Hawaii FQHC update

In 1985, at the urging of the state's senior senator in Washington, Sen. Daniel K. Inouye, D-Hawai`i, introduced its first piece of legislation to authorize properly trained psychologists to prescribe. The medical and especially the psychiatric community of Hawai`i were on alert. The legislation did not pass and the legislation was again introduced in subsequent years, including the current year. It was early in these efforts, however, that the RxP movement in Hawai`i and the mission of Federally Qualified Health Centers (FQHCs) intersected.

For those unfamiliar with FQHCs, these are health care centers that receive funding under the federal legislation referred to as the Public Health Services Act. The centers are to provide comprehensive health services, including both primary care and mental health services, either to federally designated medically underserved areas, or to a federally designated medically underserved population. Further definition of the medically underserved includes economic, cultural or linguistic barriers to accessing care. In Hawai'i, there are 13 FQHCs, and while more recent data were not available at the time this article was drafted, a legislatively requested study in 2006 indicated that a psychiatrist was on staff at only two of these centers, while seven clinical psychologists were working at the FQHCs across the islands. More on the FQHCs in Hawai'i a little later. First here is more on the intersection.

At the January 1989 convention of the Hawai`i Psychological Association (HPA), a well-attended workshop focused on the curriculum for prescribing psychologists that was being developed at Wright State University School of Professional Psychology as part of a grant from the APA Committee for the Advancement of Professional Psychology. The curriculum addressed underserved populations and issues of diversity. Meanwhile, the latest version of the legislation at that time was being heard in the Hawai'i State House. The outcome of that legislative session was to have the bill referred to the Center for Alternative Dispute Resolution (ADR) at the University of Hawai'I (UH). For a year, an ADR process was led by two UH faculty, composed of 15-20 representatives of various constituencies, including psychology. In January 1990, the center submitted the report, entitled “ Underserved Mental Health Needs and Prescriptive Privileges for Psychologists in Hawaii: A Report on the Psychotropic Medications Roundtable,” back to the Legislature. The report included suggestions to improve mental health services for the “medically underserved mentally ill,” with the clearest consensus being that there were definitely underserved and unserved citizens across Hawai`i, particularly on the neighbor islands (outside of Oahu).

A number of the recommendations incorporated some reference to teamwork or collaborative education, training or practice. These statements seemed intended to address the information that psychologists and psychiatrists would present in their testimony, which the legislators variously referred to as divergent, competing, or opposing! No statement of consensus was reached about the role for prescribing psychologists, but an addendum was included with the summary of the arguments for and against prescriptive authority for psychologists.

The 1989 legislation did not pass and was reintroduced several more times across the years, including this most recent legislative session. Two of the pieces of legislation crafted by the Hawai`i Psychological Association, however, specifically addressed the needs of the underserved populations of the State. The HPA RxP Task Force, co-chaired by Dr. Robin Miyamoto and Dr. Jill Oliveira Gray, introduced legislation in 2005 that specifically and exclusively provided for psychologists in FQHCs to prescribe medication for patients with mental health disorders and to do so in collaboration with the patient's primary care physician. During this session the Legislature requested that the State Health Planning and Development Agency identify and evaluate barriers to specialty care, including mental health, and to make recommendations to improve access to that care. At the same time, the Legislature through a House Concurrent Resolution created an Interim Task Force on the accessibility of mental health care to consider the feasibility of authorizing psychologists to prescribe. Dr. Oliveira-Gray and Dr. Ray Folen represented psychology on that six-person group, which also included two psychiatrists and two legislators. One of the representatives was a physician, who at the time was described by one of the co-chairs of the HPA RxP Task Force as “a new champion who demonstrated unwavering commitment to prescriptive authority” for psychologists. That same physician is now chairing the Committee in the Senate that (as of the writing of this article) has deferred sending the 2015 legislation forward to the full Senate.

In 2005 the recommendation from the Interim Task Force was for the Legislature to establish training requirements for prescribing psychologists with a professional affiliation with an FQHC to prescribe psychoactive medications. The report from that group also included suggestions as to specific acceptable training and education requirements for psychologists.

Subsequently, in 2006, the legislation again focused on psychologists in FQHCs and on the underserved populations in the rural and remote areas of the state. The Hawai`i Primary Care Association and the Medical Directors from several of the state's FHQCs were ardent supporters of the legislation. For the first time, the legislation passed the full House and was moving well through the Senate; however, once again the bill failed to get to the full Senate for a vote when the Commerce and Consumer Affairs Committee chair deferred the bill after a particularly argumentative hearing. This time the Senate adopted a Concurrent Resolution requesting its Legislative Reference Bureau to “study the issue” of appropriately trained psychologists prescribing “while practicing in FQHCs or licensed health clinics located in federally designated medically underserved areas or in mental health professional shortage areas.”

The report, entitled “ Prescriptive Authority for Psychologists: Issues and Considerations,” was issued in January 2007. This was prior to that year's legislative session and consideration of HPA's prescriptive authority bill, again tied to improving access to care through prescribing psychologists practicing in FQHCs. The report was a comprehensive summary of relevant information starting with the DoD Demonstration Project, and the evaluations of the graduates. It continued by looking at the laws granting prescriptive authority in Louisiana and New Mexico, and included the consideration of data on “patient safety issues.”

After proceeding through other topics (e.g., other non-physician providers), the report concluded with a review of the issues specific to FQHCs. The legislation passed both the House and the Senate this time, affirming the value that prescribing psychologists would add to the health care services for underserved populations. Unfortunately, the affirmation was not going to reach the implementation stage. The governor, known to have strong ties with organized medicine in Hawai`i, vetoed the bill, and there were not sufficient votes to override the veto.

The present 2015 prescriptive authority legislation is not tied to FQHCs, but continues the emphasis on serving the underserved populations of the State, with the introductory paragraph reading as follows:

SECTION 1.  The legislature finds there is [sic] an insufficient number of prescribing mental health care providers available to serve the needs of Hawaii's people.  The delivery of quality, comprehensive, accessible, and affordable health care is enhanced by collaborative practice between licensed clinical psychologists and medical doctors.  Providing advanced training in psychopharmacology to certain psychologists who wish to become medical psychologists would be beneficial to residents of Hawaii, particularly those who live in rural or medically underserved communities where mental health professionals with prescriptive authority are in short supply.

The Amended Report to the 2015 Legislature from the Hawai‘i Physician Workforce Assessment Project verified that there are not enough psychiatrists across the state. Shortages range from 29 to 41 percent on the neighbor islands and 7.9 percent across the state. Resolutions were submitted in March by the one physician in the House of Representatives for yet one more taskforce to study the problem. The resolution, however, seeks to exclude psychologists even further by categorizing us with rabbis, Shintu priests and other non-pharmacological healers. Accordingly, despite full passage of House Bill 1072 through the House of Representatives, individual legislators continue to ignore the safety data from those states in which prescriptive authority exists and try to delay passage of this legislation for a 31st year.