Tilling federal soil for RxP growth

From a single seed come the first shoots—and the first roots. So it is that the federal government has played a major role in the RxP movement from its earliest days. This volume of The Tablet provides something of a status update regarding federal activities vis-à-vis national RxP. I hope here to provide some perspective from which to consider the contributions of its various authors.

1994 to Late 2004: The Breakthrough Decade for State RxP

The landmark Department of Defense (DoD) Psychopharmacology Demonstration Project (PDP) graduated its first class in 1994 and was an unequivocal success. Although its graduates could only prescribe medication to military beneficiaries, the PDP proved to be a crucial steppingstone for every state RxP effort in the decade that followed. The PDP opened the door for New Mexico's breakthrough legislation in 2002; and two years later the PDP remained the only source of objectively evaluated RxP safety data when Louisiana became the second state to enact RxP legislation. If the PDP was the seminal act from which the RxP movement sprouted, then New Mexico and Louisiana were the first fruits to emerge on that shoot at the end of the decade. It would be another decade before the root structure of the RxP movement would be sufficiently developed to support a third blossom, which we now know as Illinois.

A Fertile Federal Soil

The relationship between the federal government and the states is defined by the Constitution of the United States. Generally the states retain power over their own domestic issues and are only subject to federal authority under a finite set of circumstances. However, the states may request federal assistance when national interests are at stake. The national defense and the public health are crucial national interests served by the DoD and the Department of Health and Human Services (HHS), respectively. One of the things that these departments have in common is their authority to administer uniformed services.

The DoD is a federal department, which interfaces directly with states on issues limited to the national defense. It administers several uniformed services including the Army, Air Force, Navy and Marine Corps. The Navy provides all health services to Marine Corps beneficiaries. The DoD has a primary national defense mission and; therefore, has no independent national public health authority. For this reason the granting of prescriptive authority to PDP graduates impacted only uniformed service members/retirees and their dependent family members.

On the other hand, the HHS is a federal department that has a primary national public health mission, but no independent national defense authority. The uniformed service it administers is the Public Health Service (PHS) Commissioned Corps. The PHS is comprised of 13 HHS agencies including the Indian Health Service (IHS), the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration, the Health Resources and Services Administration and its National Health Service Corps (NHSC) to name a just a few. The PHS Commissioned Corps also maintains interdepartmental agreements to provide health services to the Departments of Defense, Homeland Security and Justice.

For the sake of this discussion the PHS Commissioned Corps may be understood as a network of more than 6,500 public health professionals, many of whom are clinical practitioners assigned to hospitals and clinics of the Indian Health Service; American Indian and Alaska native tribes; Army, Navy, Air Force and Coast Guard bases; federal prisons; state departments of health; universities; and federally qualified health centers (FQHC) spanning the nation. By now, we all know that what started out as a seed with the DoD PDP sprouted in New Mexico and Louisiana as law. What hasn't been quite as clear is how the interface between state and federal authority has enabled an informational root system to grow across the nation in fertile federal soil expanding RxP awareness through the federal system over the decade from late 2004 to 2014. It comes down to a signature.

2005 to Late 2014: The Breakthrough Decade for Federal RxP

When New Mexico Governor Gary Johnson signed his state's RxP bill into law in 2002, whether he knew it or not, he set the stage for improved access to mental health care in the state of New Mexico and every state in the nation as part of the public health mission of HHS through the U.S. Public Health Service Commissioned Corps. Before he put his pen to that paper, clinical psychology was already recognized as a health profession, by federal law; specifically, the Public Health Service Act. The Public Health Service Act states, in part that:

Notwithstanding any other law, any member of the [National Health Service] Corps licensed to practice medicine, osteopathic medicine, dentistry, or any other health profession in any State shall, while serving in the [National Health Service] Corps be allowed to practice such profession in any State. 42 U.S.C. § 254f (e).

So, the moment that RxP became part of clinical psychology's scope of practice in New Mexico any New Mexico licensed prescribing psychologist was legally entitled to practice in any state in the nation; provided that said state had requested federal public health assistance and that said prescribing psychologist was sent to the requesting state by the federal government to meet that request.

New Mexico and Louisiana had created a wonderful opportunity to spread RxP awareness across the nation—to federal policy makers and state legislators alike. But, there were a number of obstacles that needed to be overcome. In 2002 there were no prescribing psychologists, anywhere; we had to make a few. And, there were no implementing regulations in New Mexico; a few of those were needed as well. And, even though the Public Health Service Act enabled the use of prescribing psychologists to fulfill its mission; it did not mandate their use by any federal agency. Each agency would have to decide whether it wanted to change its policy to include this upstart professional group. However, asking each agency to do so might have been tantamount to waking a hibernating bear to see if it was hungry. But, there was an alternative in the PHS Commissioned Corps, a uniformed service with a cross-cutting presence in many federal agencies.

It took until 2004 for New Mexico to install implementing regulations for its prescribing psychologist law. By then, Louisiana was well on its way to licensing its first medical psychologist. At about the same time I accepted a PHS Commissioned Corps assignment to the NHSC. I concluded that if I could obtain my license in Louisiana or New Mexico I might use the Public Health Service Act to set precedent within the federal government as its first licensed prescribing psychologist; and I might do so without waking up any hungry bears. In 2006 I was granted a medical psychology license by the state of Louisiana. That year I was transferred by the PHS Commissioned Corps to an FQHC in New Mexico where I wrote my first prescription under federal authority, with a Louisiana license. In 2008, while on a deployment in South Dakota I was granted prescription privileges by the IHS and became the first licensed medical psychologist to write prescriptions in that agency. Shortly thereafter, Dr. (Commander) Mike Tilus became the second PHS commissioned officer to be licensed as a prescribing psychologist. Since that time he has prescribed in North Dakota and Montana. But, prescription writing is just one of the fruits of RxP. What has been more important during this decade has taken place beneath the surface, at the root of RxP.

While RxP opponents have fought public legislative and media battles to retain the fruits of their labors, federal prescribers have been raising national awareness by installing the RxP message in the hearts, minds and political calculus of state and federal policymakers in the name of public health. Besides working in FQHCs and at IHS and tribal clinics and hospitals across the nation, federal prescribing psychologists have been influencing attitudes and making national policy that includes prescribing psychologists. In 2012 the PHS Commissioned Corps formally created commissioned officer billets for both prescribing and medical psychologists; the IHS began writing, advertising and filling similar positions for civilians in states with no RxP license laws; and the NHSC recognized the applicability of loan repayment to prescribing and medical psychologists. These are roots.

In 2015, when I brief a national policy maker or legislator on RxP, my introduction sites the thousands of prescriptions written and/or filled across the nation beginning in New Mexico and Louisiana and extending to Hawaii, Montana, North Dakota, South Dakota … Illinois … I mention the recognition of RxP by the U.S. Public Health Service Commissioned Corps, the Health Resources and Services Administration, the National Health Service Corps, the Army, Navy, and Air Force … I offer an unblemished 20-year safety record of zero licensing board complaints and zero professional liability claims …Then I wait for the inevitable question about the PDP, to which I respond in terms of all that has happened since.

2015-2024: The Harvest Decade for National RxP

I believe that the recent Illinois legislative victory signals a substantial harvest of successful RxP legislation in the coming decade; and I believe that all federal agencies will soon recognize and employ prescribing psychologists. The seed that was planted in 1994 by the PDP and sprouted in 2002 and 2004 in New Mexico and Louisiana is now supported by growing numbers of state licensed prescribing psychologists nationally; and it is firmly rooted in federal policy.