Legislators Try to Avert Veto of Psychologist Prescriber Bill

Gov. Kate Brown announced a rare veto on Tuesday. She plans to spike a bill that would allow a limited number of psychologists to prescribe medications for mental disorders.

Gov. Kate Brown has threatened to veto House Bill 3355, which would allow psychologists to prescribe psychotropic medications, but a trio of legislative healthcare leaders who work to pass the bill are still hoping to change her mind.

“I spoke to Gov. Brown yesterday that vetoing the bill would be a terrible mistake,” said Rep. Mitch Greenlick, D-Portland, the chairman of the House Health Committee. “I wasn’t surprised but I was very unhappy. We worked that bill so long and it’s got all these safeguards wired in.”

Gov. Ted Kulongoski vetoed a similar bill in 2010, but advocates hoped more thorough vetting of the policy this time would overcome opposition from the psychiatrist lobby.

A veto from Brown would likely be the death knell for the policy, which its advocates believe would help improve both the quality of care and access to psychiatric medications. Oregon doesn’t have enough psychiatrists, and their numbers are dwindling.

HB 3355 offered a potential solution, training and empowering psychologists to prescribe medications, since they are already experts in mental health and diagnosis. They would only be allowed to prescribe the medications in a medical clinic, working with a team of other healthcare professionals, such as medical doctors and nurse practitioners.

“I share the concerns about inadequate services that arose during the debate on this bill, particularly for children, vulnerable populations, and rural communities,” Brown said when announcing her potential veto on Tuesday. “Unfortunately, this is not a proven solution. There remains a lack of evidence that psychologist prescribing will improve access or quality of care. While prescription drugs may be appropriate mental health treatment for some patients, there are also significant health risks with some drug therapies.”

Most psychiatric medications are currently handed out by primary care practitioners, who have very little training in mental health or diagnoses. “They are not experts in diagnosis or mental health, yet they are making the bulk of the psychiatric prescriptions,” said Rep. Bill Kennemer, R-Canby, a retired psychologist.

The bill was partly modeled after laws in other states, which have allowed psychologists to prescribe medicine with few issues.

Kennemer and Sen. Laurie Monnes Anderson, D-Gresham, met with Brown on Thursday, hoping to persuade her to let the bill become law. Kennemer noted that it does not take effect until July 2018, giving opponents the chance to request any corrective fixes in the February 2018 short session. “I was absolutely shocked this afternoon when I got a call from her staff.”

The Canby Republican said the meeting with the governor was inconclusive but he had not given up hope on the legislation. “She listened carefully. She asked some good questions. We’ll have to see where it goes from here.”

The bill breezed through the House with just Rep. Julie Parrish, R-West Linn, and Rep. Paul Evans, D-Salem, in opposition. But in late June, the Oregon Psychiatric Physicians Association reported spending $48,500 to hire three more lobbyists to kill the bill.

Sen. Elizabeth Steiner Hayward, D-Portland, who had been a sponsor, announced her opposition, and the bill passed the Senate on a 18-11 vote -- short of the two-thirds majority needed for a veto override. Sen. Sara Gelser, D-Corvallis, also circulated a letter from the psychiatrists’ lobby, noting their opposition, which they said was built on the fact that psychologists do not have their same extensive knowledge of the human body.

Monnes Anderson circulated her own lobby letter, which was endorsed by the Oregon Nurses Association, the Oregon Association of Hospitals & Health Systems, and Providence Health & Services, which enlisted psychiatrists to testify in support of the bill.

Reach Chris Gray at chris@thelundreport.org.

 

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Comments

I have attended way too many so-called really important exeutive meetings over the last 40 years WHERE generalist physicians resisted including NPs into the world of independent providers, WHERE orthopedic physicians resisted granting operating room privileges for podiatrists, and WHERE opthalmologists resisted the integration of optometrists into mainstream eye care.

 

More recently we have witnessed the challenges of Naturopathic physicians in gaining access to equal status of other primary care providers and urologists raising objections to NPs performing vasectomies. Now we have a situation where the vast majority of resistance to psychologists being granted prescriptive privileges comes from psychiatrists. 

Rep Kennemer is absolutely correct. We now have a health care system where generalists (full disclaimer, I was a generalist from 1968 through 2012) are prescribing the vast majority of psychotropic medications, including those with black box warnings, without advanced training. 

There is no question that psychiatrists can claim, on balance, to have the most robust level of training and balance. However, we could make the same case for diabetologists, cardiologists, etc. If that is so, how is it our health care system can permit generalists to write prescriptions for diabetes or cardiac drugs?

I hope the Governor will listen to the words of Rep Kennermer, Sen Monnes-Anderson, and Rep Greenlick and allow the bill to become law. I advise the Governor to look at this issue through the eyes of the generalist PA, NP, and MD, who struggle with patients with complex set of medical and mental conditions and simply want much easier access to a wider range of consultants.

 

 

 

 

Not an open process:

Perhaps Rep Greenlick is speaking about work in 2009 or 2010? There was no work done with the Oregon Medical Association (one of the chief groups opposing this bill) or many other stakeholders in 2017. There are no safeguards in this bill for children, geriatric patients or those with complex medical conditions

This bill opposed by all of organized medicine in Oregon:

The bill in 2010 had different “safeguards” in it including supervision under the Oregon Medical Board (which makes sense for those who want to practice medicine). Why are you characterizing all opposition as from the “psychiatrist lobby?” What about the many psychologists who submitted testimony against the bill as well as family and child advocates? The Oregon Medical Association led much of the efforts to prevent this from becoming law.

No evidence for claim of improving access despite 2 states having psychologists fill this medical role:

There is no evidence that this type of legislation has increased access to mental health prescribers in any state ever. Psychologists are less distributed in Oregon then psychiatrists and PMHNPs. Only a very few psychologists have ever practiced medicine in this way. There were only 10 people trained in the military’s program that psychologists always quote and they had close and continuous supervision for many years. Those 10 psychologists are on record as opposing the minimal nonstandard types of training programs that this bill includes. 

Being colocated in the same office is not having a collaborative process:

Being in the same office is not the same as working together. There is no funding mechanism nor model of care that exists for physicians or others to supervise psychologists in primary care. Being experts in diagnosis with experience in some forms of mental illness is not the same as being an expert at prescribing medications, ordering and interpreting tests, recognizing side effects and differentiating side effects from medical illnesses, knowing and applying drug-drug interactions and drug-disease interactions.

Primary Care providers do have training:

It is a part of all primary care residencies to diagnose and treat depression, anxiety and other illnesses that people turn to their primary care providers to treat. Mr. Kennemer trained as a psychologist long ago and is unlikely to be familiar with modern physician education. Primary care providers are expert at differentiating psychiatric illness from other forms of illness and they know about drug metabolism through the liver and kidneys. They are experts at drug-drug interactions and drug-disease interactions.

Other laws in other states:

There are only 2 states that currently allow this. The laws had to evolve and change significantly from this bill in Louisiana after permanent neurological damage to children and older adults. Newer laws have not been implemented and their laws have significant safeguards that this bill lacks.

I sincerely doubt Rep Kennemer was shocked:

There should not be any shock given the large number of people INCLUDING psychologists and family/child advocates who opposed this bill because of lack of safeguards. The bill was not discussed presession with any of the medical groups in the state including the Oregon Medical Association which opposed this bill.

Regarding Providence:

Providence Health and Services had one psychiatrist testify in favor and one against while dozens of Providence psychiatrists signed a letter opposing the bill for safety reasons.

 

 

 

Not an open process:

Perhaps Rep Greenlick is speaking about work in 2009 or 2010? There was no work done with the Oregon Medical Association (one of the chief groups opposing this bill) or many other stakeholders in 2017. There are no safeguards in this bill for children, geriatric patients or those with complex medical conditions

This bill opposed by all of organized medicine in Oregon:

The bill in 2010 had different “safeguards” in it including supervision under the Oregon Medical Board (which makes sense for those who want to practice medicine). Why are you characterizing all opposition as from the “psychiatrist lobby?” What about the many psychologists who submitted testimony against the bill as well as family and child advocates? The Oregon Medical Association led much of the efforts to prevent this from becoming law.

No evidence for claim of improving access despite 2 states having psychologists fill this medical role:

There is no evidence that this type of legislation has increased access to mental health prescribers in any state ever. Psychologists are less distributed in Oregon then psychiatrists and PMHNPs. Only a very few psychologists have ever practiced medicine in this way. There were only 10 people trained in the military’s program that psychologists always quote and they had close and continuous supervision for many years. Those 10 psychologists are on record as opposing the minimal nonstandard types of training programs that this bill includes. 

Being colocated in the same office is not having a collaborative process:

Being in the same office is not the same as working together. There is no funding mechanism nor model of care that exists for physicians or others to supervise psychologists in primary care. Being experts in diagnosis with experience in some forms of mental illness is not the same as being an expert at prescribing medications, ordering and interpreting tests, recognizing side effects and differentiating side effects from medical illnesses, knowing and applying drug-drug interactions and drug-disease interactions.

Primary Care providers do have training:

It is a part of all primary care residencies to diagnose and treat depression, anxiety and other illnesses that people turn to their primary care providers to treat. Mr. Kennemer trained as a psychologist long ago and is unlikely to be familiar with modern physician education. Primary care providers are expert at differentiating psychiatric illness from other forms of illness and they know about drug metabolism through the liver and kidneys. They are experts at drug-drug interactions and drug-disease interactions.

Other laws in other states:

There are only 2 states that currently allow this. The laws had to evolve and change significantly from this bill in Louisiana after permanent neurological damage to children and older adults. Newer laws have not been implemented and their laws have significant safeguards that this bill lacks.

I sincerely doubt Rep Kennemer was shocked:

There should not be any shock given the large number of people INCLUDING psychologists and family/child advocates who opposed this bill because of lack of safeguards. The bill was not discussed presession with any of the medical groups in the state including the Oregon Medical Association which opposed this bill.

Regarding support:

There was one psychiatrist who testified in favor of this bill and many others who opposed it. But there were many more who were family medicine or internal medicine physicians who also opposed this bill. This bill is not being opposed by "only" psychiatrists.

There is already access to psychologists as consultants. This bill does not change the shortage of that specialty whatsoever. It only allows poorly trained and after a short time unsupervised psychologists to prescribe powerful medications without any medical background.