California doctors are wondering whether prescribing will be next, now that state regulations allow psychologists in the state to have admitting privileges for mental health patients.
“This would be a prelude to that, if you want to think about it from the psychologists' perspective,” said Randall Hagar, director of government affairs at the California Psychiatric Association in Sacramento. “Getting this kind of privilege would be 'physiciandom,' [so that they will now say,] 'In order to better treat our patients, we need to be able to handle the medication aspect of it. We're prevented from taking good care of our patients until we get this privilege.'”
Psychology groups, however, reject the notion that getting these regulations into place is a stepping stone to prescribing. “The big difference between prescribing and the hospital practices at issue with these laws is that the activities being envisioned by these regulations are already within the scope of the psychologist's license,” said Russ Newman, Ph.D., executive director for professional practice at the American Psychological Association in Washington. “Prescribing is not; it would require a psychology licensure change.”
The regulations, which apply to patients at psychiatric hospitals as well as those in psychiatric wards of acute care facilities, permit psychologists to admit patients, order therapy, ask for consultations, and approve ground and weekend privileges, said Charles Faltz, Ph.D., director of professional affairs at the California Psychological Association.
Dr. Faltz added that although such privileges may be very new to some psychologists, others have already been doing much of the admitting work themselves anyway. He said that before he began working for the association, he was on the full medical staff of a hospital and was admitting and managing patients. “The way it's done is in collaboration with a physician—usually with both the primary care physician and the psychiatrist who prescribes medications,” he said.
Tom Riley, director of government relations at the California Academy of Family Physicians, in Sacramento, noted that even if psychologists have admitting privileges, a physician will still have to be there to do a physical exam during the intake.
“We're following [those regulations] only tangentially,” Mr. Riley said. “The main issue is patient safety; we want things that ensure patient safety and allow access to care … we will be monitoring this to ensure that patient safety issues are met.”
Family physicians “are monomaniacally focused on trying to expand access to care in California, and some folks take that to be saying, 'We should have expanded scope' of service,” said Mr. Riley, noting that is not necessarily the case. “There are all sorts of issues regarding psychologists' knowing how the mental state of patients affects their physical attributes, and they don't have that training.”
One of the issues in dispute with the California regulations—which were first promulgated in 1978 and finally issued in April—is the way they were approved. Instead of going through the usual regulatory process, which requires public hearings, these regulations ended up going through the courts—with little public input. “These particular regulations were made using rule 100, which [means that] if the courts interpret a particular law and say 'This is what the law means,' the regulatory agencies have no particular ability to change it,” Dr. Faltz said. “So they can simply put those regulations through, and they don't have public hearings, because it isn't possible for the public to change the court's interpretation.”
But Mr. Hagar said the regulations were the result of three attempts by the psychologists to get the regulations put out without public notice or input. “This attempt succeeded, and we're having a hard time figuring that there's anything else but politics involved,” he said.
Earlier attempts involved getting the psychologists privileges to order and release seclusion and restraint treatments, Mr. Hagar continued. “This time, they got the seclusion and restraint orders and also got the ability to put someone in a hospital and release them, and also to transfer them.”
Mr. Hagar said psychologists should be forewarned that their liability rates might increase now that they have these additional privileges. But Dr. Faltz said psychologists were not concerned about such a possibility, because their experience to date with collaborative practice has proved otherwise.
“There have never been any instances where it was shown that … psychologists practicing in hospitals in this way have had increased liability for psychologists or hospitals,” he said. “In fact, when something goes wrong, all the practitioners involved with the patient are sued. So if a psychiatrist is managing the patient and has a psychologist consulting or doing testing, all involved are sued. It's equal opportunity.”