HB666.DOC

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

The legislature acknowledges that the United States Public Health Service, Health Resources and Services Administration, has officially designated much of the State of Hawaii as a mental health professional shortage area. In addition to rural areas where geographic isolation is an obvious reason for shortage problems, urban areas located minutes from downtown Honolulu, such as Kalihi-Palama and Kalihi Valley, have also received this shortage designation. The nearly statewide shortage designations indicate that both rural and urban areas suffer when it comes to accessing mental health care.

The legislature acknowledges that the mental health needs of the State continue to outweigh present capacity. From 2000‑2004, more people died from suicide than from automobile accidents or homicides. At 22.5 per cent, Hawaii's suicide rate is higher than the national average. While causes for suicide are complex, the most commonly reported reasons include depression, relationship problems, and serious medical problems, conditions with significantly high rates of occurrence within the general population.

In 2008, six domestic violence murders (three of which were murder-suicides) occurred within six months compared to an average of nine domestic killings from 1996 through 2006. The Hawaii State Coalition Against Domestic Violence acknowledged that these are the highest numbers they have witnessed in decades. Many perpetrators of these types of killings are not obviously troubled. They represent individuals from the general population, and from both rural and urban areas of Hawaii.

Last year, a review by the Honolulu police department revealed that in 2006, 1435 people were involuntarily taken to emergency rooms for psychiatric evaluation and treatment.

During the first four months of 2007, the Honolulu police department responded to four hundred four calls to assist in psychological crisis who required emergency attention. Based on a review of the records, approximately fifty-four per cent of these calls resulted from inadequate medication management.

At the same time that mental health needs are apparently growing, resources available for treatment and assistance are being reduced. Due to the State's anticipated budget short-fall, the department of health recently announced a $25,000,000 funding cut-back for fiscal year 2009 and plans reductions up to an additional twenty per cent for fiscal year 2010.

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. In recent years, Louisiana and New Mexico adopted legislation authorizing prescriptive authority for appropriately trained psychologists without regard to the service setting.

Since 2000, twenty psychologists, all born and raised in Hawaii, have received psychopharmacological training through the Tripler Army Medical Center, psychology training program. These psychologists have actively collaborated with primary care physicians to provide combined therapy and psychopharmacological care to a medically underserved patient population at eleven federally qualified health centers, Bay Clinic, Hana, Molokai, Kauai, Waianae, Kalihi-Palama, Waimanalo, Ko‘olauloa, West Hawaii, Kokua Kalihi Valley, and Waikiki, as well as a native Hawaiian healthcare system clinic located in a federally designated medically underserved area on Molokai.

To date, thousands of native Hawaiians and other ethnic minorities have received the necessary combined therapy and psychopharmacological care that has been historically lacking to address significant mental and behavioral health care needs. For example, psychologists at the Waianae Coast Comprehensive Health Center completed approximately 3,840 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 prescriptions. However, practitioners with prescriptive authority are not readily available in some areas and to some populations.

Research data soundly demonstrates that there is an insufficient amount of prescribing mental health care providers available to serve the needs of the people in Hawaii. Based on prevalence rates provided by the Substance Abuse and Mental Health Services Administration and reported in "The Behavioral Health Workforce in Hawai‘i: A Status Report" (January, 2008), 40.4 per cent of the population diagnosed with severe and persistent mental illness received services by the department of health, adult mental health division. In 2007, 14,276 out of a total of 52,064 adults with severe mental illness received services through the adult mental health division, indicating that approximately 37,788 individuals may not have received services. Adults diagnosed with severe mental illness represent 5.2 per cent of the total state population and do not include other individuals with other clinical diagnoses such as substance abuse, post-traumatic stress disorder, or a prior experience with domestic violence that may require treatment.

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, which is especially prevalent in areas with a large native Hawaiian population, such as Waianae, Molokai, Waimanalo, Maui, Puna, and Kau, and related issues. This epidemic, coupled with the economic and cultural distress of the native Hawaiian population, has created unprecedented demands for services from an already over-taxed mental health system. Further exacerbating the dire need for mental health treatment in areas across the State is the fact that patients from some cultural backgrounds are sometimes 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 and urban 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 number of years (typically four) 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 a master's degree in psychopharmacology 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 psychologists 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:

"Board" means the board of psychology established under chapter 465.

"Clinical experience" means a period of supervised clinical training and practice in which clinical diagnoses and interventions are learned and which are conducted and supervised as part of the training program.

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

"Prescription" is an order for a drug, laboratory test, or any medicine, device, or treatment, including a controlled substance, as defined by state law.

"Prescriptive authority" means the authority to prescribe, administer, discontinue, or distribute without charge, drugs or controlled substances recognized in or customarily used in the diagnosis, treatment, and management of individuals with psychiatric, mental, cognitive, nervous, emotional or behavioral disorders, or other procedures directly related thereto within the scope of practice of psychology in accordance with rules and regulations adopted by the board.

"Psychologists certified to prescribe" means a licensed, doctoral-level psychologist who has undergone specialized education and training in preparation for prescriptive practice and has passed an examination accepted by the board relevant to establishing competence for prescribing, and has received from the board a current certificate granting prescriptive authority, which has not been revoked or suspended.

"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 who applies for a conditional prescription certificate shall demonstrate all of the following by official transcript or other official evidence satisfactory to the board:

(1) The psychologist holds a current license in good standing to practice psychology in Hawaii;

(2) As defined by the board, and consistent with established policies of the American Psychological Association for educating and training psychologists in preparation for prescriptive authority:

(A) The psychologist shall have completed a master's degree in psychopharmacology or the equivalent. This is an organized sequence of study in an organized program offering intensive didactic education, and including the following core areas of instruction: basic life sciences, neurosciences, clinical and research pharmacology and psychopharmacology, clinical medicine and pathophysiology, physical assessment and laboratory examinations, clinical pharmacotherapeutics, research, professional, ethical and legal issues; and

(B) The psychologist shall have obtained relevant clinical experience sufficient to attain competency in the psychopharmacological treatment of a diverse patient population under the direction of a supervising physician. This consists of at least one year, involving four hundred hours treating a diverse population of no fewer than one hundred patients with mental disorders including at least two hours of weekly supervision. The supervising physician shall not be in the employ of the person being directed or supervised;

(3) The psychologist shall pass an examination developed by a nationally recognized body (e.g., the American Psychological Association's Practice Organization's College of Professional Psychology) and approved by the board;

(4) The psychologist shall obtain a federal Drug Enforcement Administration registration number for limited use as restricted by state law;

(5) The psychologist shall have malpractice insurance in place sufficient to satisfy the rules adopted by the board, that covers the applicant during the period the conditional prescription certificate is in effect;

(6) The psychologist has met all other requirements, as determined by rules adopted by the board pursuant to chapter 91, for obtaining a conditional prescription certificate; and

(7) The psychologist is employed or contracted by and will practice the prescribing authority at a federally qualified health center established pursuant to Title 42 United States Code Section 1396.

(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; 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 shall be authorized to prescribe, administer, discontinue, or distribute without charge, drugs or controlled substances recognized in or customarily used in the diagnosis, treatment, and management of individuals with psychiatric, mental, cognitive, nervous, emotional or behavioral disorders and relevant to the practice of psychology, or other procedures directly related thereto within the scope of practice of psychology in accordance with rules and regulations adopted by the board. The authorization shall be limited to services provided to patients under the care of the psychologist and who are enrolled at the federally qualified health center identified by 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 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 who applies for a prescription certificate shall demonstrate all of the following by official transcript or other official evidence satisfactory to the board:

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

(2) The psychologist has successfully undergone a process of independent peer review approved by the department of commerce and consumer affairs;

(3) The psychologist holds a current license in good standing to practice psychology in Hawaii;

(4) The psychologist 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) The psychologist 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 directly or by telecommunication with the doctor of medicine who oversees the patient's general medical care to ensure that:

(A) Necessary medical examinations are conducted;

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

(d) The prescription certificate shall be immediately relinquished by the psychologist if the psychologist no longer meets the requirements of subsection (a).

§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."

SECTION 3. Chapter 465, Hawaii Revised Statutes, is amended by designating sections 465-1 to 465-15 as part I and adding a title before section 465-1, Hawaii Revised Statutes, 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~~] the 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~~] that 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. 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 6. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

SECTION 7. This Act shall take effect on July 1, 2009.

INTRODUCED BY:	_____________________________

HOUSE OF REPRESENTATIVES	H.B. NO.	666
TWENTY-FIFTH LEGISLATURE, 2009
STATE OF HAWAII