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F I S C A L I M P A C T R E P O R T

SPONSOR Sandoval

DATE TYPED 2/16/05

HB 463

SHORT TITLE Prescriptions By Psychologists

SB

ANALYST Hanika-Ortiz

APPROPRIATION

Appropriation Contained Estimated Additional Impact Recurring

or Non-Rec

Fund

Affected

FY05

FY06

FY05

FY06

See Narrative

SOURCES OF INFORMATION

LFC Files

Responses Received From

Board of Medical Examiners (BME)

Health Policy Commission (HPC)

Regulation and Licensing Department (RLD)

Department of Health (DOH)

SUMMARY

Synopsis of Bill

House Bill 463 adds language that would broaden the definition of “psychotropic medication”

from the existing definition to expand the class of medication a psychologist may prescribe, and

authorizes uses not FDA-approved, for the treatment of mental, emotional, behavioral or cogni-

tive disorders or for the management of side effects. “Off-label” or for uses not FDA-approved,

include prescribing medication in a different dose, for a longer duration of time, or for a different

medical indication than recommended in the prescribing information.

Significant Issues

The proposed redefinition of “psychotropic medication” would greatly increase the number and

array of medications that prescribing psychologists will be able to prescribe, as well as the condi-

tions for which those medications could be prescribed.

Agencies report the issues are whether the psychologist’s training is sufficient in scope, content

and clinical expertise to insure comparability of care as that provided by other practitioners with

House Bill 463-- Page 2

prescribing authority; whether there are significant cost savings for health care delivery; and

whether this provides more options to patients from rural areas where physician shortages exist.

The HPC reports children are particularly vulnerable when drugs are used without FDA-approval

as they have significant pathophysiologic differences from adults. Drug trials involving children

or adolescents are almost non-existent.

The Board of Medical Examiners has the following comment:

The Prescriptive Authority for Psychologists Act adopted by the NM Legislature in 2002

made New Mexico the first state in the nation to allow psychologists prescribing author-

ity. The Medical Board and the Board of Psychologist Examiners convened a Joint

Committee and worked for 2 years to research, develop and reach consensus on a set of

proposed rules. The Medical Board approved those rules in August 2004 and after dis-

cussion with RLD, the Board of Psychologist Examiners adopted a final set of rules

which went into effect in January 2005.

There was consensus among the participants that the definition of “psychotropic medica-

tion” that was included in the original law was the best and safest way to protect the pub-

lic while at the same time allowing expanded access to mental health care. The entire set

of proposed rules regarding the education and training of prescribing psychologists that

was negotiated and agreed to by the Medical Board was based on the definition of psy-

chotropic medication as presented in the original statute.

The proposed re-definition of psychotropic medication supplants a legitimate and re-

spected measure of drug efficacy, FDA indication, with vague language about “custom-

ary use” by “qualified practitioners.” It adds cognitive disorders to the scope of practice

of prescribing psychologists. It ultimately allows psychologists who have received sig-

nificantly less medical training in drug interactions, pharmacological complications in

children and the elderly, and other important topics to prescribe controlled substances

off-label, as well as a nearly unlimited array of other medications to treat side effects.

PERFORMANCE IMPLICATIONS

The HPC reports the Administrative Rules that would need to be changed to implement the bill:

•

The Formulary (16.22.27.8 NMAC) currently does not allow a psychologist to prescribe

non-psychotropic medication.

•

Education requirements (16.22.23.8 NMAC) for a conditional prescriptive certificate.

The New Mexico Board of Psychologist Examiners rules and regulations would need to be re-

vised to come into compliance with this bill.

FISCAL IMPLICATIONS

Proposed legislation may offer a savings in mental health care and delivery costs. Rural areas

may have additional benefits regarding early intervention services and care that a psychologist

can provide when a physician is not available.

House Bill 463-- Page 3

ADMINISTRATIVE IMPLICATIONS

The RLD note additional training needs for staff to evaluate educational requirements and phar-

macological training and for the drafting of rules and regulations for prescribing psychologists.

CONFLICT, DUPLICATION, COMPANIONSHIP, RELATIONSHIP

None

TECHNICAL ISSUES

The Board of Medical Examiners note proposed definition includes the vague term “customarily

used,” which could cause confusion and possibly lead to misuse.

HPC notes use of the phrase “psychotropic medication” in its customary use in the field of be-

havioral health has a more limited meaning, than drugs that have no active psychotropic ingredi-

ents.

The DOH proposes adding an additional definition for “drugs used to treat side effects” to more

clearly define the circumstances under which a psychologist could prescribe.

OTHER SUBSTANTIVE ISSUES

The DOH notes proposed change allows psychologists to manage the side effects of drugs they

have prescribed. Side effects may be difficult to distinguish from other co-occurring medical

conditions and may be difficult to diagnose without a medical degree. Side effects of psychotro-

pic medications, especially metabolic and neurologic conditions, can be serious and medically

complicated to treat, such as drug-caused diabetes, lipid abnormalities, liver disease and hy-

pothroidism. The proposed change allowing the use of any drug listed in drug references raises

uncertainty about the distinction between the expanded role for psychologists and that of medical

practice.

The HPC notes that the bill is silent on any specific limitations in this expanded prescriptive au-

thority. The range of conditions that constitute “side effects” is very broad, from headache or

weight gain to impotence, elevated blood pressure, seizures, rash and others.

For physicians working in consultation, concurrence, and collaboration with a psychologist who

is prescribing medications for a patient, there is no barrier to medical malpractice liability simply

because the physician is not the person who wrote the prescription.

ALTERNATIVES

“Medical Psychologists" with a certificate of prescriptive authority will be able to prescribe psy-

chotropic medications as described in the bill only in consultation, collaboration, and with the

concurrence of the patient’s primary or attending physician. The prescriptive authority of psy-

chologists to be limited as follows:

•

Only those drugs related to the diagnosis and treatment of mental and emotional disorders

may be prescribed.

House Bill 463-- Page 4

•

Prior to making changes in a medication regimen, including dosage adjustments or add-

ing or discontinuing any medication, the psychologist is required to re-consult with the

primary or attending physician.

•

Both the psychologist and the physician are required to document the consultation in the

patient’s medical record.

•

The psychologist cannot delegate the prescribing function and cannot prescribe for pa-

tients who have no primary or attending physician.

•

Only those psychologists who have undergone specialized training in clinical psy-

chopharmacology will be eligible to prescribe.

The Board of Medical Examiners suggests leaving the definition of psychotropic medications as

is, and allow the collaborative relationship between primary health care practitioners and pre-

scribing psychologists to ensure that patients receive appropriate medication.

This issue could be revisited next legislative session which will give psychologists time to adjust

their practices to the final set rules agreed to and adopted January 2005.

WHAT WILL BE THE CONSEQUENCES OF NOT ENACTING THIS BILL.

The current language limiting prescriptions by psychologist to drugs intended and approved for

the treatment of mental disorders would remain in the law. Prescribing psychologist will con-

tinue to be required to collaborate with primary healthcare practitioners with broader prescriptive

authority as envisioned by the original Prescriptive Authority for Psychologists legislation.

Prescribing psychologists will not be allowed to administer and manage common medications for

side effects that are considered appropriate in the treatment of mental health disorders.

AHO/yr