Article archive / September 1, 2012
Originally published: . Volume 4, No. 1. Source pages: 1, 9, 10, 11.
July 2012 marked three years since the passage of Act 251. Act 251 repealed the landmark 2004 Act 11 that gave Louisiana psychology prescribing privileges, an achievement requiring a decade of effort and by some accounts, a million dollars of funding.
Act 251 not only repealed Act 11, it moved medical psychologists and their practice of psychology under the authority of the medical board.
The secretly lobbied legislation, when discovered, launched a civil war in the Louisiana Psychological Association (LPA). Among those who opposed the measure, some of the anger was fueled by suspicions that Louisiana Academy of Medical Psychologists (LAMP) members had inappropriately used LPA resources to lobby the Act.
This past July, asking as a member of LPA, I requested copies of the financial records and grant information to help clarify these questions. The Executive Committee gave me the documents in August.
The following is what I found about what happened in Louisiana.
In the spring of 2009 when LPA members became aware of Act 251, a firestorm followed on the LPA listserve. The then president Dr. Darla Burnett, posted a formal response to members on the list, writing, “As president of LPA I wanted
to address the passage of Senate Bill 294 [Act 251]. This bill will affect licensure of those psychologists who are licensed as medical psychologists. The Louisiana Academy of Medical Psychology, a statewide organization comprised of medical psychologists, has been involved legislatively during the passage of this bill. LPA has monitored this bill, as it does all bills potentially affecting psychology, but took no formal position on the bill. The Louisiana Academy of Medical Psychology and the Louisiana State Board of Medical Examiners have negotiated what they both believe to be the best compromise on the legislation.”
Conflict continued through the summer and into the fall at a high pitch, with complaints about funds and multiple roles, particularly of Dr. Jim Quillin, who was the LPA Legislative Chair and who had acknowledged formally his involvement as a designer of Act 251, and Dr. Warren Lowe, LPA Chair of Medical Psychology. Both were also leaders in LAMP.
In November 2009, a group of 18 psychologists wrote to the new LPA president, Dr. Judith Levy, and posed questions about funds and Act 251. Signing the letters were Drs. F. William Black, Wes Brockhoeft, Charles Burchell, Eric Cerwonka, Michael Chafetz, Gail Gillespie, Bryan Gros, Tom Hannie, and others, and also me, the Times publisher.
On November 18, 2009, the then president Levy answered the questions. She posted her answers on the list. She wrote that the Legislative Chairman, Dr. Jim Quillin, helped with responses.
The psychologists asked, “Were any funds from LPA used for lobbying efforts by Courson and Nickel related to Senate Bill 294, now known as Act 251, or were funds used in any other efforts related to Senate Bill 294?” Drs. Levy and Quillin, answered, “No.”
Members also asked, “Did LPA provide any funding to LAMP for lobbying efforts or any other efforts related to Senate Bill 294?” Levy and Quillin answered, “No.”
“Were any funds, provided by the American Psychological Association to LPA, used for any lobbying or legislative
efforts?” members asked.
Levy and Quillin answered, “Yes. CAPP has provided grants to be used for lobbying and legislative efforts over the years and some of those efforts included prescriptive authority and the advancement of medical psychology.”
But according to 2009 financial records I obtained this past August, LPA did pay Courson Nickel during the 2009 legislative season. The association paid the lobbyists $6,000 a month from January to August, 2009, a total of $48,000. $30,000 came from an account with grant money from APA (and CAPP) and $18,000 came from another account.
And, during the same time period, LAMP paid nothing to Courson Nickel, based on a review of the records for the LAMP political action committee from the state Ethics Board.
It was only in October 2009 that LAMP finally paid Courson Nickel, an amount of $6,000. Then in December 2009, LAMP paid them again, this time $20,831.
As I reported in the November, 2009 issue of the Times, Courson and Nickel posted on the state Ethics Board website that both LPA and LAMP were their clients.
Ethics Board records from October 2009, showed that the lobbyists reported being paid “less than $24,999,” from LPA, and from “$25,000 to $49,999” by LAMP. The time
period for this was from January 2009 to “present,” in this case meaning from January to November 2009.
Based on the most recent LPA records, and the 2009 postings, it seems that the lobbyists may have been confused about who was paying them. There was no written contract, an ethical concern that Dr. John Simoneaux voiced at a town hall meeting in December 2009.
In 2009 I called Mr. Nickel but he declined to answer until speaking with Dr. Quillin and ignored future calls.
(Note: I have asked Dr. Burnett, Levy, and Quillin for clarifications, but no answers had arrived by press deadline.)
This picture changes in the fall of 2009, when Dr. Quillin sent a follow-up report to APA, which indicated that Act 251 had been, in fact, a goal of LPA. He wrote:
“In a series of confidential meetings with medicine, both groups expressed the desire to try to avoid the political and financial bloodletting another fight between the groups would entail and alternative means of achieving our joint goals were explored.” […]
“Negotiations between medicine and psychology led to the development of a framework of an agreement for medical psychology to be regulated by LSBME
after January 1, 2010 as a new healthcare professional (sic), medical psychology, under the jurisdiction of that regulatory body. Under this framework, medicine would formally recognize medical psychologists as qualified for a limited practice of medicine, in addition to the practice of psychology, while, in turn, psychology recognized that the prescription of medications and the attending clinical activities necessary to do so represents a practice of medicine and is optimally so regulated.”
This theme was repeated in another follow-up to APA, this time written in the fall of 2010 by then LPA president Dr. Kelly Ray, also a LAMP member. She wrote:
“ … These monies were used entirely to assist paying our contracted lobbyists, CoursonNickel for services which totaled $72,000 in 2009,” she wrote.
“LPA and our sister organization, the Louisiana Academy of Medical Psychologists (LAMP), were put in a position to again address
threats to the vision of psychology and unrestricted access to underserved citizens. The Louisiana State Board of Medical Examiners (LSBME) promulgated a draft of proposed rules to govern the roles of physicians who consult and collaborate with medical psychologists. These draconian rules, as proposed, would have resulted in artificial barriers to the practice of medical psychology and infringe on the jurisdiction of the Louisiana State Board of Examiners of Psychologists (LSBEP) in the regulation of that practice.” […]
“While controversial with some,” Dr. Ray wrote, “careful consideration demonstrates that Act 251 simultaneously achieved multiple goals of long term importance to psychology in Louisiana.”
Was there a real threat to medical psychologists from the rule-making efforts of the medical board?
During the initial firestorm about Act 251, a number of medical psychologists reported to me that Act 251 was needed because the medical board’s “onerous” rules for physicians would
have “put medical psychology out of business.”
Dr. Levy also noted this in her March 2010 newsletter to members. “A group within medicine had proposed rules to LSBME that were about to be published,” she wrote, “which would have made it extremely difficult, and on a practical level impossible, for primary care physicians to consult and collaborate with medical psychologists regarding their prescribing psychotropic medications. This, in effect, would have shut down the practice of medical psychology. Negotiations began and eventually became Act 251.”
However, based on minutes from both boards, and several undisclosed sources, and a review of the different drafts of rules themselves, there is little evidence that the rules were a serious threat.
Additionally, I consulted two attorneys who said that rules could not circumvent the purpose of the law, in this case, the 2004 law allowing psychologists to prescribe.
A first draft of the rules was presented in July 2008, and outlined necessary paperwork for physicians working with medical psychologists.
According to minutes of both boards, the medical board sent a draft of the rules to the psychology board for review and in August 2008 a meeting was held at the psychology board to discuss changes. Dr. Robert Marier, director of the medical board attended. Also attending was Dr. Jim Quillin according to minutes.
A source close to the LSBEP and attending the meeting told the Times that the negotiations regarding the rules were completely constructive, but that a long discussion occurred after the meeting between Dr. Quillin and Dr. Marier.
Following this, modifications were made around October 2008 and the rules were “noticed” in the December 2008 Louisiana Register. In January 2009 a hearing was held at the medical board in New Orleans, when Dr. Glenn Ally, psychology board Legislative Chair, and LAMP member, attended.
Also attending this meeting were Drs. Quillin, Lowe, and Courtney, according to a message sent by Ally to APA Practice Directorate after the passage of Act 251.
The medical board then made changes and completed the rules in March 2009. They published their intended ruled in April 2009. They held another public hearing in June 2009 and no one attended. There were no comments.
The rules directed physicians regarding paperwork such as patient authorization, patient identity, the medical psychologist’s treatment plan, and under what circumstances a physician could withdraw from the arrangement. Between the first and final drafts, changes such as using “communication” in place of “discussion,” and deleting the words, “intended role of medication,” and verifying the identity of the medical psychologist if unknown, were made.
Additionally, I spoke with two medical psychologists who said that sending this type of paperwork to the physician was appropriate, relatively simple, and good marketing.
In a document I obtained shortly after the passage of Act 251, a letter from Dr. Glenn Ally to the APA Practice Directorate, Ally wrote:
“As you know, for the past 2-3 years Louisiana has talked about ‘going for the big enchilada.’ The ‘big enchilada’ has been the term that LAMP has used to develop legislation to remove the ‘concurrence’ clause from our statute. The need for prior concurrence has been the most difficult aspect of our prescriptive authority for both psychologists and the physicians with whom we have consulted. …”
“In addition to the ‘prior concurrence’ concept being just unworkable, the need to remove this from our statute was driven home by the recent attempt by the LSBME to publish rules that would have made it quite onerous for any physician to give concurrence to medical psychologists regarding medication management.”
Act 251 created the “advanced practice” certificate which removed the consultation and collaboration clause for experienced medical psychologists. (In comparison, it took 14 years for psychology to remove a similar clause from the psychology practice act.)
And, in different writings by LAMP leaders, there appears to be a hope that a more expanded role in practicing medicine may be forthcoming.
It is too soon to know if independence in prescribing may have come at too high a price. The medical board has full authority for establishing standards for medical psychology including their practice of psychology and it is not clear how this will evolve with the different leaders of medicine.
Practical problems with Act 251 continue, an example being a confusing Opinion by the psychology board allowing medical psychologists without a state psychology license to supervise psychology interns. It was a move that Dr. Steve DeMers, Executive Director of Association of
State and Provincial Psychology Boards, called “playing with fire.”
Act 251 also drew criticism from national groups, including the APA Board of Educational Affairs, the Interdivisional Healthcare Committee, the APA Committee for the Advancement of Professional Practice (CAPP), and the national Academy of Medical Psychology.
The Times asked APA Director Dr. Katherine Nordal if her group had received the grant follow-ups. She wrote that she had, and, “… I want to assure you that since then CAPP has clearly indicated that states that use the term ‘Medical Psychologist’ or attempt to move authority for psychology licensure under the auspices of the medical board will not be eligible for legislative grant support for these efforts.”
The prescribing independence also came at the cost of serious conflict, perhaps permanent, between psychologists, with a majority of medical psychologists dropping from LPA.
Dr. Bryan Gros, current President of LPA, noted that he is trying to bridge the gap and be more “welcoming” to medical psychologists. He told the Times he does not believe that the 2009 Executive Council ever really discussed Act 251. “… Executive Council, including presidents, were kept largely in the dark about Act 251,” he said, and he has committed himself to openness. “The culture is no longer secretive, but transparent,” he said, “even on legislative issues. We are accountable, as I believe we should be.”
“LPA has become invigorated. Now is a better time than any to join and be an active member,” he said.
So, it remains to be seen if the arrangement LAMP made with the medical board is going to be worth the costs, to the “new profession,” and to psychology as a whole.
Dr. John Simoneaux at a 2009 Meeting. He warned members about ethics.
Dr. Jim Quillin (L) designer of Act 251, and Dr. Michael Chafetz, leader of the group that formed to oppose the measure, called Grassroots. The two men talked briefly at the NAN convention in New Orleans in late 2009.
Some of the conflict about Act 251 in the Louisiana Psychological Association (LPA) was channeled into changes to the LPA bylaws, to make the organization more democratic in the future. Here LPA members vote on changes in 2010, led by President Levy. But over time many of the medical psychologists who worked on the bylaws changes have dropped from LPA.
Act 251 created a new, hybrid profession, under the medical board. But national groups are not supportive of the move. Above, the Medical Psychology Advisory Committee meets with the Executive Director of the Medical Board at a 2012 meeting. From L to R, Drs. Quillin (facing away), Marier, Ally, and Lowe.
This article is part of a historical newspaper archive. Read the original issue for its original layout, photographs and graphics.