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					                     Journal of the Academy of Medical Psychology


             Prescribing Psychologists in Private Practice:
The Dream and the Reality of the Experiences of Prescribing Psychologists

                                       Elaine S. LeVine*
                                       Jack G. Wiggins
                                          Erin Masse

                                           Abstract
  An open-ended ―depth‖ survey of psychologists now prescribing was conducted to
learn how prescriptive authority laws for psychologists were implemented. Prescribing
psychologists were proudly collaborating with medical healthcare professionals and
found their prescribing practices financially rewarding. The major practice obstacle found
was the Louisiana law required mandatory agreement between the prescribing ―Medical
Psychologist‖ and the prescribing medical doctor. This concurrence clause resulted in an
amendment placing ―Medical Psychologists‖ under the regulation of the Louisiana
Medical Board. A ―concurrence‖ clause is not in the New Mexico law.
  NM Prescribing Psychologists and LA Medical Psychologists agreed in their survey
responses despite differences in prescribing laws. Responders stated their RxP training
goals were achieved preparing them to prescribe safely and effectively. Practices and
incomes increased substantially. Prescribing Psychologists treated patients with mental
and physical conditions from previously underserved populations. Responders were
optimistic about the future of prescribing psychology as a way to better serve their
patients.
  A survey dealing with the use of vital signs, physical examinations, clinical laboratories,
and dual diagnoses was mailed to NM Prescribing Psychologists in March 2011. There
was a significant increase in Prescribing Psychologists over two the past two years,
especially in the public sector. This represented increased acceptance of Prescribing
Psychologists by the public, healthcare facilities and other healthcare professionals. This
suggests that the chronic shortage of mental health specialists could be overcome by
public funding of prescriptive authority training of licensed psychologists.

  Introduction: The Emergence of Prescriptive Authority for Psychologists
                Through the Independent Practice Movement
  This article describes the implementation of a long-term dream of many psychologists
to make the practice of psychology a ―full-service health profession.‖ Public recognition
of psychology in healthcare health dates back over 60 years when the Department of
Veterans Affairs began training clinical psychologists as specialists in mental healthcare.
Unmet public needs for mental health specialists to diagnose and treat behavioral
disorders with both psychological and physical interventions became the challenge to
clinical psychology. Leaders in clinical psychology advocated psychologists treat mental
and behavioral disorders with a broad array of treatment techniques including the use of
_________________________________
*Correspondence Address: Elaine S. LeVine, PhD, ABMP Through the Looking Glass
1395 Missouri Ave. Las Cruces, NM 88001 email eslevine@hotmail.com
                   Journal of the Academy of Medical Psychology

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psychotropic medications. Dr. Elaine LeVine was instrumental in the passage of the
historic New Mexico law that granted prescriptive authority to psychologists trained in
psychopharmacology to prescribe psychotropic medications for mental and behavioral
conditions. This law required breaking down long-standing legal and medical barriers to
the practice of psychology. She was also a primary author of the required regulations
implementing the New Mexico law into practice.
  Dr. LeVine conducted two surveys of how licensed prescribing /medical psychologists
implemented their skills into their practices. She chose private practice as being the
most representative of professional psychologists operating under their own aegis
unfettered by facility protocols. She recognized prescribing psychologists serve as a
benchmark as full-service health care profession. She asked that a historical background
be included to highlight the magnitude of this struggle and significance of psychology’s
achievement as a prescribing profession. The following overview of development of
prescriptive authority for the profession is offered to honor Dr. Levine and her colleagues
that made this achievement a reality.

I. Historical Basis for Prescriptive Authority for Psychologists (1)
  The private practice of psychology is an outgrowth of the healthcare legislation to deal
with returning veterans readjusting to civilian life following World War II. The war effort
had created a pent-up unmet demand for medical services in the civilian population that
were aggravated further by the return of veterans of military service. There was no plan
for how to overcome the healthcare shortages and to pay for the needed ―medical
services.‖ The Taft-Hartley Act of 1947 attempted to deal with these health issues by
making healthcare a tax-deductible benefit of workers. This Act also created union–
based Trusts that would use tax-exempt corporate healthcare funds for unions to
organize and provide healthcare for their members. Unions negotiated health plans with
insurers for their members and set the tone of the post-war healthcare market that
private practitioners of psychology hoped to enter.
  Pre-paid healthcare was a bonanza for general healthcare but not for mental health.
Nervous and mental disorders, alcoholism and tuberculosis were the three chronic
health conditions exempted from standard health insurance contracts. Tuberculosis
became a covered condition by insurance with the development of penicillin and other
antibiotics. However, there were no effective medications for mental disorders or
alcoholism. It was not until 1958 when the US Government began to include ―nervous
and mental disorders‖ and ―alcoholism‖ in its insurance contracts for federal employees
that private practice of psychology began to flourish. Prior to this time the bulk of
psychologists were employed primarily in public schools and in state or federal hospitals.
The expansion of postsecondary education had provided some opportunities for both the
teaching and the practice of psychology.
  From the end of the Civil War to the end of World War II care for the mentally ill and
mentally retarded had become a responsibility of states. State operated facilities had
become the dumping grounds for unwanted relatives or non-self-supporting citizens. A
major treatment problem was to separate the mentally ill from the mentally retarded.
Psychologists were hired to use their psychometric skills to accomplish this cost-saving
diagnostic task. However, states had few if any standards. States did not comply with
federally required reporting systems for mental conditions. The diagnostic system was
inadequate and the DSM-I was just coming into use. Dorothea Dix’s optimistic dream for
                   Journal of the Academy of Medical Psychology

                                            3
humane public healthcare for the insane had become a costly nightmare to states and to
the federal government.
  During the general healthcare boom of the 1950’s the public rejected state operated
mental hospitals for the care and treatment of their loved ones. Public demand for
rehabilitation of WW II veterans with mental conditions had required the Department of
Veterans Affairs (VA) to expand its services for mental health specialists. The VA then
created a doctoral level program to train clinical psychology as mental health specialists.
The demand for these trained doctoral level psychologists by state hospitals outstripped
the supply. Dr. Karl Heiser anticipated this supply/demand issue and in 1946 codified the
doctoral standard in the first law certifying psychologists. This began the 30-year
struggle for statutory recognition of psychology by licensure in all 50 states. Demand for
improved standards of care for outpatient treatment of those with mental conditions
overwhelmed the meager supply of doctors willing to treat and manage these conditions.
Psychiatrists in working in state hospitals began to develop lucrative private practices
and recruited psychologists to assist them in their practices.
  Enterprising psychologists realized they were providing the same services as
psychiatrists and found opportunities to set up their own outpatient practices for
diagnostic testing and psychotherapy. Psychiatrists began treating mental conditions
with newly marketed psychotropic medications, such as Thorazine and the
benzodiazepines as they became available. Although there was a growing market for
psychological treatments, psychologists were not included in pre-paid health insurance
plans. Mental disorders were considered to be medical conditions and reimbursement
for diagnosis and treatment was restricted to medical doctors. The rapid increase in the
availability of insurance coverage for mental disorders made it clear that the private
practice of psychology for had little future in the diagnosis and treatment of mental
conditions had little future unless payments for their patients could be reimbursed by
insurance. The major objections to insurance coverage of psychological diagnosis and
treatment were: 1. Psychologists could not provide a full range of care for those requiring
hospitalization and 2. Psychologists could not prescribe medications.
  If psychologists provided the same services as psychiatrists in the diagnosis and
psychotherapeutic treatment of patients, psychologists asked themselves, ―why
shouldn’t patients requiring mental care be entitled to seek services from whomever that
was legally qualified to provide those services?‖ In 1967 Drs. A. Eugene Shapiro and
Morris Goodman of New Jersey obtained passage of the first ―freedom of choice‖ law in
New Jersey that required insurers to reimburse patients of psychologists for the
diagnosis and treatment of mental conditions. Insurers complied with this law by simply
defining licensed psychologists as ―physicians‖ under the terms of their health insurance
contracts. This ignited psychological practitioners to seek licensing laws with a ―defined
scope of practice‖ rather than certification acts that merely protected the title of
psychologist. This movement was bolstered by Dr. Nicholas Cummings’ seminal findings
that proper treatment of mental and behavioral conditions using psychotherapy could
result in significant cost savings in medical treatments that more than offset the cost of
the psychotherapy.
  The APA Committee on Health Insurance (COHI) was established to expand insurance
coverage of psychological healthcare treatments. The success of COHI obtaining
inclusion of psychological services in many private and state group insurance contracts
                   Journal of the Academy ofMedical Psychology

                                            4
for outpatient services did not remove the barriers of prescribing medications and
hospital privileges for psychologists. Union Trusts were exempt from state ―freedom of
choice‖ laws and psychology was not enumerated as a health profession in Section
1861 (r) of Medicare or in federal Medicaid requirements for the states to provide mental
health services for the medically indigent. Consumer rights for mental care that were
granted by state ―freedom of choice‖ insurance laws were then abolished by the federal
Employee Retirement Income Security Act of 1975 (ERISA). ERISA gave business
corporations similar rights to form insurance trusts that labor unions had gained under
the Taft-Hartley Act. Thus, ERISA became the legislative foundation for managed care
corporations of the insurance industry. The APA Committee on Health Insurance was
―discontinued‖ as being no longer necessary. Several years of advocacy for private and
public practice were lost before healthcare advocacy was re-established as the APA
Practice Directorate.
  The hospital treatment of the mentally ill had remained the private preserve of
psychiatry except for some private consultation for psychological testing and delegated
duties assigned to psychologists who were employees of the hospitals. The American
Medical Association’s Joint Commission for the Accreditation of Health Organizations
(JCAHO---formerly JCAH) had been given ―deemed status‖ of a government agency
under Medicare to regulate hospital care. Hospital staff privileges of admission,
―attending‖ status, transfer, and discharge, were denied to psychologists who were
classified as Allied Professionals in JCAHO regulations. However, the Commission for
the Accreditation of Rehabilitation Facilities (CARF), a multi-disciplinary peer
organization to JCAHO, did permit staff privileges for psychologists. Dr. Jack Wiggins
persuaded the Ohio Psychological Association and the Ohio Attorney General to sue
JCAHO on antitrust grounds that JCAH regulations were a restraint of trade on the
practice of psychology. After a 3 year struggle JCAHO signed a consent decree to abide
by state laws regarding the hospital practice of psychology. Then, psychologists lobbied
states to enact laws authorizing hospitals to include psychologists on their medical staffs
and give them appropriate privileges to care for their patients in hospitals.
  Prescriptive authority remained as one of the last scope of practice barriers for
psychological practitioners in order to make psychology a full-service healthcare
profession once hospital practice was attained. Psychologists in New Mexico and
Louisiana with psychopharmacology training have achieved prescriptive authority
despite difficult, prolonged legislative battles. Now, it is time to learn about how
prescriptive authority is the viewed from the standpoint of the experiences and attitudes
of colleagues prescribing as professional psychologists. Dr. LeVine, continued her
advocacy by conducting a survey of how prescribing psychologists incorporated their
skills of psychopharmacotherapy into their private practices. She believed that private
practice, unfettered by healthcare facilities, would be the best measure of psychology as
a prescribing healthcare profession.

II. The Current Status of Prescribing Practices of Psychologists in New
Mexico and Louisiana
 A person-to-person survey was deemed necessary to learn the exigencies of
prescribing psychologists in private practice in New Mexico and Louisiana. Lists of
Prescribing Psychologists were obtained from the New Mexico Board of Psychologist
Examiners and Medical Psychologists from the Louisiana Board of Psychologist
                         Journal of the Academy of Medical Psychology

                                                           5
Examiners. The prescribing/medical psychologists            in private      practice were
identified by asking colleagues that knew who were the prescribing psychologists in
their state. Of the 18 Prescribing Psychologists in New Mexico in the fall of 2008, 9 were
identified as maintaining a part- or full-time private practice. Of the 41 medical
psychologists in Louisiana at the time, only 14 were identified as maintaining a part- or
full-time private practice. Each of the prescribing/medical psychologists identified to be in
private practice were emailed a request for their participation in a telephone interview
and asked for a time when it might be possible to talk.
  An open-ended oral interview format was used so that the range of independent
practice approaches could be fully explored. Twenty-seven interview questions were
designed to explore the psychologist’s views on the relevance and appropriateness of
their training, changes in relationships with colleagues, practical and financial aspects of
practice related to prescribing, and the perceived advantages and disadvantages of
being able to prescribe. Possible differences in response patterns between New Mexico
and Louisiana psychologists were examined statistically for 10 questions1. The results of
the analyses suggested that it was not necessary to reject the null hypothesis and that
the populations are the same.
  Upon completion of all interviews, the answers were placed in logical categories.
Survey questions are categorized as follows:
  A. Goals and results in RxP training
  B. Description of use of psychopharmacology in practice
  C. Inter-professional relationships as a prescribing/medical psychologist
  D. Financial aspects of practice from prescribing
  E. Changes in practice associated with prescribing
  F. Advantages and problems of prescribing in practice

A. Goals and results of RxP training category questions included:
Q1. What prompted you to decide to take RxP training?
Q2. What did you expect from RxP training?
Q3. Has RxP training prepared you for independent practice as a medical/prescribing
psychologist?
  Psychologists interviewed had expressed a desire to increase their expertise. These
psychologists believed their RxP training and practica met their goals for training and
prepared them to prescribe safely and effectively (17/17). Also, they (17/17) are
optimistic about their own future and that of psychology as a prescribing are optimistic
about their own future and that of psychology as a prescribing health profession to meet
the needs of underserved populations.
B. Description of use of psychopharmacology in practice questions were:
Q4. What is the nature of your private practice?
Q5. How long have you been prescribing?
Q6. How many patients do you treat a week?
Q7. For what percent of your private practice population are you prescribing?
Q8. Of these, what percent are you seeing for psychotherapy and
medication management combined?
_______________
1
 Chi-square analyses by the Monte Carlo method were employed on questions: Q. 4, 5, 6, 7, 8, 9, 18, 22, 23 and
combined. None of these scores were significant. However, it must be recognized that the lack of detection of difference
from the null hypothesis may reflect the low power due the small sample size. The authors thank Dr. David Daniel of the
Business Statistics Department of New Mexico State University for his assistance in research methodology.
                  Journal of the Academy of Medical Psychology

                                           6
Q9. What percent are you seeing for medication management alone?
Q10. Has the nature of your patient population changed since you
have been prescribing?
  The majority of these practitioners were in solo practice (14/17) with three in
partnership practices and most (13/17) had been prescribing for two or more years.
Their practices were increasing with new practice opportunities in psychiatric hospitals,
nursing homes, underserved prisons, rural clinics, military facilities and other public
agencies. They were receiving more referrals from primary care physicians (PCPs).
Most of those interviewed (9/17) were treating 30 or more patients a week, 4 treated 20
patients or more and 3 were new in their practices. The percent of patients that were
prescribed for ranged from 31% to over 91%with the median between 71% and 80%.
Psychotherapy combined with medication was being provided for over 90% of the
patients seen by 9 of 13 psychologists responding to this question. Similarly, 9 of 14 of
those responding were treating 10% or less of their patients on mediations alone. One
psychologist in an extremely rural area was so inundated with patients requiring
medication that he had little time to treat with psychotherapy. Most (13 of 17) reported
that their practices were more varied and had changed since they added prescribing to
their practices. They were seeing more seriously disturbed patients and more patients
with comorbid psychological and medical conditions. They also reported seeing more
Medicaid patients and patients that had been misdiagnosed.

  C. Inter-professional relationships as a prescribing /medical psychologist. Questions
were:
Q11. Have any PCP’s refused to allow you to prescribe the medication you felt was most
appropriate?
Q12. If so, how did you handle this situation?
Q13. What do you see as the benefits of this collaborative relationship?
Q14. Do you see any drawbacks to it?
Q19. What is your relationship with pharmaceutical companies? Are you being visited by
pharmaceutical representatives? If so, how much time do you spend with them? Do they
leave you samples? Are they giving you gifts? Please describe.
Q25. How do you describe your relationship with pharmacists? Are they responsive,
respectful?

  Questions related to collaboration provided interesting commentary on the increased
interactions between psychologists and physicians, as well as, interactions with
pharmacists. The increased collaboration physicians and pharmacists substantiated that
prescribing/medical psychologists were well received by the healthcare community in a
short period of time. The survey questions were not directed toward psychologists’
relationships with nursing or social work and little information about interactions with
these professions was obtained.
  Of particular interest were the responses to Question 11 ―Have any PCPs refused to
allow you to prescribe the medication you felt was the most appropriate? The answer
was a clear ―no‖ for 10 of the 17 responding who reported that PCPs ―really appreciated
the calls.‖ Of the 7 reporting some difficulty it was less than 10% of the time. This
occurred more frequently (7/8) in Louisiana where collaboration with a prescribing
physicians is mandatory and the psychologist must obtain ―concurrence‖ from the
collaborating physician before prescribing. When ―concurrence‖ of the medication
                   Journal of the Academy of Medical Psychology

                                              7
prescribed was not attained by 4 responders, the treatment plan was disrupted. Thus,
the requirement of ―concurrence‖ collaboration in the LA law became a source of
contention in the collaboration relationship between psychologists and physicians. It
must be noted here that this survey was conducted prior to the RxP law in Louisiana
being changed placing Medical Psychologist‖ under the regulation of the Medical Board
without a requirement that they maintain their license as a psychologist. The lack of
oversight requirement by the Board of Psychologist Examiners in LA is now a source of
contention within the practice of psychology. Thus, great care in specifying the nature of
collaboration is essential in the drafting of collaboration language in scope of practice
legislation.
  In New Mexico, psychologists must collaborate with the primary care physician before
prescribing medication unless the patient’s need for a psychotropic medication is critical
(in which case, there is a 48-hour period in which to contact the primary care physician
after prescribing) or in a disaster area (in which case, the on-call physician can serve in
the role of the primary care physician). The New Mexico law or regulations do not
specify that the collaborating physician must agree with the psychologist’s
recommendation. New Mexico regulations allow for the psychologist to present an
overall plan to the collaborating physician rather than to contact the physician about
each specific change in medication.
  Prescribing/medical psychologists saw many benefits in collaborating with other
healthcare professionals. However, there can also be seemingly unnecessary
frustrations associated with the required mandatory collaboration with the primary care
physicians. Part of this may be due to a physician’s lack familiarity with psychologists as
a profession or not having had the opportunity of working with a specific psychologist.
Responders cited two circumstances where the specifics of collaboration may become a
practice issue:
  1. Medicaid regulations for nursing homes state that only the admitting physician can
prescribe medications. Consulting Psychologists, just as Consulting Psychiatrists,
cannot prescribe without the permission of the patients’ attending physician. This
regulation is designed to prevent aged and debilitated patients from being over
medicated. This regulation places psychology and psychiatry on the same status in
nursing homes but does not require the attending doctor to have specialty training or
continuing education in prescribing or monitoring psychotropic medications when
prescribing them.
  2. When consulting in hospitals, prescribing/medical psychologists may be called in to
see patients where the attending physician does not have an ongoing collaborating
arrangement with the psychologist and may be uncomfortable cosigning prescriptions of
the psychologist.
  Despite the difficulties in collaborating encountered as described above, prescribing/
medical psychologists see great value in collaborating with other healthcare professions.
They (16/17) used their relationship skills and professional contacts in the community so
that any difficulties in the collaboration with another health professional did not interfere
with the overall care of the patient. Collaboration resulted in better integration of clinical
care was cited (12/17), PCPs appreciating consultations were noted by (5/17) and
consultation was seen as a practice building opportunity (3/17).
  Drawbacks of collaboration understandably listed time required (15/17), overburdened
PCPs were not interested in collaborating, looking at more laboratory records, or
PCPs giving pro forma agreements. Despite the time required for consultation on
                   Journal of the Academy of Medical Psychology

                                            8
medications and inconveniences in making contact, one practicing psychologist said
s(he) would do it anyway when appropriate even if it were not mandated.
  Question 19 is multi-factored regarding representatives of pharmaceutical companies.
Most prescribing psychologists (13/17) reported ―drug detail‖ representatives of
pharmaceutical companies were not interested in marketing their medications to them.
The other 4 were left drug samples and/or token gifts such as pens/ prescription pads,
etc. Free drug samples to start patients on medication were appreciated but not sought
by psychologists.
  Relationships between psychologists and pharmacists were described as being
excellent (17/17). Psychologists saw pharmacists as courteous, responsive, and helpful
in monitoring medications and excellent sources of information.
  Frustrations with insurance companies appear to stem in part from the term
―Prescribing Psychologist‖ is a term of art in NM. (The redundant term
―medical/psychologist‖ used in the paper to note inclusion of LA prescribing
psychologists.) NM medical/prescribing psychologists must work with medication
formulary limitations, which are designed to keep down the cost of medication. The
current formulary can limit providing the most efficacious medication to a patient. One
psychologist described experiences dealing with a particular managed care company to
obtain prior authorization to prescribe medication not on a formulary as ―surrealistic.‖
After being referred to several offices and finally speaking to the correct administrator,
the administrator only wanted to know the identifying data of the insured. Therefore, the
entire authorization process was perfunctory for purpose of discouraging the use of off-
formulary medications rather than an authentic review of the appropriateness of
medications. Another psychologist reported a large state managed care company tried
to force her into practice within the traditional medical model. Payments for
psychotherapy with medication management for several chronically depressed patients
with bipolar disorder were denied. Instead, reimbursement was restricted to 15 minutes
or 30 minutes for medication management checks.

  D. Financial aspects of practice from prescribing questions were:
Q15. Are you able to charge more per session? Please describe.
Q16. What new costs have you incurred?
Q17. Has supervision by managed care changed? If so, in which ways?
Q18. Are you using health and behavior codes? Are you getting reimbursed through
them?
  Responders to the survey reported varying degrees of difficulty in getting paid by
managed care companies. Most found little change in supervision by insurers as a result
of prescribing (9/17). Health and Behavioral Codes were rarely used (2/17). This lack of
use of Health and Behavioral codes is surprising since most prescribing psychologists
reported they were treating more patients with medical as well as behavioral conditions.
Insurers refused to reimburse for prescriptive services of Conditional licensed RxP
trained psychologists regardless of codes used according to reports by all nine of the
New Mexico respondents!
  All (17/17) of the prescribing/medical psychologists reporting stated they were able to
increase their fees. Over half (9/17) reported they were making ―considerably‖ more
money because they were able to discontinue managed care contacts and provide only
fee-for-service care or simply raise rates. Some were able to obtain contracts that paid a
                         Journal of the Academy of Medical Psychology

                                                           9
similar rate as psychiatry. However, 2 of 17 reported losing money on Medicaid patients.
  Half (8/17) of private practitioners who were serving patients drawn from the managed
care pool reported only a slight increase in fees of about $10 to $15 per session. Even
so, these ―slight increases‖ on an annualized basis can amount from $15,000 up to
$22,500 of increased income. Thus, it is estimated that the median income increase
from a prescribing practice is minimally about $20,000 per year.
  Increased costs of practice were cited as drawbacks to practicing as a prescribing/
medical psychologist. Increased costs mentioned were: Liability insurance costs
increased 15%. (This 15% increase could typically translate into about $150 in increased
costs. Ed.) The initial cost of the federal DEA license to prescribe and dispense
medications was $500.00 with an annual renewal fee of $51. Some purchased software
programs to assist them in accurate record keeping of prescriptions written. Some
reported added record keeping and ―unbillable‖ time reviewing clinical laboratory reports
was problematic as a function of prescribing.2 Some said they were attending more
expensive CE courses dealing with RxP. The reported income increases gained from
prescribing more than offset any increased costs related to prescriptive authority they
cited as drawbacks!

  E. Changes in practice associated with prescribing questions were varied by
practitioner and lacked a central theme for practice. They were treated as separate
items.
Q20. How do you cover telephone calls from patients on a 24-hour basis?
Prescribing/medical psychologists still tend to handle their telephone messages through
an answering service (10/17), although some (6/17) take calls by their cell phone or
have special cell phone arrangements. About 1/3 had a telephone coverage
arrangement with another prescribing psychologist, nurse practitioner or physician.
Q21. What provisions do you make to assure the accuracy of your prescriptions?
Duplicate prescription pads were used by (9/17) of the prescribers. Online prescribing
services and dictated prescribing in front of the patient were mentioned. Giving the
patient the prescription and having them read it back was also cited.
Q22. Are you using an online pharmacy prescribing service that monitors medication
usage and interactions?
Only 3 prescribers of the 14 responding stated they were using such an online pharmacy
prescribing service and 11 said they were not.
Q23. How often do you run computerized drug interaction studies?
Six of the 16 responding reported they ran a computerized medication check on every
patient and six did not, unless multiple medications were involved. Only one reported
doing medication checks by to textbooks.
Q24. Has RxP changed your record keeping practices?
More extensive note taking was reported by (8/17) of the prescribers. Four were having
their patients co-sign prescriptions written by them. Five were using computers more to
assist them in office practices and/or scanning in laboratory reports. Two were using
symptom-rating scales with their RxP patients. Informed consent forms were mentioned
as being problematic by four responders although the consent forms apply to all patients
and are not a function of RxP requirements.
  Prescribing/medical psychologists still tend to handle their telephone messages
__________
2
  The importance of laboratory findings was not addressed in the original survey. A second survey on use of
clinical laboratory testing by psychologists appears in Addendum III of this article.
                  Journal of the Academy of Medical Psychology

                                            10
through an answering service (10/17), although some (6/17) take calls by their cell
phone or have special cell phone arrangements. About 1/3 of the respondents had a
telephone coverage arrangement with another prescribing psychologist, nurse
practitioner or physician.
  F. Advantages and problems of prescribing/medical psychologists questions were
presented as in a direct but non-leading open-ended format:
Q26. What do you see as the greatest difficulties and hindrances of becoming a
prescribing/medical psychologist?
Q27. What do you see as the greatest advantages of becoming a prescribing/medical
psychologist?
  Psychologists opposing prescriptive authority have emphasized the potential hazards
of prescribing medications including a change of attitudes or behavior of psychological
practitioners to become ―junior psychiatrists.‖ Those suggested hazards appear to be
political fear tactics. These fears have not materialized as far as the prescribing/medical
psychologists surveyed. Survey respondents were forthright when stating their
complaints, as well as, the advantages of prescribing in their practices. Two of the 17
spontaneously mentioned the need to remember, ―we are psychologists first‖ and ―one
does not over-prescribe.‖ The difficulties or hindrances they do report are the broadened
oversight in patient care and concerns about medication effects (10/17). The increased
sense of responsibility of prescribing was offset by satisfactions from practice and the
feeling of empowerment RxP providers gained from providing a more integrated, better
quality of care (15/17). They believe the care they provide is more timely, thus, less
expensive for the patient (6/17). Part of this satisfaction from practicing as a prescriber
came from reducing rampant over-prescribing from polypharmacy, that is using multiple
medications of the same class of medications to treat a single diagnosed condition of the
patient (5/17).
  Time considerations due to collaboration requirements and increased record keeping
were also mentioned as hindrances (9/17). One unexpected complaint of RxP
prescribers was the amount of time required to read clinical laboratory test results. There
were no complaints that their increased incomes from prescribing did not adequately
compensate them for obtaining RxP training or practicing as a prescribing/medical
psychologist!
  Several comments of responders add a personal flavor to the data obtained. Problems
with insurers regarding reimbursement persisted for prescribing/ medical psychologists
just as they do for other prescribing professions (3/17). Some felt that patient
expectations from medications were too high (2/17). Two were also concerned about the
possibility of increased liability insurance risks. Two prescribers reported greater patient
trust and better patient treatment compliance when medications were used in treatment.
Another responder stated prescribing enabled him to have a greater impact on the
seriously mental ill. One complained they could not treat all referrals that needed help.
While another felt prescribing offered more consulting opportunities to expand help to
treatment centers.

III. Addendum of Behavioral and Medical Practice Issues in New Mexico
 Presentations (2,3) of the original RxP survey data raised more curiosity regarding how
prescribing/medical psychologists practice. There has been significant interest in
obtaining more detailed information about how the connections between physical and
behavioral conditions were addressed in the practices prescribing/medical psychologists’
                    Journal of the Academy of Medical Psychology

                                             11
practices. The low usage of Health and Behavior codes were of particular concern to
some since this might suggest psychologists were not treating patients with primary
medical conditions. On the other hand, there were spontaneous comments by
prescribing/medical psychologists regarding clinical laboratory reports being time
consuming even though the survey questions did not address issues of clinical
laboratory findings. Therefore, a follow-up survey was contemplated. Amendments to the
Louisiana law and regulations were adopted and negated the utility of repeating the
original survey. Yet, the interplay of physical and mental health issues of patients of
prescribing psychologists still required further investigation. The following 5-item
questionnaire was mailed in March 2011 to licensed psychologists in New Mexico
authorized to treat with psychotropic medications as Prescribing Psychologists.

                              Survey Questions March 2011
Please estimate how often you do this each week:
1. Take one or more set of vital signs (blood pressure, weight, height, etc.)?
2. Conduct a physical examination?
3. Order laboratory testing?
4. Treat someone with a dual diagnosis—medical condition, as well as, a psychological
condition?
5. Treat someone with psychotropics who has a medical condition affecting their
psychological condition?
  Responses were received from 22 of the 29 licensed prescribing psychologists for a
response rate of 72%. Their data was recorded separately for their primary and
secondary work sites.
  The results indicate that Prescribing Psychologists working in federally qualified health
centers, as well as, mental and general hospitals are taking vital signs, conducting some
physical examinations and ordering laboratory tests according to protocols of the facility.
This represents a significant difference in the practices of Prescribing Psychologists
when working in a medical facility than when they work as private practitioners. This
finding supports LeVine’s view that private practice best describes the prescribing
practice patterns of psychologists that resulted in her choice of prescribing in private
practice survey. When these same psychologists provide their services in private
practice, it appears that they rely upon a collaborating medical practitioner to conduct
physical examinations. This underscores that these prescribing psychologists
understood the boundaries of practice and abided by them!
  Prescribing Psychologists working in medical facilities and private practice both
diagnose and treat many complicated cases. Prescribing Psychologists working in
private practice settings are treating and medicating patients with dual diagnoses—
psychological and medical conditions. They are ordering clinical laboratory tests to help
manage the care of their patients in the use of prescribed and ―unprescribed‖
psychotropic medications, such as alcohol and psychoactive substances. In underserved
areas where medical sources are scarce or unavailable licensed prescribing
psychologists may take vital signs of patients as they are trained to do.
  The number of Prescribing Psychologists licensed in New Mexico increased from 18 to
29 (62%) in the two years since the completion of the original survey. There were 8
psychologists were prescribing in private practice at the end of 2008. Now, there are 11
prescribing psychologists in at least part-time private practice but only 5 are still solely in
private practice. Growth in numbers of prescribing psychologists in public facilities has
                          Journal of the Academy of Medical Psychology

                                                             12
tripled in this same time period. This growth indicates that prescriptive authority of
psychologists is increasing access for all population sectors and not just to those who
can afford insurance coverage for mental disorders. This highlights that the shortage of
behavioral care specialists in public facilities can be overcome by public financing of RxP
training of licensed psychologists. Prescribing psychologists in public facilities, as well as
in private practice, in New Mexico have demonstrated they are willing to treat
complicated cases where their patients have ―dual-diagnosed‖ multiple psychological
and medical needs.
  Where indicated these prescribing psychologists expand clinic facilities by taking vital
signs of patients and even do partial physical examinations according to the protocols of
the facility. Only a psychologist consulting in nursing homes did not do vital signs, order
laboratory tests or treat dual-diagnosed patients.3 Most of the Prescribing Psychologists
performed vital signs and ordered clinical laboratory tests according to facility protocols
and evaluated clinical laboratory results for the benefit of their patients. Most Prescribing
Psychologists diagnosed and treated patients with dual-diagnoses. Only in a military
facility was the psychologist restricted by regulation from treating dual-diagnosed
patients. The frequency of occurrence of dual-diagnosed patients varied markedly
according to the facility. Thus, the variety and flexibility of clinical skills that Prescribing
Psychologists possess has been welcomed and sought after in rural areas, military
facilities, understaffed community clinics, Indian reservations and by medical
practitioners. In brief, –Prescribing Psychologists have been welcomed both by the
public and serve as an important functional addition to the New Mexico healthcare
community!

                                          Summary and Comment
  The NM /LA survey documents the consensus of positive attitudes of prescribing/
medical psychologists in private practice regarding prescriptive authority. For these
RxPtrained psychologists, prescribing medications for their patients has become a
satisfying way to practice as a licensed psychologist. Legislated authority to prescribe
psychotropic medications by RxP-trained psychological practitioners gave the public
access to needed treatments for underserved people who would have remained
untreated otherwise. This new added access to psychological services was well received
by the public, medical doctors and other health practitioners.
  Collaboration between RxP trained psychologists and other prescribing professionals
required by law worked to increase public access to specialists in mental and behavioral
healthcare. However, unnecessary restraint imposed by requiring a ―consensus‖ in
collaboration was a major impediment to RxP trained psychologists prescribing as
practitioners in Louisiana. Mandated ―consensus‖ creates an imbalance in discussions
unless both parties have the right to agree or disagree in the decision making process.
Without this provision for collegiality collaboration was only ―conditional practice
authority‖ of physician agency extension.
  New Mexico legislated prescriptive authority had negotiated a two year limitation to its
Conditional Authority licensure supervision provision clause. The two-year Conditional
Authority prescribing period remains an insurance reimbursement problem in New
Mexico but has become less of a problem as prescribing health professionals become
more familiar with Prescribing Psychologists.
________________
3
  Medicaid regulations restrict prescriptive authority to the attending physician of the patient in skilled nursing facilities
(SNF).
                     JournaloftheAcademyofMedicalPsychology

                                             13
  The ―conditional authority to prescribe‖ for Louisiana Medical Psychologists resulted
amending their LA prescribing law to be regulated by the Louisiana Medical Board
without oversight by the Louisiana Board of Examiners of Psychologists. This amended
legislation for Medical Psychologists as prescribers versus licensed psychologists
regulated by the Louisiana Board of Psychologist Examiners has created major conflicts
among psychologists in Louisiana. Board Certification by the American Board of Medical
Psychology requires diplomates to agree to regulations of state licensing Boards of
Psychologist Examiners. Thus, psychologists with American Board of Medical
Psychology diplomates desiring prescribing under the Louisiana Medical Psychologist
license provisions must retain their psychology license in addition to their Medical
Psychology license in order to satisfy ABMP requirements. Needless to say, this
confusion in professional titles and practices has created public confusion, as well.
  This Louisiana RxP licensing amendment has also limited the value of the survey data
obtained to the time period prior to the enactment of the amendment for transferring
regulation of prescription authority to the Louisiana Medical Board. It is precisely for this
reason that a re-analysis of any differences in survey data between these two states was
undertaken and is reported here. Although the original statistical analysis found no
significant statistical differences between New Mexico and Louisiana survey responder’s
replies, legislative approaches and outcomes are strikingly different. The lack of
statistically significant differences was attributed to the small size of the sample. Over-
analysis of small sample data is always a research danger, yet the importance of the
questions asked regarding ―collaboration‖ among health professionals begged for a
second look at the data at hand.
  Conditional Licensure for a stipulated period of time may be an important legislative
strategy for passage of RxP legislation but does not achieve an increased access to
specialty care for underserved people. Instead, it creates another ―medical extender‖
category under the control of prescribing health professions that are already
overburdened in their practices and lack time to collaborate. Further, many medical
practitioners have self-imposed limits to their practice and therefore lack continued
education training in behavioral health treatments or specialty training in the prescribing
of psychotropic medications.

                        Implications and Recommendations
  Healthcare reform is inadequate without a strong behavioral care component. The
current mental health system in the United States and worldwide is in disarray due to a
shortage of medical mental health specialists whose expertise is primarily the
prescription of psychotropic drugs rather than psychosocial interventions. The numbers
of these medical mental health specialists are so few that they cannot even provide
sufficient psychotropic services required to meet current demands nor treat the
psychosocial components that are an integral part of the rehabilitation of mental and
behavioral disorders. Medicating behavioral conditions has been turned over to primary
care physicians (PCP) whose principal interest is physical diseases without any
requirement they be trained or even have continuing educations requirements for
prescribing of psychotropic medications. PCPs are well intended but are already
overburdened treating patients physical conditions they were trained to provide care. It is
an unrealistic expectation to extend the practices of PCPs further by collaborating in
treatment of behavioral disorders that require added time to deal with the psychosocial
                    JournaloftheAcademyofMedicalPsychology

                                           14
aspects of patients’ conditions. Patients expecting medications provided by PCPs to
cure their problems are not receiving the benefits of specialty care they require.

  We must incorporate the psychological expertise of that is currently available in the
community to deal with the crisis of a shortage behavioral care for our underserved
civilian population and the returning military service men and women. Prescribing
Psychologists in public facilities, as well as in private practice in New Mexico have
demonstrated they are willing to treat complicated cases where their patients have ―dual
diagnosed‖ multiple psychological and medical needs.
  Enactment of prescriptive authority for psychologists in these two states and practicing
effectively in federal services has proven RxP-trained psychologists provide the
necessary increased access to behavioral care, as well as, prescribe the psychotropic
medications required for comprehensive healthcare reform. Data presented indicates
that prescriptive authority of psychologists increases access for all population sectors
and not just to those who can afford insurance coverage for mental disorders. This
suggests that the shortage of behavioral care specialists in public facilities can be
overcome by public financing of psychopharmacology training of licensed psychologists.

                                      References
1. Wiggins JG. A History of the Reimbursement of Psychological Services: The
Education of One Psychologist in the Real World. In Wright R & Cummings N (eds) The
Practice of Psychology: The Battle for Professionalism. 2001, Zeig, Tucker & Theisen,
Phoenix AZ.
2. LeVine E & Wiggins J. Prescribing in a Private Practice Setting. Independent
Practitioner 2009, 29 (1), 30-32.
3. LeVine ES & Wiggins JG. In the Private Practice Setting: A Survey on the
Experiences of Prescribing Psychologists. In Mcgrath R & Moore B (eds)
Pharmacotherapy for Psychologists: Prescribing and Collaborative Roles. 2010, Am
Psychol Assn, Washington, DC.

				
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