Doctors Guarding Their Turf as Other Practitioners Push to Expand Services

By LAURENCE DARMIENTO
Staff Reporter

The argument from psychologists seemed reasonable to local Assemblywoman Judy Chu, herself a psychologist by training.

Shouldn't state law be changed to give psychologists the authority to sign people out of 72-hour involuntary holds after being picked up by police on the fear they could harm themselves or others?

After all, psychologists have the authority to admit psychiatric patients to mental hospitals. Why should they not be allowed to discharge them when a psychiatrist isn't around?

"I had a session with them and they told me their stories about how patients had to sit around because they could not find a psychiatrist," said Chu, a Democrat from Monterey Park.

Chu's bill, introduced in February, never made it out of the Assembly Health Committee last month it's the latest example of what happens when so-called "scope-of-practice" bills run into opposition from the powerful California Medical Association, which aggressively protects doctors' turf.

These bills seek to expand the practice areas of psychologists, optometrists and other licensed health professionals who provide various types of care but do not hold the gold standard in licensing a medical license.

Other examples include bills that would allow optometrists to treat eye infections and podiatrists to perform whole foot amputations. Some of these efforts have been successful, but many have not.

And while efforts to expand scopes of practice has been a perennial issue in health care as doctors and other professionals fight over turf, the battle is expected to get only more heated across the state and nation.

In March, for example, New Mexico became the first state to grant psychologists the privilege of writing prescriptions, a watershed event that came after 14 other states, including California, defeated similar efforts over the past decade.

Health-care costs are rising even as many individual providers are finding it harder than ever to make a buck. And the search is on at all levels to find more efficient and cost effective ways of delivering care an argument allied health professionals often make in seeking to expand their practices.

"As health care funding (for providers) has become more scarce and everybody is struggling to survive, the tension in these regards will only get worse," predicts Dr. Jack Lewin, president of the medical association.



Some compromises

The CMA is not against all scope of practice bills. The association has worked with physicians assistants, nurses and others in developing bills that both sides can live with.

An example of that was legislation that now allows nurse practitioners and physician assistants to write drug prescriptions under the direct authority of a physician.

"The ideal solution is for doctors and other professionals to work as teams on behalf of the patient rather than creating competing parallel professional tracts that cost us more and confuse patients," argues Lewin.

But that means the association generally takes a dim view of legislation that would give health professionals without a license the ability to prescribe drugs independently or perform services normally done by a doctor.

A classic example of that is the high-profile effort by psychologists to gain the privilege to write prescriptions for popular anti-depressants such as Prozac, or anti-anxiety and anti-psychotic drugs.

Dean Given, past president of the California Psychological Association, argues there is no reason why psychologists such as himself should not be allowed to prescribe such drugs.

Psychologists have extensive training and are often a patient's primary doctor for any psychological treatment. And in rural areas even finding a psychiatrist can be difficult. On top of that, the drugs psychologists wish to prescribe are generally very safe, he said.

"The message that the CMA gives is that no one but a graduate of medical schools should be writing prescriptions. There are so many scare tactics, and it's silly because these are very safe medications," Given said.

Two years ago psychologists tried to get a toehold in the door with a bill that would have allowed psychologists who have specialized Department of Defense training in writing prescriptions to write in the state.

That got shot down after the CMA decided it was a back-door way to generally expand the privilege to non-military trained psychologists through the creation of mirror, civilian programs.

"If you want to be a prescriber, spend the time and money to get a medical degree and be a psychiatrist," said Bob McElderry, associate director of the CMA's government relations program.

The CMA maintains that its tough stance has saved California residents from dangerous bills, such as efforts by midwives in 2000 to work independently of doctors.

But many believe that the CMA's opposition is rooted in economics, prompting the organization to oppose bills that make good sense.

"It's pure economic protectionism for their membership," said Mark Rakich, a lobbyist with the California Podiatric Medical Association. "They have to buck up for the specialties that are major components of the CMA."

Podiatrists, who are allowed to perform limited surgery on feet and ankles, sought passage of a bill this year that would have codified and expanded their scope of practice.

A provision in the bill would have allowed podiatrists, whose patients include diabetics with circulation problems, to amputate an entire foot. The bill was shot down earlier after CMA opposition but the podiatrists plan to try again next year.

"They can cut into bone but what they want to do is lop off the entire foot. That is something we prefer somebody who has the benefit of a medical education should do," said McElderry, referring to the podiatrist bill.



Prescription fears

Doctors fear psychologists could write prescriptions that could cause drug reactions with other medications their patients are taking for other medical conditions.

"There are already 90,000 deaths annually due to prescribing last year, allergic reactions, drug interactions, confused writing," Lewin said. "We are working on reducing medication errors and the best way to do this is not to have people with less training writing prescriptions."

The CMA, for all its success, is not all-powerful. Among its most high-profile losses was a successful effort two years ago by optometrists to significantly expand their scope of practice.

Now, for the first time in California, which still has some of the toughest regulations in the nation, optometrists can prescribe medications for the common eye infection, conjunctivitis.

Dr. Elise Brisco, who operates Hollywood Vision Center in West Hollywood, says her patients pay $59 instead of having to shell out four times as much for an ophthalmologist, if they are paying cash and don't have insurance.

"We are real doctors too," she argues. "It's a turf battle. They are worried about losing patients."

The California Association of Health Plans, which represents insurers, has stayed largely neutral on the issue.

"I used to play tennis. If I want to improve my game, I don't need Andre Agassi to teach me. The local tennis pro will do," said association president Walter Zelman. "And in many cases with providers the local nurse practitioner is just fine, but there is a certain bar you don't want to drop below from a quality perspective."

For reprint and licensing requests for this article, CLICK HERE.