Lessons From New Mexico

On March 5 New Mexico Governor Gary Johnson signed into law a bill to allow psychologists to prescribe psychoactive medications. Unfortunately his decision was about politics and not what is best for patients with mental illness.

Several factors came together to make New Mexico the “perfect state” for this ill-conceived bill to succeed. The factors included a committed core of psychologists who zealously lobbied with often incorrect information, a legislature with a history of liberally extending scope of practice, a governor who has often done the unexpected, and a predominantly rural geography, with the problem of all rural areas—access to specialists.

It is important to note that psychologists already had been conducting their prescribing “education program” at New Mexico State University (NMSU) for about two years and had been lobbying for their bill for about a year before the Psychiatric Medical Association of New Mexico (PMA) learned of those activities in fall of 2000. That was only three months before the first, unsuccessful version of the bill was introduced into the legislature.

Certainly the fact that the psychologists had that much time to work on their plans without our knowledge was a key to their success. They also had two of the top lobbyists in the state and subsequently hired a third lobbyist. Additionally they had as sponsors of their bill two of the most influential legislators, Rep. Ed Sandoval (D) and Sen. Manny Aragon (D).

From the outset the psychologists distorted information in two main areas.

Since the real issue is having the proper training to prescribe safely, the psychologists’ first area of distortion was making their background and the proposed training sound adequate. For example, they took advantage of confusion about the difference in training between psychiatrists and psychologists to say that they receive as much training as psychiatrists. While the truth is that a Ph.D. psychologist generally has fewer years of postgraduate training than a psychiatrist, the more important point is that, regardless of the number of years in training, none of that training is medical. The psychologists also called the Department of Defense (DoD) Psychopharmacology Demonstration Project a “proven program” without mentioning that it was discontinued five years ago. Then they stated their “program” at NMSU was modeled on that DoD program and comparable to it, despite the fact that it involved less coursework than medical schools require, was not done through an accredited program, and was not at a medical school. This was also despite the fact that the clinical portion of the NMSU program has only 400 hours of supervision in an outpatient setting with a single physician, who does not have to be a psychiatrist.

The second area of distortion saw the psychologists presenting information to make it sound as if, with prescribing privileges, they would solve the problem of mental health care access in rural areas. A favorite misrepresentation, and one that the governor believed, was that psychologists are already routinely telling primary care physicians how to prescribe for patients with mental illness.

The psychologists also misrepresented the facts when reporting on the number of psychiatrists in New Mexico. Prior to this year’s legislative session the psychologists paid for a “marketing survey” of psychiatrists in which the results were obviously incorrect, reporting that there are only 95 psychiatrists in the state and 18 in rural areas. In reality there are more than 150 psychiatrists in Albuquerque alone. The total number of psychiatrists in New Mexico is 274, based on numbers from the state Board of Medical Examiners, and there are about 60 in rural areas.

Armed with this misinformation, the psychologists proceeded to conduct aggressive grass-roots lobbying with legislators and the governor.

Soon after the latest bill was introduced, a couple of events occurred that ensured that an amended bill would be passed.

First, the New Mexico Medical Society (NMMS) introduced an alternative bill, which added that the Board of Medical Examiners would provide oversight. It also provided for continuing supervision of psychologists. In response to those additions, the chair of the House Judiciary Committee immediately set up a meeting to which he invited the president of the NMMS, Alan Haynes Jr., M.D., to discuss the bills with New Mexico Psychological Association representatives.

We opposed any compromise, but no psychiatrist was invited to that meeting. However, the NMMS did agree to a compromise bill that allowed psychologists to gain independent prescribing privileges, but added the provision requiring the Board of Medical Examiners to work jointly with the Board of Psychologist Examiners to oversee the psychologists who qualify to prescribe. NMMS leadership did this for two reasons—to protect patient safety but also to keep them from spending political capital they might need for other issues.

Unfortunately the compromise gave the perception of a relatively “safe” bill that had NMMS approval. The bill as amended passed easily in both houses and was sent to the governor. With the addition of Board of Medical Examiners oversight, the governor decided the public was adequately protected, and he signed the bill.

What now? The bill becomes law on July 1. This does not mean the psychologists will be prescribing on that date. The two oversight boards are forming their committees and establishing their process. They need to report to the legislature and the governor by December 31, and again by December 31, 2003, on progress being made on enacting the bill or reasons progress isn’t being made.

It is thus imperative that psychiatry remains involved and continues to advocate for patient safety! ▪