ASAP Reader #123

2-7-2002

Greetings ASAP Readers,

By the time you read this I hope we will know the outcome of the New Mexico Senate Public Affairs Committee vote on HB 170 (rap). Mario, Elaine and their Counsel have been doing a magnificent job. We all wish them every success in the Hearing scheduled for tomorrow.

Brian Ramirez, a Doctoral Candidate at Wright State University posted the results of his survey of 500 licensed psychologists attitudes toward prescriptive authority. I will take the liberty of editorial commentary following presentation of his results.

"I have just completed preliminary data analysis for my dissertation and would like to share some of the findings with the list. I conducted a national survey of licensed psychologists regarding their attitudes and opinions regarding the RxP issue.

500 licensed psychologists randomly selected from across the country were mailed 2- page surveys on issues related to RxP. 222, 44%, were returned. 52% were male, 48% were female. Mean age of respondents was 47. 58% held a Ph.D., 42% held a Psy.D.

• Average number of years licensed was 8. 84% of respondents either agreed or strongly agreed that appropriately trained psychologists should be able to prescribe psychotropic medication. 6% disagreed and 4% strongly disagreed with this statement. 6% were neutral.

• 75% agreed or strongly agreed that prescription privileges would enhance the image of psychologists in the public eye. 11% disagreed or strongly disagreed and 14% were neutral.

• 75% agreed or strongly agreed that RxP would lead to higher incomes for psychologists. 9% disagreed or strongly disagreed and 20% were neutral.

• 85% agreed or strongly agreed that malpractice rates would increase as a result of obtaining RxP. 6% disagreed or strongly disagreed and 9% were neutral.

• 55% agreed or strongly agreed that they would be willing to pay higher malpractice rates for RxP. 30% disagreed or strongly disagreed with the statement, and 15% were neutral.

• 60% A or SA that RxP are a logical extension of current clinical modalities. 23% D or SD, and 17% were neutral.

• 37% A or SA that RxP would lead to the medicalization of psychology. 43% D or SD, and 20% were neutral. 20% A or SA that RxP would adversely affect therapy skills. 63% D or SD, and 17% were neutral.

• 11% A or SA that RxP would adversely affect assessment skills. 75% D or SD, and 14% were neutral.

• 62% A or SA that RxP would increase length of graduate school training, 20% D or SD, and 18% were neutral.

• 65% A or SA that RxP training should be available during graduate school, 27% D or SD, and 8% were neutral.

• 83% A or SA that RxP training should occur at the postdoc level, 9% D or SD, and 8% were neutral.

• 26% A or SA that existing postdoctoral training programs in psychopharmacology provide adequate training to prescribe medication. 28% D or SD, and 46% were neutral.

• 81% A or SA that postdoctoral psychopharm training programs should be monitored by APA. 7% D or SD, and 12% were neutral.

• 40% A or SA that if RxP were allowed today they would seek the additional training. 44% D or SD with the statement and 16% were neutral.

• 49% A or SA that RxP would jeopardize psychology's relationship with psychiatry. 26% D or SD, and 25% were neutral.

• 35% A or SA that they would be willing to work to implement RxP legislation in their state. 45% D or SD with the statement and 20% were neutral.

• Regarding the % of their own clients psychologists referred for medication in the last year:

  • <10%=11%

  • 11 - 20%=24%

  • 21 - 40%=28%

  • 41- 60%=24%

  • 61 - 80%=11%

  • 81 - 100%=2%

• Regarding the average waiting period from request for medication evaluation to completed eval:

  • <1 week=7%

  • 1 - 2 weeks=21%

  • 2 - 3 weeks=40%

  • >3 weeks=32%

• Regarding how % of clients on medication has changed in last 5 years:

  • Decreased: 1%

  • Increased: 60%

  • No change: 39%

Regression analysis revealed that gender was the only demographic variable that significantly correlated with any of the opinion variables. Males were significantly more likely to agree that existing postdoctoral programs in psychopharmacology for psychologists provide adequate training than were females. Males were also significantly more likely to be willing to work to implement legislation for prescription privileges."

That's what I have so far. Given the liveliness of this debate, especially with the events of New Mexico, I thought I would put these early results out for the list."

Dr. Wiggins comments: Brian J. Ramirez Doctoral Candidate in Clinical Psychology Wright State University Brian is to be commended for his gathering current information and providing it in a timely way.

My comments are my own and do not necessarily represent those of ASAP. I am assuming this random sample is representative of the psychological community. I present my remarks to identify those areas where I see a misperception in the sample which needs attention through further education on the part of ASAP.

The perception of "85% that malpractice rates will rise as the result of obtaining RxP" shows a misunderstanding of how professional liability rates are established. Insurance rates of all kinds are likely to increase as a result of re-insurance rates having increased because (1) interest rates are lower [Insurers make most of their money from lending money to others. Lower interest rates reduce their profitability and so they try to recoup their earning by raising premiums]; (2) the catastrophic loses of 911 have shaken the re-insurance market [Insurers reduce their exposure to risk by buying re-insurance on their risks from other insurers. This sharing of the risk with other insurers stabilizes the insurance market. However, when major disasters occur most insurance companies share in the loss and this drives premiums up. Since many re-insurers are multiple line companies, the fact that the disaster is in a casualty area does not prevent them from recouping their losses from an non casualty area, such as professional liability.]

With that being said about the re-insurance market, professional liability insurance contracts are experience rated. This is why professional liability insurance can cost more in one state than another and the premiums for one profession can be different from another profession for the same coverage. Despite the scare tactics of opposition to RxP that people will die as the result of psychologists prescribing the risk load of suit for prescribing by psychiatry is about 8%. If you assume a risk load of 60% on the premium leaving a 40% or the premium dollar to cover overhead and profit, prescriptive authority for psychologists might have a 5% effect on premium rates other things being equal. This cost might be sustained by the insurer in order to save the contract rather than inure the cost of finding other businesses or professions to insure.

Advanced nurse practitioners, physician assistants and optometrists who prescribe all pay lower liability premiums than psychologists for the same coverage. This is due patient/ therapist intimacy liability losses which overshadow any increase in liability cost of prescribing. If it turned out there was a significant added risk to psychologists prescribing this cost could be passed on to those who prescribe rather than increasing the cost to all psychologists.

In sum, ASAP has a major education task to inform its membership and our colleagues on the value and costs of liability coverage for prescriptive authority. Buying low cost coverage is not necessarily smart business. Despite the suspicions of colleagues who believe APA Insurance Trust premiums are too high, it is my judgment that the Trust is doing an excellent job in holding down costs and offering a rich level of benefits.

The next misperception by some is the notion that RxP would lead to medicalization of psychology. The results of the survey refute this argument when 60% agree that the number of clients on medication has increased and the median 28% refer 21 - 40% of their patients for medication.

Thus, psychology is being "medicalized" to a significant extent without being able to prescribe. We may ask what is the added risk to our patients to have wait over a week for medication the psychologist feels is necessary for their patients? As a profession we must not be silent in the health care system when harm may come to our patients because they cannot get an appointment for needed medication and with proper training psychologists can obviate this risk.

The issue of length of graduate training and the desire to have RxP training in graduate school may be confounded in this survey. APA and ASAP have advocated for postdoctoral training only. With the possibility for GME funding of postdoctoral training that is hospital based and APA approved suggests that it may be possible to preserve current graduate training and psychopharmacology training be subsidized by GME funding. This statement is neither to support maintaining the status quo in graduate training nor to avoid re-evaluating current graduate training curricula and/or practices. Graduate training in psychology is another issue entirely. Again we are confronted with an area of needed educating of our colleagues. The fact that only 26% of psychologists agree that existing postdoctoral training programs in psychopharmacology provide adequate training to prescribe medication is a factoid that is likely to be picked out by RxP adversaries. The 46% neutral rating suggests that many of our colleagues have not really investigated training that is available. Yet, 40% indicate they would seek this training if RxP were allowed.

That 49% say that RxP would jeopardize psychology's relationship with psychiatry is misleading. The DoD experience suggests otherwise. While psychiatry was initially hostile or negative to psychologists who prescribed, within a short time they accepted and respected psychologists who prescribed. This is another area for education of colleagues.

It may seem it is a low number that only 35% of the psychologists responding would be willing to work to implement RxP legislation in their state. I do not doubt this number. I am encouraged that 1 out of 3 psychologists would work on any common project. Knowing practitioners time constraints and the diverse settings in which they work, this percentage delights me. Recall that Margaret Mead opined that any major movement in the affairs of mankind started with a small band of dedicated people. I would like to see the response to this question later assuming we will have favorable action in New Mexico.

One final comment on the 40% stating they would seek training if RxP were allowed. I believe that if those with RxP training sought consulting relationships with pharmacy chains and for nursing homes pharmacists there would be many job opportunities for these psychologist pioneers in psychopharmacology. There is a dire shortage of pharmacists and drugstore chains are paying signing bonuses for R.Ph.s in addition to offering them salaries of up to $80,000 having just finished their 4 year bachelor degree. The Pharm.D. degree takes 60-70 course hours more (about 2 years more). There is little financial incentive to do this even though pharmacists are getting limited prescriptive authority in over 30 states. Filling 200 prescriptions a day leaves little or no time for patient counseling. Drugstores now consider themselves mini-marts ala Walmart. In major cities, drugstore chains are considering centralized dispensing facilities where prescriptions would be filled and then delivered to the local drugstore. This would set up another barrier between pharmacists and patients needing counseling because clerks would actually hand the package to the patient and ring up the sale. Drugstore chains derive less than 10% of their profits from sales of prescribed pharmaceuticals although they may locate the pharmacy in front so that the customer can drop off the prescription then go on back in the store to shop for other merchandise. Then on their way to the pay out counter they can stop and pick up their prescription.

Yes, I do see an opportunity for well-trained enterprising psychologists to establish important consultancies in psychopharmaceutical counseling in this period prior to obtaining prescriptive authority. Pharmacy consultation and nursing homes are currently my favored possibilities but there are others. I will share these with you after my hiatus of 4- 6 weeks.

Anton Tolman will be managing both the ASAP and the RxP Listserves in my absence.

Best, Jack

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