SB1004 CD1

SECTION 1. The legislature finds that there is limited access to mental health care treatment services for citizens in the rural areas of the State. The delivery of comprehensive, accessible, and affordable mental health medical care may be enhanced by providing trained medical psychologists, licensed in Hawaii, with limited prescriptive authority for the specific purpose of providing care in federally qualified health centers. The legislature has previously authorized prescription privileges to advanced practice registered nurses, optometrists, dentists, podiatrists, osteopaths, and physician assistants.

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. Recently, Louisiana and New Mexico adopted legislation authorizing prescriptive authority for psychologists without regard to the service setting.

Since 2000, fourteen psychologists in Hawaii, all native to Hawaii, have received psychopharmacological training through the Tripler Army Medical Center, Native Hawaiian Psychology Training Program. These psychologists actively collaborate with primary care physicians to provide combined therapy and psychopharmacological care to a medically underserved patient population at seven federally qualified health centers at Bay Clinic, Hana, Molokai, Kauai, Waianae, Kalihi-Palama, and Waimanalo, and two native Hawaiian healthcare systems clinics located in federally designated medically underserved areas on Kauai and Molokai.

To date, thousands of native Hawaiians and other ethnic minorities have received the necessary combined therapy and psychopharmacological care that was sorely lacking to address significant mental and behavioral health care needs. For example, psychologists at the Waianae Coast Comprehensive Health Center completed approximately three thousand eight hundred forty patient encounters in 2004; seventy per cent of these patients received necessary psychotropic medication for the treatment of mental illness. Psychologists in several federally qualified health centers in the State have formed 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 provider to obtain the requisite prescription. However, physicians are not readily available in some areas and for some populations.

This is a particular hardship for patients of the federally qualified health centers on Oahu and the neighbor islands. Patients of federally qualified health centers include the uninsured (thirty-six per cent), the poor (fifty-six per cent), native Hawaiians (twenty-seven per cent, sixty per cent in rural areas), other Pacific Islanders (seven per cent), and the homeless (five per cent). Timely, efficient, and cost-effective treatment of mental illnesses in federally qualified health centers could avoid the significantly greater social, economic, and medical costs of delayed treatment or non-treatment for these underserved populations.

Research data soundly demonstrates that there are not enough prescribing mental health care providers available to serve the needs of all the people in Hawaii. Further, the economically disadvantaged and medically underserved would receive little or no mental health services if not for the federally qualified health centers and the services provided by clinical psychologists. At present, only three federally qualified health centers have psychiatrists on staff. In contrast, 2004 data from the Hawaii Primary Care Association indicates that there are 9.71 psychologists employed in full- or part-time positions to provide mental/behavioral health service in nine of the thirteen federally qualified health centers--the most recent expansion of these services has occurred within the short span of four years.

Since 1988, federal law has recognized the extraordinarily poor health of native Hawaiians. In Hawaii, native Hawaiians have the highest rate of untreated medical and psychological concerns, and higher rates than other indigenous and minority individuals in the United States. Recent concerns include the impact of the crystal methamphetamine epidemic and related substance abuse issues such as those occurring in Waianae, Molokai, and Waimanalo. This epidemic, coupled with the economic and cultural distress of the native Hawaiian population, has created unprecedented demands for services from an already overtaxed mental health system.

Further exacerbating the dire need for mental health treatment in underserved areas is the fact that patients from diverse cultural backgrounds are reluctant to seek treatment due to the 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 areas.

The United States Congress, through the Native Hawaiian Health Care Professions Scholarship program, requires scholarship recipients to work in federally designated medically underserved areas for a duration (typically four years) equal to the number of years they received scholarship funding. Under this program, psychologists of native Hawaiian ancestry are now using modern training and education to deliver health care in a culturally appropriate manner to other native Hawaiians through their placement in federally qualified health centers, native Hawaiian health systems clinics, and other federally designated health clinics in medically underserved areas.

The American Psychological Association has developed a model curriculum for the education and training of prescribing psychologists. Independent evaluations of the Department of Defense Psychopharmacological Demonstration Project by the United States General Accounting Office and the American College of Neuropsychopharmacology have found that appropriately trained medical psychologists prescribe safely and effectively.

The purpose of this Act is to authorize appropriately trained and supervised licensed medical psychologists practicing in federally qualified health centers, to prescribe psychotropic medications for the treatment of mental illness.

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:

"Narcotics" means natural and synthetic opioid analgesics, and their derivatives used to relieve pain.

"Psychotropic medication" means only those agents related to the diagnosis and treatment of mental and emotional disorders, including controlled substances except narcotics.

"Supervising physician" means a medically trained and licensed physician or psychiatrist who accepts professional responsibility for the provision of psychopharmacotherapy.

§465-B Conditional prescription certificate; application. (a) A psychologist may apply to the board for a conditional prescription certificate. The application shall be made on a form approved by the board, and be accompanied by evidence satisfactory to the board, that the applicant:

(1) Holds a current license in good standing to practice psychology in the State of Hawaii;

(2) Has successfully completed a planned sequence of psychopharmacological training from a regional accredited institution of higher learning. The training shall be consistent with the American Psychological Association's Recommended Postdoctoral Training in Psychopharmacology for Prescription Privileges. The training shall include a two-year postdoctoral program of no less than forty-four credit hours (six hundred sixty hours of classroom instruction) in at least the following core areas of instruction:

(A) Anatomy and physiology;

(B) Biochemistry;

(D) Pharmacology and clinical pharmacology;

(E) Psychopharmacology;

(F) Pathophysiology;

(G) Health assessment, including relevant physical and laboratory assessment; and

(H) Clinical pharmacotherapeutics;

(3) Has successfully completed twelve credit hours consisting of a supervised practicum:

(A) Of at least one year;

(B) Involving four hundred hours treating a diverse population of no fewer than one hundred patients with mental disorders;

(C) Supervised by a medically trained and licensed physician or psychiatrist who accepts professional responsibility for the provision of psychopharmacotherapy and who is not in the employ of the person being directed or supervised; and

(D) Including at least two hours of weekly supervision;

(4) Has passed a national proficiency examination approved by the board that tests the applicant's knowledge of pharmacology in the diagnosis, care, and treatment of mental disorders; provided that the board shall establish what constitutes a passing score and the number of times an applicant may re-take the examination within a specific time period;

(5) Has applied for a federal Drug Enforcement Administration registration number for limited use as restricted by state law;

(6) Has malpractice insurance in place, sufficient to satisfy the rules adopted by the board, that will cover the applicant during the period the conditional prescription certificate is in effect;

(7) Is employed or contracted by, and will practice the prescribing authority at a federally qualified health center established under Title 42 United States Code Section 1396; and

(8) Meets all other requirements, as determined by rules adopted by the board pursuant to chapter 91, for obtaining a conditional prescription certificate.

(b) The board shall issue a conditional prescription certificate if it finds that the applicant has met all of the requirements of subsection (a).

(c) The conditional prescription certificate 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) Continue to hold a current license to practice psychology in Hawaii and continue to maintain malpractice insurance;

(2) Inform the board of the name of the supervising physician under whose supervision the psychologist will prescribe psychotropic medication and the name of the federally qualified health center; 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 doctor of medicine who oversees the patient's general medical care.

(b) A psychologist holding a conditional prescription certificate may:

(1) Administer and prescribe psychotropic medication within the recognized scope of the profession; provided that those medications are not prohibited by the exclusionary formulary list, pursuant to section 465‑G; and

(2) Prescribe only those medications in paragraph (1) to patients under the care of the psychologist and who are enrolled at the federally qualified health center identified to the board.

(c) When prescribing psychotropic medication for a patient, a psychologist holding a conditional prescription certificate shall maintain an ongoing collaborative relationship with the doctor of medicine who oversees the patient's general medical care to ensure supervision so 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 written by a psychologist holding a conditional prescription certificate shall:

(1) Comply with applicable state and federal laws;

(2) Be identified as issued by the psychologist as "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 person. Records of all prescriptions shall be maintained in the prescribing psychologist's patient records.

(f) When authorized to prescribe controlled substances, a psychologist holding a conditional prescription certificate shall file with the board, in a timely manner, all individual federal Drug Enforcement Administration registration numbers.

§465-D Prescription certificate. (a) A psychologist may apply to the board for a prescription certificate. The application shall be made on a form approved by the board and be accompanied by evidence satisfactory to the board that the applicant:

(1) Has been issued a conditional prescription certificate and has successfully completed two years of prescribing psychotropic medication as certified by the supervising physician;

(2) Has successfully undergone a process of independent peer review approved by the board of medical examiners and the Hawaii Primary Care Association;

(3) Holds a current license to practice psychology in the State of Hawaii;

(4) Has malpractice insurance in place, sufficient to satisfy the rules adopted by the board, that will cover the applicant as a prescribing psychologist; and

(5) 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 it finds that the applicant has met all of the requirements of subsection (a).

(1) Continues to hold a current license to practice psychology in Hawaii and continues to maintain malpractice insurance;

(2) Annually satisfies the continuing education requirements for prescribing psychologists, as set by the board, which shall be no fewer than twenty hours each year, at least half of which shall be in pharmacology or psychopharmacology; and

(3) Continues to maintain an ongoing collaborative relationship with the doctor of medicine who oversees the patient's general medical care to ensure supervision so that:

(A) Necessary medical examinations are conducted;

(B) Psychotropic medication prescribed is appropriate for the patient's medical condition; and

§465-E Administration. (a) The board shall adopt rules pursuant to chapter 91 establishing the procedures to be followed to obtain a conditional prescription certificate, a prescription certificate, and renewal of a conditional prescription certificate and prescription certificate. The board may set reasonable application and renewal fees.

(b) The board shall adopt rules pursuant to chapter 91 establishing the grounds for denial, suspension, or revocation of conditional prescription certificates and prescription certificates, including provisions for suspension or revocation of a license to practice psychology 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 registrations and 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 a narcotic.

§465-G Exclusionary formulary list. The exclusionary formulary list shall specify the types of medications that psychologists holding either a conditional prescription certificate or a prescription certificate shall be prohibited from prescribing or administering. The exclusionary formulary list shall include the following types of medications:

(1) All narcotics;

(2) All monoamine oxidase inhibitors;

(3) All anti-psychotic medications;

(4) All amphetamines;

(5) All non-psychotropic medications;

(6) Lithium; and

(7) Serzone.

§465-H Joint formulary advisory committee; establishment, composition, and duties. (a) The department of commerce and consumer affairs shall establish a joint formulary advisory committee to periodically review the exclusionary formulary list under section 465-G.

(b) The joint formulary advisory committee shall recommend amendments to the exclusionary formulary list as it deems fit, subject to the limitations set forth in section 465-G. The board shall adopt the recommended exclusionary formulary list as established by the joint formulary advisory committee in its rules.

(c) The joint formulary advisory committee shall review the exclusionary formulary list no less than once per quarter, and as frequently as it deems necessary.

(d) The joint formulary advisory committee shall consist of:

(1) Two persons licensed as physicians specializing in psychiatry under chapter 453;

(2) Two persons licensed as psychologists under chapter 465 working at federally qualified health centers;

(3) One person licensed as a pharmacist under chapter 461; and

(4) The medical director of a federally qualified health center in the state."

SECTION 3. Chapter 465, Hawaii Revised Statutes, is amended by designating sections 465-1 to 465-15 as part I and to read as follows:

"PART I. 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; [~~and~~]

(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 organizations which 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 rendered.

(d) Nothing in this chapter shall prevent the provision of expert testimony by a psychologist who is otherwise exempted by this chapter.

[~~(e) Nothing 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. The Hawaii state health planning and development agency shall submit to the legislature a report, including any proposed legislation, no later than twenty days prior to the convening of the regular session of 2013, evaluating the status of mental health care in the State after providing prescriptive authority to certain psychologists. To assist the legislature in assessing the viability of continuing prescriptive authority for psychologists, the report shall include recommendations on whether prescriptive authority for psychologists should be amended, repealed, or continued.

SECTION 6. 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 7. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

SECTION 8. This Act shall take effect upon approval; provided that:

(1) Prescriptive authority for qualified psychologists shall not be granted until July 1, 2008;

(2) Section 5 of this Act shall take effect on July 1, 2009; and

(3) On July 1, 2014, this Act shall be repealed and 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.

THE SENATE	S.B. NO.	1004
TWENTY-FOURTH LEGISLATURE, 2007		S.D. 2
STATE OF HAWAII		H.D. 2
		C.D. 1