Article archive / December 2018
Originally published: . Volume 9, No. 12. Source pages: 7, 8.
RxP–Where Are We Now? by J. Nelson
It was over two decades ago now that the American Psychological Association (APA) endorsed prescriptive authority, called “RxP," for psychologists. Louisiana became one of the first test cases. APA contributed at least $527,000 to the effort, launched by the Louisiana Psychological Association and members of the first "class" graduating from a professional school's psychopharmacology program created for the RxP effort.
Some have said that APA chose Louisiana as a testing ground for RxP because it is a small state and therefore relatively inexpensive to wage a political battle. It is also corrupt. Times-Picayune's Tim Morris writes Louisiana owns the top spot for corruption. Locals say, “For $1 million you can pass any law you want.”
The strategy worked so well that in 2004 RxP was passed in Louisiana, the second state in the US to do so. Medical psychologists, “MPs,” were now official. One insider reported, “When we went to APA, we were rock stars. Here, at home, nothing was going on.”
But was the genie out of the bottle? In late 2008, the LAMP leader, Dr. Jim Quillin, began secret negotiations with the Executive Director of the Louisiana State Board of Medical Examiners to move MPs under medicine. MPs were told by their leaders that the proposed rules were so "onerous" that the medical board would "shut down the practice of medical psychology."
No factual evidence of this threat ever emerged, but what did finally emerge was stated in a confidential letter to APA officials from Dr. Quillin."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.”
Conflicts broke out because Act 251 repealed the earlier law, moved the title of psychologist to medicine, and because the rank and file members in the Louisiana Psychological Association were not informed and many felt deceived. Eventually it was discovered that the lobbyists for Act 251 were paid from LPA and APA funds.
Turmoil continued for years when, through a variety of skillful political and psycho- logical maneuvering, LAMP was able to hold control of the state psychology board and push decisions which benefitted medical psychologists. This was despite the fact that medical psychologists represented only five percent of those licensed under the psychology board.
Control of the LSBEP by LAMP was accomplished primarily through the stealth political maneuvers of the high-priced lobbying team of Courson Nickel. Evidence of their and LAMP's involvement was only able to be proven due to one reference on an obscure email from an aide in the Governor's office, uncovered by a documents request. Then, in the only other time the two lobbyists were sighted, was in the audience at a Senate committee, chatting with MP members of the psychology board, accidently caught by the archival video taping.
During the eight years that LAMP members held the majority on the state psychology board, they were able to write themselves into the psychology laws and rules, including authorizing themselves to be supervisors for the state psychology license, even when they do not hold the license themselves. They dragged one candidate to the Ethics Board in an attempt to have her disqualified, to which the Ethics Board said, “Why did you bring this to us?” after they dismissed the issue as irrelevant. And, those in control made several efforts to interfere with the "list" of names going to the Governor, another example.
For reasons unknown, in 2016 they seemed to stop, and the traditional psychologists gained the majority vote on the psychology board. LAMP appears to be going about its business, and the rest of the psychology community appears to be going about its business, too.
So for this article, we take a look at some of where things are today.
Growth in Medical Psychologists
In 2011, one year after Act 251 took effect, there were 77 medical psychologists licensed under the state medical board. Seven of those were out of state professionals. Of the total 70 Louisiana individuals, 41 held a license under the state psychology board while 29 had dropped their state psychology license.
Currently, for November 2018, there are 123 medical psychologists listed under the medical board in the medical psychology category. Three of these are listed as "in progress."
There are 17 of the 123 that are listed as inactive or with a closed account.
Twenty-five of those listed are from out-of-state, and five of these 25 are closed or inactive.
Individuals from other states that are licensed, or were licensed here, include those from Alabama, California, Florida, Kentucky, Maryland, Massachusetts, Mississippi, New Jersey, New Mexico, Oklahoma, Oregon, Texas, Virginia, and Washington, DC. There appears to be one individual from France.
Fifty-two of the individuals listed hold a Certificate of Advanced Practice.
Of those who received the medical psychology license in the first year that it was available (2010), 49 are now qualified for the Certificate of Advanced Practice.
Over the last five years, 32 new individuals have received a medical psychology license.
Comparing the list of MPs to a list of licensed psychologists published by the state psychology board this year after the renewals, 35 individuals are currently retaining both their psychology board license and a medical board license.
In comparison, the psychology board currently lists 734 licensed psychologists in the state.
Medical psychologists pay an annual renewal fee of $200 and $100 for a Certificate of Advanced Practice. In comparison, a psychologist's license with the psychology board is $350.
Is it Safe? Discipline and Lawsuits
According to the current records on the medical board site there have been three disciplinary events plus one surrendered license for medical psychologists.
One individual was disciplined for working outside of license parameters. Another was dealing for substance abuse issues and a traffic violation. Both discipline issues have been resolved.
A third medical psychologist is currently on probation for improper control over office staff regarding medications.
Another individual voluntarily surrendered his license after conviction for insurance fraud.
None of the disciplinary actions appear to involve negligence in actual prescribing for a patient.
However, the Times was able to locate some legal complaints about medical psychologists. One case in Baton Rouge was a claim about an adverse reaction to Savella, a drug often used to treat symptoms of fribromyalgia.
In another case, this one in Lafayette, the individual claimed misdiagnosis and improper use of Pristiq and Ritalin.
In a third case, this one in Lake Charles, plaintiffs claimed that a medical psychologist improperly prescribed Tenex and worsened a child's seizure disorder.
It is not known if any of these went to trial or if they settled out of court, or what the settlement might have been. None of these medical psychologists had any discipline actions listed for them on the state medical board's site.
Based on the total disciplinary events, three to four in 10 years, the base rate is approximately .003. This is similar to the base rate for traditional psychologists.
Compensation
Medical psychologists can monitor medication and so are reimbursed for CPT codes from 99213 to 99215, called evaluation and management. This is one area for medication services.
One source explained that the reimbursement varies for this service but the average runs somewhere in the $40 or $50 range, for a 15-minute session.
According to documents and fee schedules obtained from the state Medicaid program, the reimbursement for CPT 99213, a 15-minute check for an "expanded problem" is $34 to $58. For this code, medical psychologists are reimbursed at the same rate as physician assistants (PAs), and advanced practice registered nurses (APRNs). Psychiatrists are reimbursed at $42.80 to $72.76.
For many other services, psychologists, medical psychologists (MPs), PAs, and APRNs are all at the same reimbursement, such as for 90837, "Psychotherapy, 60" with patient present." Medicaid reimburses $61.39 for these providers, but $76.74 for psychiatrists and $53.72 for social workers and counselors.
For psychotherapy for crisis, 90839, psychiatrists are reimbursed at $125.53, and psychologists, MPs, PAs, and APRNs are reimbursed at $100.42. Social workers and counselors are reimbursed at $87.87.
There are some irregularities. For instance, 90880, medical hypnotherapy, is only reimbursed for psychiatrists, PAs, APRNs, and MPs. Psychologists are not reimbursed and social workers and counselors are not reimbursed.
Another example is with 90833, psychotherapy for 30 minutes, add-on, with patient present. MPs are reimbursed and regular psychologists are not.
Is not clear how the fees were established. However, a medical psychologist is a consultant to the behavioral health office of the state.
Separate Entities for LAMP Professional Assn and LAMP Politics
In 2010, LAMP functioned as both a Political Action Committee (PAC) and a professional organization. The fee to be a member was $2500, which was paid by the members to the PAC, according to sources and records.
For their fee, medical psychologists received continuing education credits which was written into Act 251 and to be provided by LAMP.
In 2013, LAMP split into a PAC and a professional organization, after a group of traditional psychologists filed an inquiry with the state Ethics Board asking for an Opinion about whether the fees given to a PAC in that manner violates regulations.
The Ethics Board never made public any determination but LAMP changed its methods after that.
The professional association came into being in 2013 and is headed up by President, Dr. David Thomason, Dr. Donna Aucoin as Treasurer, and Dr. Jessica Brown as Secretary. The organization is a non-profit corporation, registered in Baton Rouge.
Full members must be a licensed medical psychologist or completed a post-doctoral masters in psychopharmacology. Dues are $1500 according to the website.
They hold a yearly conference and Act 251 requires that medical psychologists be able to receive 20 hours of training from the association.
The LAMP-PAC appears to operate separately in most ways, currently.
In the 2011–2013 time-frame contributions to LAMP were $324,771. For the most recent full year reported to the state Ethics Board, 2017, contributions to the LAMP PAC totaled $30,200. Approximately 60 individuals contributed $500 each.
PAC records show no payments to lobbyists, but the lobbying team Coursen & Nickel indicate that they still work for LAMP.
According to lobbyist records posted on the Ethics site, each of the two lobbyists, Bud Coursen and Jim Nickel contract with the LAMP for between $25,000 and $50,000 per year.
Included in their political donations, LAMP donates $5000 per year to Governor Edwards, and either $250 or $500 to many legislators.
Also according to the records for the PAC, LAMP also makes regular charitable donations. They have donated to the Baton Rouge Area Foundation, Louisiana First Foundation, Nebraska Psychological Association, East Baton Rouge Council on Aging, the Morehouse Council on Aging, and the African-American Parade Celebration, for examples.
Final Thoughts
It does appear that Act 251 did create a new profession, one that is in line with medical treatment such as that by PAs and APRNs. Perhaps compensation and career advancements are possible for some MPs that would not have had those opportunities in psychology private or consulting business. It is not clear how any of this translates into meaningful innovations in healthcare, especially given the newest CDC numbers that show psychological well-being across the nation is still declining. Perhaps the more things change, the more they stay the same.
LAMP lobbyist, Bud Courson, chatting with psychology board members. This was one of the few pieces of evidence of LAMP's influence with the LSBEP.
Dr. Jim Quillin (L) a key leader in RxP and LAMP, and Dr. Michael Chafetz, one of many that opposed Act 251, speaking briefly in New Orleans in late 2009.
Leaders in LAMP at a meeting of the Advisory Committee, with the Executive Director of the state medical board. Act 251 moved medical psychologists under the regulatory authority of the medical board.
This article is part of a historical newspaper archive. Read the original issue for its original layout, photographs and graphics.