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F I S C A L I M P A C T R E P O R T
SPONSOR Papen
DATE TYPED 2/17/05
HB
SHORT TITLE Medicine Prescriptions By Psychologists
SB 591
ANALYST Hanika-Ortiz
APPROPRIATION
Appropriation Contained Estimated Additional Impact Recurring
or Non-Rec
Fund
Affected
FY05
FY06
FY05
FY06
See Narrative
Duplicates HB 463
SOURCES OF INFORMATION
LFC Files
Responses Received From
Board of Medical Examiners
Health Policy Commission (HPC)
Regulation and Licensing Department (RLD)
Department of Health (DOH)
SUMMARY
Synopsis of Bill
Senate Bill 591 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.
pg_0002
Senate Bill 591-- Page 2
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
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
pg_0003
Senate Bill 591-- Page 3
can provide when a physician is not available.
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.
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.
pg_0004
Senate Bill 591-- 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