The law, which bars these facilities from discriminating against licensed doctoral psychologists, contains the strongest language of any state legislation on this issue covering private or public hospitals.

The new law will allow psychologists to treat hospital patients without being supervised by a psychiatrist. Psychologists are hopeful that the language will be adopted by other states. For years, psychologists have lobbied for medical staff membership and full independent clinical privileges. Without them, psychologists cannot independently admit, diagnose or discharge patients. They also cannot direct treatment ?even when their own patient is admitted to the hospital. Instead, a psychiatrist must supervise them.

'Whatever happens in the public sector affects what happens in the private sector,' says Charles Faltz, PhD, chair of the California Psychological Association?s (CPA) hospital-practice committee.'Psychologists now have the strongest language in the public sector in California and this is bound to be useful.'

APA?s Practice Directorate agrees that the California law might influence other state legislatures to pass similar measures. 'Legislation is very precedent-driven,' says Cherie Jones, APA?s assistant director for legal and regulatory affairs.'The fact that a legislature can point to another state with a similar law or similar language is compelling.'

Seventeen states and the District of Columbia have laws or regulations specifically allowing psychologists to obtain medical staff membership and clinical privileges. Several other states?including Illinois, Michigan and Pennsylvania?have considered similar legislation.

These laws do not expand psychologists? scope of practice: They allow psychologists to do the work they were trained to do without supervision by a physician. The laws also allow psychologists to serve as voting members on the hospital staff, thus giving them the chance to influence hospital policy on the quality of care.

Increased patient referrals

In the private sector, these laws provide additional benefits. Psychologists who are medical staff members are often automatically eligible to be network providers for that hospital and receive patient referrals. As hospitals develop into health-care organizations that provide a continuum of care?including outpatient, partial hospitalization, residential and after-care treatment?medical staff membership gives psychologists access to the integrated health-care delivery system emerging across the country, says Russ Newman, PhD, JD, APA?s executive director for practice.

'Given the changes in the health-care system and decreased amount of [psychological] care that is actually occurring in hospitals on an inpatient basis, there is often a misperception that there isn?t the incentive or need to pursue a medical staff agenda,' says Newman.

'In many ways, the importance and significance of psychologists having medical staff membership in the current health-care system is even greater now because it determines whether you can practice in the entire continuum of care,' Newman adds.

While state-owned and state-operated facilities have not yet developed into full-service health-care organizations like private hospitals have, they eventually may adopt the same integrated systems of care, Newman says. Many private hospitals are merging and affiliating with a network of facilities to provide care, including doctors? practices, clinics, community hospitals, hospices and managed-care companies. Potentially, medical staff membership could offer psychologists at state-owned hospitals access to similar integrated health-care delivery systems, he says.

Psychologists practicing at state-owned facilities in California have been advocating for staff membership for 20 years. Although a 1978 state law gave those psychologists the right to apply for medical staff membership, psychiatrists at the state facilities have systematically refused to allow them to join the staffs, Faltz says.

Legislative remedy fails

In 1996, legislators tried to remedy this discrimination by passing a law stating that state health facilities may permit clinical psychologists to'provide psychological services within the legal scope of their licensure, without physician supervision and without discriminatory restrictions.'

However, Faltz says the discrimination didn?t end because the law allowed current medical staff members to vote on changing their bylaws to conform to the law. As a result, psychiatrists at some state hospitals didn?t vote in the changes that were required, he says.

Two of California?s state-owned health facilities have no bylaw provision to allow psychologists to join the medical staff, says Bill Safarjan, CPA?s president.

And nearly half the psychologists who practice at the three remaining state-owned facilities do not have medical staff membership, says Safarjan, chair of the department of psychology at Atascadero State Hospital.

At the state-owned facilities where the bylaws have been changed to comply with the law, some staff members proposed changes that would have been damaging to psychologists, says Faltz.

'There was a danger that the bylaws would be changed in ways that were cosmetic and would not produce a change in what the psychologists were able to do in state hospitals,' he says.

For example, one hospital considered requiring psychologists to have a certain number of years of experience before being considered for the medical staff. Another hospital considered a proposal to require psychologists to complete extensive course work in pharmacology to qualify for the medical staff.

'That requirement would have excluded virtually all psychologists from the medical staff for a long time because it would have been the equivalent of many semesters of training similar to medical school,' says Faltz.

When CPA went back to the legislature and explained what was happening, they found that there was broad support for a tougher measure, Faltz says.

The new law emphasizes the nondiscriminatory language by stating'that the rules and regulations of the health facility not discriminate on the basis of whether the staff member holds an MD, DO, DPM, or doctoral degree in psychology, within the scope of the member?s respective licensure.'

Meanwhile, many psychologists at private California hospitals have become medical staff members. Private hospitals hoped that adding psychologists to their staffs would increase hospital admissions, Faltz says.

'There was an economic incentive to add psychologists to the medical staff in order to increase the number of patients,' he says.'This incentive does not exist in the state hospital system. Psychiatrists are under no pressure by state hospitals to add psychologists to the staff because it does not help to ensure the economic viability of the hospital.'

Nearly all of California?s private psychiatric hospitals have psychologists on the medical staff, Faltz says. Many, but not all, private hospitals have psychologists on their medical staff, including general medical hospitals without psychiatric units.

The new law emphasizes the nondiscriminatory language by stating'that the rules and regulations of the health facility not discriminate on the basis of whether the staff member holds an MD, DO, DPM, or doctoral degree in psychology, within the scope of the member?s respective licensure.'

Although university medical schools have been slow to add psychologists to their medical staffs, the University of California, Los Angeles, recently granted psychologists medical staff status. (See related article, page 18.)

Psychologists in California have learned that getting a law passed does not always end the battle.

'These issues need to be pursued continually, and gains are really made over the long haul,' Faltz says.'One needs to keep adding to these gains because the opposition will continue to try to make inroads into those gains.'