Nonphysicians eager to pick up prescription pad

Nonphysicians such as naturopaths and psychologists, having seen their colleagues in other states win the right to prescribe or otherwise expand their scope of practice, are expected to push hard for the same authority in more states in 2005. Meanwhile, organized medicine is getting ready to fight their efforts.

According to the American Psychological Assn., psychologists in Hawaii, Wyoming and Tennessee are talking to their legislators about introducing bills that would expand their prescription authority, and psychologists are expected to do likewise in another three to six states this year.

The American Assn. of Naturopathic Physicians says at least 11 states will see licensing campaigns by its constituents in 2005.

Practitioners from podiatrists to nurse anesthetists to optometrists are also planning to seek to expand their scope of practice to include tasks normally performed only by physicians.

Russ Newman, PhD, executive director for professional practice at the American Psychological Assn, said psychologists want to prescribe because otherwise, many people would not get the mental care they need.

"The access issue is not uniquely a rural issue," Dr. Newman said. "Access issues also take place in urban areas, as evidenced by waiting times to see psychiatrists. ... When people run into obstacles to accessing care, often they decide to not continue to seek care and never get any."

Steven Sharfstein, MD, president-elect of the American Psychiatric Assn., said such arguments don't adequately address patient safety. His group opposed legislation in New Mexico and Louisiana allowing psychologists to prescribe psychotropic medications and is fighting a bill in New Mexico to expand their prescription formulary to include off-label drugs.

"Prescribing [psychotropic] medication is very complicated," said Dr. Sharfstein, a Baltimore psychiatrist. "As physicians, we know what our limits are. We know when we need to ask for help."

Organized medicine is gearing up to help physicians protect patients and keep medicine within the ranks of those trained to practice it.

John C. Nelson, MD, MPH, president of the American Medical Association, said the organization's prime concern is patient safety.

"A person who is not a physician ought to be able to practice within their training," Dr. Nelson said. "If they want to increase their scope, they should do it through education, not legislation."

The AMA's newly formed scope-of-practice advisory committee, made up of representatives from state medical and specialty societies, is considering ways to bolster physician resources, including the possibility of establishing a resource center on scope-of-practice issues. Activities of such a center might include researching rural health and seeing whether access actually improves when nonphysicians gain prescribing rights.

The Federation of State Medical Boards also has stepped into the fray. James N. Thompson, MD, president and CEO of the federation, said its special committee on scope of practice had drafted a list of guidelines to enable legislators to make educated decisions on scope-of-practice bills. The proposed guidelines will go before FSMB delegates in May.

Why scope is expanding

One of the forces propelling nonphysicians is deepening public acceptance of their trade. According to the latest Institute of Medicine report, "Complementary and Alternative Medicine by the American Public," one-third of U.S. adults use some form of alternative medicine, such as herbal remedies, acupuncture and naturopathy. Total visits to these practitioners now exceed those to primary care physicians on an annual basis, and these patients spend more than $27 billion a year out of their own pockets for this care.

In California, the 13th state to license naturopaths, such acceptance underpinned naturopaths' efforts to gain prescribing rights. While they may prescribe medication only under physician supervision, they may order diagnostic tests and prescribe and administer herbs, vitamins and mineral supplements.

California issued its first batch of naturopathic doctor licenses in January, and by January 2006, it should finalize the formulary NDs may prescribe under physician supervision.

Because California is considered a bellwether for health care trends, the American Assn. of Naturopathic Physicians hopes to duplicate what it achieved in California, particularly winning enough prescribing authority for NDs to be considered front-line health care practitioners.

Tara Levy, ND, one of the state's first licensed naturopaths and president of the California Naturopathic Doctors Assn., is looking forward to the added freedom to order her own diagnostic tests and do a limited amount of prescribing.

"This will change my role as a doctor for some of my patients," she said. "I feel like I've been operating with one hand behind my back until now."

The success of such nonphysicians reflects growing demand for health care that focuses on wellness, rather than only traditional therapies, she said, and physicians should see this as an opportunity, not a threat.

While naturopaths in California are marching along in their licensing process, so are psychologists in Louisiana and New Mexico, the only two states that allow psychologists to prescribe psychotropic drugs. Both recently finalized regulations outlining their licensing processes. But it took New Mexico three years to complete these regulations, while Louisiana did it in less than a year. In part this was because New Mexico required its Board of Medical Examiners and the Board of Psychologist Examiners to work together to develop its regulations.

Louisiana, in contrast, permitted the state's psychologists to develop the prescription licensing regulations without physician input.

Jack Lewin, MD, CEO of the California Medical Assn., which opposed licensing NDs, said physicians facing similar legislative efforts should approach them without being defensive.

"The plain and simple fact is that most patients, once they become fully aware of the difference between a physician and a naturopath, will ultimately choose physician care for most of their needs," he said.