HOUSE OF REPRESENTATIVES
TWENTY-SIXTH LEGISLATURE, 2011
STATE OF HAWAII
A BILL FOR AN ACT
relating to psychologists.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:
SECTION 1. The legislature finds that there is limited access to mental health care treatment services for some citizens across the State of Hawaii. The delivery of comprehensive, accessible, and affordable mental health medical care may be enhanced by providing trained medical psychologists, licensed in Hawaii, with prescriptive authority. The legislature has previously authorized prescription privileges to advanced practice registered nurses, optometrists, dentists, podiatrists, osteopaths, and physician assistants. Further, psychologists with appropriate credentials have been allowed to prescribe medications to active duty military personnel and their families in federal facilities and the Indian Health Service for years. In recent years, Louisiana (2004) and New Mexico (2002) adopted legislation authorizing prescriptive authority for psychologists for appropriately trained psychologists without regard to the service setting.
The legislature acknowledges that the United States Public Health Service, Health Resources and Services Administration, has officially designated much of the State of Hawaii as a mental health professional shortage area. In addition to rural areas where geographic isolation is an obvious reason for shortage problems, urban areas located minutes from downtown Honolulu, such as Kalihi-Palama and Kalihi Valley, have also received this shortage designation. The nearly statewide shortage designations indicate that both rural and urban areas suffer when it comes to accessing mental health care.
The legislature acknowledges that the mental health needs of the State continue to outweigh present capacity. From 2000‑2004, more people died in Hawaii from suicide than from automobile accidents or homicides. At 22.5 per cent, Hawaii's suicide rate is higher than the national average. While causes for suicide are complex, the most commonly reported reasons include depression, relationship problems, and serious medical problems, which are conditions with significantly high rates of occurrence within the general population.
In Hawaii, six domestic violence murders (three of which were murder-suicides) occurred within six months in 2008, compared to an average of nine domestic killings from 1996 through 2006. The Hawaii State Coalition Against Domestic Violence acknowledged that these are the highest numbers in decades. Many perpetrators of domestic violence murders are not obviously troubled. They represent the general population, and rural and urban areas of Hawaii.
Last year, information from the Honolulu police department revealed that in 2006, 1,435 people were involuntarily taken to emergency rooms for psychiatric evaluation and treatment. During the first four months of 2007, the Honolulu police department responded to four hundred and four calls to assist in psychological crises that required emergency attention. Based on a review of the records, approximately fifty-four per cent of these calls resulted from inadequate medication management.
At the same time that mental health needs are apparently growing, resources in the State that are available for treatment and assistance are being reduced. Due to the State's budget crisis, the department of health experienced significant funding cuts totaling approximately $25,000,000 for fiscal year 2009 and will be faced with an additional twenty per cent in cuts for fiscal year 2010. In certain parts of the State such as West Hawaii, Waianae, Kaneohe and most recently, Molokai, the department of health's adult mental health division clinics have undergone severe cuts that have forced some clinics to close their doors entirely, leaving hundreds of patients with severe and persistent mental illness without adequate medication management and overall treatment.
Since 2000, twenty psychologists, all born and raised in Hawaii, have received additional training in psychopharmacology through the Tripler Army Medical Center and Argosy University. These psychologists have actively collaborated with primary care physicians to provide combined therapy and psychopharmacological care to medically underserved patient populations at twelve federally qualified health centers such as Bay Clinic, Hana, Molokai, Kauai, Waianae, Kalihi-Palama, Waimanalo, Ko’olauloa, West Hawaii, Kokua Kalihi Valley, and Waikiki, as well as two native Hawaiian healthcare system clinics located in federally designated medically underserved areas on Molokai and Maui. This psychology training program has increased the state workforce of uniquely trained psychologists who are culturally competent and able to work effectively with primary care teams to provide population-based behavioral health care. As a result, thousands of native Hawaiians and other ethnic minorities have received the necessary combined therapy and psychopharmacological care that has been historically lacking to address significant mental and behavioral health care needs.
For example, psychologists at the Waianae Coast Comprehensive Health Center completed approximately 3,840 patient encounters in 2004; seventy per cent of these patients received necessary psychotropic medication for the treatment of mental illness. Currently, psychologists hold full or part-time staff positions in ten of the fourteen federally qualified health centers across the State and continue to maintain successful collaborative relationships with primary care physicians for mental health treatment of the underserved.
Psychologists are licensed health professionals with an average of seven years of post-baccalaureate study and three thousand hours of post-graduate supervised practice in the diagnosis and treatment of mental illness. Because the current scope of psychologists' practice does not include prescribing medications, patients must consult with and pay for another health care provider to obtain psychotropic medications. However, practitioners with prescriptive authority are not accessible in some areas of the State. Further, they are not available to some populations, such as the uninsured or under-insured, who are often turned away from psychiatrists who do not accept certain forms of health care insurance such as Ohana Health Care or Evercare.
Research data demonstrates that there is an insufficient amount of prescribing mental health care providers available to serve the needs of the people in Hawaii. Based upon prevalence rates provided by the Substance Abuse and Mental Health Services Administration and reported in "The Behavioral Health Workforce in Hawai‘i: A Status Report" (January 2008), 40.4 per cent of the population diagnosed with severe and persistent mental illness received services from the department of health, adult mental health division. In 2007, 14,276 out of a total of 52,064 adults with severe mental illness received services through the department of health adult mental health division. This indicates that approximately 37,788 individuals may not have received necessary mental health services. Adults diagnosed with severe mental illness represent more than five per cent of the total state population, which does not include individuals with other clinical diagnoses such as unipolar depression, anxiety disorders, adjustment disorders, substance abuse, or post-traumatic stress disorder.
Since 1988, federal law has recognized the extraordinarily poor health of native Hawaiians. According to the 2000 United States Census, significant health disparities exist for native Hawaiians and other Pacific Islanders as compared to other races for certain health concerns such as diabetes mellitus, infant mortality, hepatitis B, and asthma. Compared to other indigenous and minority populations, native Hawaiians have the highest rates of untreated medical and psychological conditions in the United States. Recent concerns include the widespread impact of crystal methamphetamine addiction and related issues, which are especially prevalent in areas with a large native Hawaiian population, such as Waianae, Molokai, Waimanalo, Maui, Puna, and Kau. The crystal methamphetamine epidemic, coupled with the economic and cultural distress of the native Hawaiian population, has created unprecedented demand for services from an already overburdened mental health system. Further exacerbating the dire need for mental health treatment is the reluctance of individuals from some cultural backgrounds to seek treatment, due to the perceived stigma of mental health problems. Timely access to accurate diagnosis and effective treatment of emotional and behavioral disorders may contribute substantially to the State's responsibilities to Hawaii's "Felix" children and needy adults in underserved rural and urban areas.
Co-occurring physical and mental health disorders represent another area of health care in need of significant attention. Community health centers are an ideal outpatient primary care setting in which to incorporate integrated models of care that provide an adequate safety net for underserved populations in need of both physical and mental health treatment. Chronic illnesses with known psychological components that may be a factor in the development or intensification of physical symptoms that include coronary artery disease, arthritis, diabetes, hypertension, and asthma. For example, rates of depression are higher in patients with diabetes than in those without diabetes, and depression has been associated with a higher risk for diabetic complications, poor control of blood sugar levels, and a reduced quality of life. Similarly, depression, anxiety, and generalized psychological distress may significantly impact the severity of asthma and should be treated simultaneously with the patient’s medical treatment. As many as thirty per cent of asthma patients also have symptoms of panic disorder and an additional thirteen per cent are agoraphobic.
The American Psychological Association has developed a model curriculum for a master's degree in psychopharmacology for the education and training of prescribing psychologists. Independent evaluations by the United States General Accounting Office and the American College of Neuropsychopharmacology of a similar post-doctoral program established by the United States Department of Defense found that appropriately trained post-doctoral clinical psychologists prescribed safely and effectively.
The purpose of this Act is to authorize appropriately trained and supervised psychologists to prescribe psychotropic medications for the treatment of mental illness at certain health care facilities.
SECTION 2. Chapter 465, Hawaii Revised Statutes, is amended by adding a new part to be appropriately designated and to read as follows:
"Part . PRESCRIPTION CERTIFICATION
§465-A Definitions. As used in this part, unless the context otherwise requires:
"Board" means the board of psychology established under section 465-4.
"Clinical experience" means a period of supervised clinical training and practice in which clinical diagnoses and interventions are learned and that are conducted and supervised as part of the training program.
"Narcotics" means natural and synthetic opioid analgesics and their derivatives used to relieve pain.
"Prescription" is an order for a drug, laboratory test, or any medicine, device, or treatment, including a controlled substance.
"Prescriptive authority" means the authority to prescribe, administer, discontinue, or distribute without charge, drugs, or controlled substances recognized in or customarily used in the diagnosis, treatment, and management of individuals with psychiatric, mental, cognitive, nervous, emotional, or behavioral disorders within the scope of the practice of psychology in accordance with rules adopted by the board.
"Psychologist certified to prescribe" means a licensed psychologist who has:
(1) Completed a doctoral degree in psychology;
(2) Completed specialized psychopharmacology education and training relating to prescriptive practice;
(3) Passed an examination accepted by the board relevant to establishing competence for prescribing; and
(4) Received from the board a current certificate granting prescriptive authority that has not been revoked or suspended.
"Psychotropic medication" means only antipsychotic, antidepressant, or anti-anxiety medications approved by the United States Food and Drug Administration for the treatment of mental and emotional disorders provided that the term shall not include narcotics.
"Supervising physician" means a medically trained and licensed physician, including an osteopathic physician or psychiatrist, who accepts professional responsibility for the provision of psychopharmacotherapy by a psychologist with prescriptive authority.
§465-B Conditional prescription certificate; application. (a) A psychologist who applies for a conditional prescription certificate shall demonstrate all of the following by official transcript or other official evidence satisfactory to the board:
(1) A current license in good standing under part I;
(2) As defined by the board, and consistent with established policies of the American Psychological Association for educating and training psychologists in preparation for prescriptive authority:
(A) A master's degree in psychopharmacology that includes study in an organized program offering intensive didactic education, and including the following core areas of instruction: basic life sciences, neurosciences, clinical and research pharmacology and psychopharmacology, clinical medicine and pathophysiology, physical assessment and laboratory examinations, clinical pharmacotherapeutics, research, professional, ethical and legal issues; and
(B) Clinical experience sufficient to attain competency in the psychopharmacological treatment of a diverse patient population under the direction of a supervising physician, which consists of not less than one year, including four hundred hours treating a diverse population of no less than one hundred patients with mental disorders including at least two hours of weekly supervision by a licensed physician. The supervising physician shall not be in the employ of the person being directed or supervised;
(3) Successful completion of an examination developed by a nationally recognized body (e.g., the American Psychological Association's Practice Organization's College of Professional Psychology) and approved by the board;
(4) A federal Drug Enforcement Administration registration number for limited use as restricted by this part;
(5) Malpractice insurance coverage sufficient to comply with rules adopted by the board, which covers the applicant during the period the conditional prescription certificate is in effect;
(6) Completion of all other requirements, as determined by rules adopted by the board pursuant to chapter 91, for obtaining a conditional prescription certificate; and
(7) Employment, including by contract, at an appropriate health care facility, including:
(A) A federally qualified health center established pursuant to Title 42 United States Code Section 1396;
(B) A licensed health clinic located in a federally designated medically underserved area as defined by title 42 Code of Federal Regulations part 62; or
(C) A licensed health clinic located in a mental health professional shortage area.
(b) The board shall issue a conditional prescription certificate only if the applicant has met all of the requirements of subsection (a).
A conditional prescription certificate issued by the board shall be immediately relinquished by the psychologist if the psychologist no longer meets the requirements of subsection (a).
§465‑C Conditional prescription certificate; powers, duties, and responsibilities. (a) A psychologist holding a conditional prescription certificate shall:
(1) Maintain a current license under part I and malpractice insurance at all times;
(2) Inform the board of the name of the supervising physician under whose supervision the psychologist will prescribe psychotropic medication; provided that the psychologist shall promptly inform the board of any change of the supervising physician; and
(3) Maintain an ongoing collaborative relationship with the physician who oversees each patient's general medical care.
(b) A psychologist holding a conditional prescription certificate shall be authorized to prescribe, administer, discontinue, or distribute without charge, drugs or controlled substances recognized in or customarily used in the diagnosis, treatment, and management of individuals with psychiatric, mental, cognitive, nervous, emotional, or behavioral disorders and relevant to the practice of psychology, within the scope of practice of psychology in accordance with rules adopted by the board; provided that the authorization shall be limited to services provided to patients under the care of the psychologist and who are enrolled at a facility as indicated in section 465‑B(a)(7).
(c) When prescribing psychotropic medication for a patient, a psychologist holding a conditional prescription certificate shall maintain an ongoing collaborative relationship with the physician who oversees the patient's general medical care to ensure that:
(1) Necessary medical examinations are conducted;
(2) The psychotropic medication is appropriate for the patient's medical condition; and
(3) Significant changes in the patient's medical or psychological condition are discussed.
(d) A prescription issued by a psychologist holding a conditional prescription certificate shall:
(1) Comply with applicable state and federal laws;
(2) Clearly identify the issuing psychologist as a psychologist certified to prescribe; and
(3) Include the psychologist's board number or the identification number assigned by the department of commerce and consumer affairs.
(e) A psychologist holding a conditional prescription certificate shall not delegate prescriptive authority to any other person. The prescribing psychologist shall maintain records of all prescriptions issued to patients.
(f) A psychologist holding a conditional prescription certificate shall file with the board, in a timely manner, the individual's federal Drug Enforcement Administration registration numbers.
§465-D Prescription certificate. (a) A psychologist who applies for a prescription certificate shall demonstrate by official transcript or other official evidence satisfactory to the board that:
(1) The psychologist has been issued a conditional prescription certificate and has successfully completed two years of prescribing psychotropic medication as certified by the supervising physician;
(2) The psychologist has successfully undergone a process of independent peer review approved by the department of commerce and consumer affairs;
(3) The psychologist holds a current license in good standing to practice psychology in Hawaii;
(4) The psychologist has malpractice insurance coverage, sufficient to comply with the rules adopted by the board, that will cover the applicant as a prescribing psychologist; and
(5) The psychologist meets all other requirements, as determined by rules adopted by the board pursuant to chapter 91, for obtaining a prescription certificate.
(b) The board shall issue a prescription certificate if the applicant meets all of the requirements of subsection (a).
(c) A psychologist with a prescription certificate may prescribe psychotropic medication if the psychologist:
(1) Is licensed under part I and maintains malpractice insurance;
(2) Annually satisfies the continuing education requirements for prescribing psychologists, as established by the board, which shall be no less than twenty hours each year, at least half of which shall be in pharmacology or psychopharmacology;
(3) Continues to prescribe only as an employed or contracted provider of a federally qualified health center; and
(4) Continues to maintain an ongoing collaborative relationship directly or by telecommunication with the physician who oversees each patient's general medical care to ensure that:
(A) Necessary medical examinations are conducted;
(B) Psychotropic medication prescribed is appropriate for the patient's medical condition; and
(C) Significant changes in the patient's medical or psychological condition are discussed.
(d) The prescription certificate shall be immediately relinquished by the psychologist to the board if the psychologist no longer meets the requirements of subsection (a).
§465-E Administration. (a) The board shall adopt rules pursuant to chapter 91 establishing the procedures to obtain a conditional prescription certificate, a prescription certificate, and renewal of a conditional prescription certificate and prescription certificate. The board may establish reasonable application and renewal fees.
(b) The board shall adopt rules pursuant to chapter 91 establishing the grounds for denial, suspension, or revocation of a conditional prescription certificate and a prescription certificate, including provisions for suspension or revocation of a license under part I upon suspension or revocation of a conditional prescription certificate or prescription certificate. Actions of denial, suspension, or revocation of a conditional prescription certificate or a prescription certificate shall be in accordance with this chapter.
(c) The board shall maintain current records on every prescribing psychologist, including federal Drug Enforcement Agency registration numbers.
(d) The board shall provide to the board of pharmacy an annual list of psychologists holding a conditional prescription certificate or prescription certificate that contains the information agreed upon between the board and the board of pharmacy. The board shall promptly provide the board of pharmacy with the names of any psychologists who are added or deleted from the list.
§465-F Narcotics; prohibited. This part shall not be construed to permit a psychologist holding a conditional prescription certificate or prescription certificate to administer or prescribe narcotics of any type."
SECTION 3. Chapter 465, Hawaii Revised Statutes, is amended by designating sections 465-1 to 465-15 as part I, entitled: "GENERAL PROVISIONS".
SECTION 4. Section 465-3, Hawaii Revised Statutes, is amended to read as follows:
"§465-3 Exemptions. (a) This chapter shall not apply to:
(1) Any person teaching, lecturing, consulting, or engaging in research in psychology insofar as the activities are performed as part of or are dependent upon employment in a college or university; provided that the person shall not engage in the practice of psychology outside the responsibilities of the person's employment;
(2) Any person who performs any, or any combination of the professional services defined as the practice of psychology under the direction of a licensed psychologist in accordance with rules adopted by the board; provided that the person may use the term "psychological assistant", but shall not identify the person's self as a psychologist or imply that the person is licensed to practice psychology;
(3) Any person employed by a local, state, or federal government agency in a school psychologist or psychological examiner position, or a position that does not involve diagnostic or treatment services, but only at those times when that person is carrying out the functions of such government employment;
(4) Any person who is a student of psychology, a psychological intern, or a resident in psychology preparing for the profession of psychology under supervision in a training institution or facility and who is designated by a title as "psychology trainee", "psychology student", "psychology intern", or "psychology resident", that indicates the person's training status; provided that the person shall not identify the person's self as a psychologist or imply that the person is licensed to practice psychology;
(5) Any person who is a member of another profession licensed under the laws of this jurisdiction to render or advertise services, including psychotherapy, within the scope of practice as defined in the statutes or rules regulating the person's professional practice; provided that, notwithstanding section 465-1, the person does not represent the person's self to be a psychologist or does not represent that the person is licensed to practice psychology;
(6) Any person who is a member of a mental health profession not requiring licensure; provided that the person functions only within the person's professional capacities; and provided further that the person does not represent the person to be a psychologist, or the person's services as psychological; or
(7) Any person who is a duly recognized member of the clergy; provided that the person functions only within the person's capacities as a member of the clergy; and provided further that the person does not represent the person to be a psychologist, or the person's services as psychological.
(b) Nothing in this chapter shall in any way restrict any person from carrying on any of the psychological activities as defined in section 465-1; provided that such person does not offer psychological services as defined in this chapter except as such activities are incidental to the person's lawful occupational purpose.
(c) A person may use the title of industrial/organizational psychologist, provided that the person registers with the board, and:
(1) Is professionally competent in the practice of
industrial/organizational psychology; [
(2) Holds a doctoral degree from an accredited institution of higher education with training and education in industrial/organizational psychology, satisfactory to the board; and
(3) Provides psychological service or consultation to
which] that does not involve the delivery or
supervision of direct psychological services to individuals or groups of
individuals, without regard to the source or extent of payment for services
(d) Nothing in this chapter shall prevent the provision of expert testimony by a psychologist who is otherwise exempted by this chapter.
in this chapter shall be construed as permitting the administration or
prescription of drugs, or in any way engaging in the practice of medicine as
defined in the laws of the State.]"
SECTION 5. In codifying the new sections added by section 2 of this Act, the revisor of statutes shall substitute appropriate section numbers for the letters used in designating the new sections in this Act.
SECTION 6. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.
SECTION 7. This Act shall take effect on July 1, 2011, and shall be repealed on June 30, 2015; provided that section 465-3, Hawaii Revised Statutes, shall be reenacted in the form in which it read on the day before the effective date of this Act.
Prescriptive Authority; Psychologists
Authorizes prescriptive authority for qualified psychologists who practice at a federally qualified health center .
The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.