MANAGED CARE April 2001. ©MediMedia USA
Issues like HMO solvency, physician antitrust waivers, and external review come and go, but you'll find scope-of-practice bills in state legislatures year after year. State laws determine what optometrists, naturopaths, psychologists, and other allied health practitioners can do. Despite vigorous opposition from state medical associations, scope-of-practice bills succeed in changing those laws every year.
"You bang on that door long enough, and it's going to open," is how Jim Anderson puts it. As associate director of government affairs for the Oregon Medical Association, he's doing his best to keep Senate Bill 45 from passing.
In 1991, Oregon optometrists gained the right to prescribe and administer topical agents. SB 45 would allow them to prescribe all classes of drugs. To Anderson, who argues that optometrists don't have the training to use these drugs, "This is the have-nots wanting to have."
"Optometrists get more hours of pharmaceutical training than ophthalmologists," counters Wayne Schumacher, executive director of the Oregon Optometric Physicians Association. "Nationally, the formal pharmacology curriculum in colleges of optometry equals 101 hours. In medical schools, it's 93 hours."
Schumacher couches SB 45 in terms of good care and cost containment. When a systemic drug is indicated, optometrists must send their patients to a primary care physician to get a prescription. Most physicians want to see patients before prescribing — meaning an office visit, which increases costs and can delay care.
Though Section 4 states that SB 45 is not intended "to permit a doctor of optometry to perform invasive or laser surgery," Anderson thinks that day won't be far off if optometrists gain prescribing authority.
"It's pretty clear that optometrists want to get into those big-dollar items, like laser surgeries," he says. "They're cautious and calculating in how they do it, but that's where they're headed."
Schumacher contends that refractive surgery is a vision issue, which puts it squarely within optometrists' scope of practice. Of Anderson's assertion, he says "There have been no discussions regarding that at this point."
Eighteen states defeated optometry bills in 2000, but California and Utah passed widely publicized compromise legislation. The California law allows optometrists to provide a full range of ophthalmological care short of surgery.
'Trained' by law?
"We feel the legislature is the wrong place for these people to go," says Nancy Auer, M.D., president of the Washington State Medical Association, which is fighting bills by optometrists and naturopaths. "If they want to be physicians, they should go to medical school."
But naturopaths have the same anatomy, physiology, and pharmacy training as allopaths, argues Jeff Larson, who is lobbying for passage of SB 5518 in Washington State. The bill would allow naturopaths to prescribe testosterone for menopause, codeine syrup for coughs, hydrocodone for pain relief, and all antibiotics.
Auer says she is astounded that naturopaths want to prescribe drugs, since they claim to use only "natural" therapies.
"We're trying to reduce costs and serve our patients better," Larsen responds. "When you have to refer out for codeine cough syrup, for example, it drives up costs for the business community and insurance plans. Plus, people lose time from work to get a second opinion for something that's already been diagnosed."
Interestingly, the Association of Washington Healthcare Plans takes no position on scope-of-practice legislation. Executive Director Donna Steward says the issue doesn't make it past the organization's filter for issues worth watching.
Larson concedes the bill will have trouble this year, the first time it has been heard, but expects that, ultimately, it will pass. That would fit the pattern for scope-of-practice bills, which often take several years to become law.
State medical associations complain that the ability of nonphysician providers to focus their resources on a single objective, year after year, gives them an advantage over organized medicine, which often deals simultaneously with a multitude of legislative issues — liability, fraud, medical errors, to name a few.
Anderson fumes that legislators, especially limited-term ones with no experience in health care issues, are sitting ducks for the blandishments of lobbyists who push these bills. He adds that consumers may be equally vulnerable, because many nonphysician providers call themselves "doctors" and "physicians."
The National Conference of State Legislatures notes that in various states, bills that would expand practice scope or grant prescribing privileges are circulating on behalf of registered and advanced practice nurses, physician assistants, acupuncturists, certified nurse midwives, chiropractors, massage therapists, naturopaths, nurse anesthetists, oral surgeons, optometrists, occupational therapists, pharmacists, physical therapists, podiatrists, psychologists, and speech-and-hearing and respiratory-care therapists.
Back east, prescriptive authority for Ph.D. psychologists is the objective of SB 584 in the Connecticut legislature. While their accents differ, stakeholders' arguments are familiar.
"We think it's a very dangerous thing for patient care to have inadequately trained psychologists prescribe psychotropic drugs, like Ritalin, all the way up to lithium and other medications to treat mental illness," says Meg Morelli, director of government relations for the Connecticut State Medical Society.
Doctoral-level psychologists get the equivalent of a master's degree in psychopharmacology, counters Michael Schwarzchild, Ph.D., president of the Connecticut Psychological Association. He says medical doctors, including psychiatrists, spend less time learning about pharmacokinetics than people assume.
In fact, says Schwarzchild, 70 to 80 percent of psychoactive medications are currently prescribed by family physicians, internists, and pediatricians, who have little training in mental health issues. By extension, psychologists are logical candidates to prescribe these drugs.
Shut out of the market
At the same time, Schwarzchild makes no bones about the fact that he backs the bill because he and other psychologists who couldn't find a psychiatrist to prescribe for their patients were simply shut out of the market.
Connecticut health plans haven't taken a position, viewing this as an "intramural professional struggle," in the words of Connecticut Association of Health Plans lobbyist Keith Stover. He adds, "Our model relies very heavily on input from the patient's primary care physician," which suggests that insurers take a dim view of circumventing the gatekeeper's role.
What would definitely get health insurers' attention is legislation mandating equal reimbursement for providers who perform the same services. A chiropractor who fixes a patient's back would be paid the same rate as an orthopedic surgeon. Such a bill has been introduced in Connecticut in each of the last few sessions, but Stover doesn't expect it to get far.
The effort to secure prescriptive authority for psychologists goes back at least six years in Connecticut, but this is the first year for an actual bill. Schwarzchild says he doesn't expect more than a public hearing this year.
Does that mean the bill will be reintroduced next year? "That's exactly what it means," says Schwarzchild.