oversight

Defense Health Care: Need for More Prescribing Psychologists Is Not Adequately Justified

Published by the Government Accountability Office on 1997-04-01.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to the Chairmen and Ranking
                 Minority Members, Committee on Armed
                 Services, U.S. Senate, and Committee on
                 National Security,
                 House of Representatives
April 1997
                 DEFENSE HEALTH
                 CARE
                 Need for More
                 Prescribing
                 Psychologists Is Not
                 Adequately Justified




GAO/HEHS-97-83
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Health, Education, and
      Human Services Division

      B-276291

      April 1, 1997

      The Honorable Strom Thurmond
      Chairman
      The Honorable Carl Levin
      Ranking Minority Member
      Committee on Armed Services
      United States Senate

      The Honorable Floyd Spence
      Chairman
      The Honorable Ronald V. Dellums
      Ranking Minority Member
      Committee on National Security
      House of Representatives

      The Military Health Services System (MHSS) provides for the mental health
      care needs of the approximately 1.7 million active-duty members of the
      U.S. armed services. To meet its military readiness requirements, the MHSS
      had 478 psychiatrists and 395 clinical psychologists on board in fiscal year
      1996.

      Some functions of psychiatrists and clinical psychologists overlap. As
      physicians, however, psychiatrists are trained in and licensed to practice
      medicine and are therefore qualified to prescribe medication for both
      mental and physical conditions. Because no medical training is required to
      practice clinical psychology, clinical psychologists, whether in the military
      or the civilian sector, historically have not been permitted to prescribe
      drugs.

      This changed for some clinical psychologists in the military when the MHSS
      instituted the Psychopharmacology Demonstration Project (PDP) in 1991.
      The PDP has trained military psychologists to prescribe psychotropic
      medication1 for mental conditions such as depressive and adjustment
      disorders. Before the PDP, MHSS psychologists were not allowed to
      prescribe medication. The first PDP participants completed the program in
      1994. To date, seven psychologists have finished the PDP training, and the
      MHSS has authorized all of them to prescribe certain medications for
      mental conditions. An additional three psychologists are expected to
      complete the PDP in June 1997.



      1
       These are drugs that affect psychic function, behavior, or experience.



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                   The National Defense Authorization Act for Fiscal Year 1996 (P.L.
                   104-106) required that the PDP end by June 30, 1997, and that we evaluate
                   the project. On the basis of discussions with your offices, our evaluation
                   includes (1) an assessment of the need for prescribing psychologists in the
                   MHSS, (2) information on the implementation of the PDP, and
                   (3) information on the PDP’s costs and benefits. To develop this
                   information, we reviewed the military’s needs determinations for
                   psychiatrists and clinical psychologists. We examined reports and
                   assessments of the PDP by the Army, the Army Surgeon General’s blue
                   ribbon panels, and the American College of Neuropsychopharmacology
                   (ACNP) as well as several articles on the issue of psychologists prescribing
                   drugs. We also reviewed both a feasibility study and a cost-effectiveness
                   analysis conducted by Vector Research, Inc. (VRI).2

                   In addition, we interviewed all PDP participants who completed the project
                   and others at the facilities where participants were practicing, Department
                   of Defense (DOD) Office of Health Affairs officials, and other DOD medical
                   officials. We also met with representatives of the American Psychiatric
                   Association and the American Psychological Association. Our work was
                   performed from July 1996 through February 1997 in accordance with
                   generally accepted government auditing standards.3


                   The MHSS has more psychiatrists than it needs to meet its current and
Results in Brief   upcoming readiness requirements, according to our analysis of DOD’s
                   health care needs. Therefore, the MHSS needs no prescribing psychologists
                   nor any other additional mental health care providers authorized to
                   prescribe psychotropic medication. Moreover, DOD does not even account
                   for prescribing psychologists when determining its medical readiness
                   needs.

                   Although DOD met its goal to train psychologists to prescribe drugs, it
                   faced many difficulties in implementing the PDP. Not all of these were
                   resolved. For example, the MHSS never had a clear vision of the prescribing
                   psychologist’s role, did not meet recruitment goals, and repeatedly
                   changed the curriculum. Consequently, ACNP recommended in 1995 that
                   unless these issues were addressed, the PDP should end.



                   2
                    Cost-Effectiveness and Feasibility of the DOD Psychopharmacology Demonstration Project: Final
                   Report, VRI (Arlington, Va.: May 17, 1996). For a detailed description of this study’s methodology and
                   results, see app. I.
                   3
                    See app. II for a more detailed description of our methodology.



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             The total cost of the PDP, from start-up through the date the last
             participants will complete the program, is about $6.1 million or about
             $610,000 per prescribing psychologist, according to our estimate.
             Ultimately, the PDP will have added 10 mental health care providers who
             can prescribe drugs to an MHSS that already has a surplus of psychiatrists.
             Opinions differ on the effect of adding these prescribing psychologists to
             the MHSS concerning such issues as quality of care and collaboration
             between psychologists and physicians.

             Without a clear purpose or role for prescribing psychologists and given the
             uncertainty about the extent to which they would replace higher cost
             providers, we cannot conclude that the benefits gained from training
             prescribing psychologists warrant the costs of the PDP. Training
             psychologists to prescribe medication is not adequately justified because
             the MHSS has no demonstrated need for them, the cost is substantial, and
             the benefits are uncertain.


             The main mission of the MHSS, which spends more than $15 billion a year,
Background   is medical readiness.4 This mission requires the MHSS to (1) provide
             medical support to active-duty military personnel in preparation for and
             during combat and (2) maintain the health of the active-duty force during
             peacetime. The Army, Navy, and Air Force all maintain uniformed health
             care providers to fill their MHSS medical readiness needs.

             To the extent that military space, staff, and other resources are available,
             the MHSS may also support DOD’s mission to care for nonactive-duty
             beneficiaries (dependents of active-duty members, retired members and
             their dependents, and survivors of deceased members). Whenever
             nonactive-duty beneficiaries’ need for health care exceeds the MHSS’
             resources available to them, DOD purchases services for them from the
             civilian health care sector.

             The role of psychiatrists and clinical psychologists in meeting the MHSS
             medical readiness mission is to provide mental health care that helps
             military active-duty personnel perform their duties before, during, and
             after combat or some other military operation. Both psychiatrists and
             clinical psychologists, whether in the military or civilian sector, provide a

             4
              According to DOD, “Medical readiness encompasses the ability to mobilize, deploy and sustain field
             medical services and support for any operation requiring military services; to maintain and project the
             continuum of health care resources required to provide for the health of the force; and to operate in
             conjunction with beneficiary health care.” See Medical Readiness Strategic Plan, 1995-2001, DOD
             (Washington, D.C.: Mar. 20, 1995).



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variety of mental health services, some of which are similar. Both can
diagnose mental conditions and treat these conditions with
psychotherapy. A degree in medicine is required to practice psychiatry,
however, so psychiatrists may treat mental disorders medically, that is,
with medication. Because medical training is not required to practice
clinical psychology, psychologists are not qualified to prescribe
medication.

To practice medicine, psychiatrists complete 4 years of medical school
and a 1-year clinical internship during which they are trained to evaluate
and treat all types of organic conditions5 and to perform general surgery.
After this, they complete a 3-year psychiatric residency during which they
learn to evaluate and treat mental conditions and the organic conditions
associated with them. Because psychiatrists practice medicine, they can
diagnose organic as well as mental conditions and treat each with
medication. They consider a full range of possible organic causes for
abnormal behavior when diagnosing a condition. Therefore, they can
distinguish between mental conditions with an organic cause, such as
schizophrenia6 and bipolar disorder,7 and organic conditions, such as
diabetes and thyroid disease, which have symptoms that mimic a mental
disorder. Organic mental disorders are best treated through a combination
of medication and psychotherapy, according to DOD officials.

Clinical psychologists, on the other hand, practice psychology, not
medicine. Typically, they complete 6 years of graduate school leading to a
doctoral degree and 1 to 2 years of postdoctoral clinical experience.
Clinical psychologists are trained in theories of human development and
behavior, so their general approach to diagnosing and treating mental
illness is psychosocial8 rather than medical. They are trained to diagnose
and treat all mental conditions and rely on the behavior a patient displays
to diagnose these conditions.



5
 These are diseases associated with observable or detectable changes in the organs or tissues of the
body.
6
 This is a fundamental mental derangement characterized by loss of contact with the environment;
noticeable deterioration in the level of functioning in everyday life; and disintegration of personality
expressed as disorders of feeling, thought, and conduct.
7
 This is a disorder in which the patient exhibits both manic and depressive episodes. Mania is
excitement manifested by mental and physical hyperactivity, disorganization of behavior, and
elevation of mood. Depression is marked by sadness, difficulty in concentration, feelings of dejection
and hopelessness, and sometimes suicidal tendencies.
8
 This refers to relating social conditions to mental health.



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The MHSS created the PDP to increase the scope of practice of clinical
psychologists in the military so they could treat their patients with
psychotropic medication when needed. DOD established this project in
response to a conference report dated September 28, 1988, which
accompanied the fiscal year 1989 DOD Appropriations Act (P.L. 100-463).
The report specified that, “given the importance of addressing ‘battle
fatigue,’ the conferees agreed that the Department should establish a
demonstration pilot training program in which military psychologists may
be trained and authorized to issue appropriate psychotropic medications
under certain circumstances.”

The Army’s Office of the Surgeon General was tasked with designing and
implementing the PDP. A blue ribbon panel9 was formed by the Army
Surgeon General in February 1990 to determine the best method for
implementing the PDP. After considering various models, the panel
endorsed a training model that included course work at the Uniformed
Services University for the Health Sciences (USUHS). In February 1991, the
Chairmen of the Senate and House Subcommittees on Defense of the
respective Committees on Appropriations then recommended that DOD
develop a 2-year training model for the PDP in accordance with the panel’s
recommendations. DOD later formed a committee to develop a suitable
training program to provide clinical psychologists with the knowledge
required for safely and effectively using a limited list or formulary of
psychotropic medication. This committee recommended a special 3-year
postdoctoral fellowship program for the PDP with (1) 2 years of course
work at USUHS, followed by (2) 1 year of clinical experience at Walter Reed
Army Medical Center.

This training began in August 1991 with four participants. For subsequent
classes, however, the PDP consisted of 2 years of training—1 year of
classroom and 1 year of clinical training. Classroom training included
courses at USUHS in subjects such as anatomy, pharmacology, and
physiology. PDP participants’ clinical experience took place on inpatient
wards and outpatient clinics at Walter Reed Army Medical Center in
Washington, D.C., or the Malcolm Grow Medical Center at Andrews Air
Force Base in Maryland. There, participants were trained to take medical
histories and incorporate them into treatment plans and to prescribe
medication for patients with certain types of mental disorders. After their
clinical year, participants received a certificate of “Fellowship in


9
 This panel consisted of representatives of the Surgeons General of each of the three services; the
Office of the Assistant Secretary of Defense for Health Affairs; and professional organizations of
psychiatrists, psychologists, and physicians.



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Psychopharmacology for Psychologists” and became known as
“prescribing psychologists.”

Once PDP participants graduated from training, they completed 1 year of
supervised or proctored practice; their respective services assigned
participants to military medical facilities for this 1 year of practice. These
facilities authorized participants to prescribe a specified formulary of
psychotropic drugs. Although the medical education received under the
PDP qualified clinical psychologists to treat mental conditions with
medication, it was less extensive than psychiatrists’ medical training.
Therefore, the MHSS limits prescribing psychologists’ scope of practice.
They may only treat patients between the ages of 18 and 65 who have
mental conditions without medical complications as determined by their
supervisors.

ACNP helped develop and evaluate the PDP. ACNP is a professional
association of about 600 scientists from disciplines such as behavioral
pharmacology, neurology, pharmacology, psychiatry, and psychology.
ACNP’s principal functions are research and education. It conducted several
assessments of the PDP under contract to the Army and made a number of
recommendations on the project’s goals and implementation. One of them
was for DOD to establish a PDP Advisory Council to help develop criteria
and procedures on implementing the PDP. DOD established this council in
1994.

The American Psychiatric Association, American Psychological
Association, and literature on this topic have noted the possible
advantages or disadvantages of allowing psychologists in the civilian
sector to prescribe medication. One article has suggested that training
psychologists to prescribe psychotropic medication could be particularly
beneficial if they were permitted to practice this skill in clinical settings
such as nursing homes, mental institutions, or medically underserved
areas. Some have suggested that using prescribing psychologists could
reduce the cost of care and maintain the continuity of patient care by
eliminating the need to switch patients from psychologists to psychiatrists
when drug therapy is indicated. On the other hand, because prescribing
psychologists would receive only partial training in medicine, some are
concerned about the quality of care these psychologists would be able to
provide.

No state licensing authority allows psychologists to prescribe medication.
A few states are considering legislation, however, that would allow those



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                        already licensed by the state’s psychologist licensing board to be certified
                        to prescribe medication after completing certain courses in medicine and
                        gaining clinical experience. Under legislation introduced in Hawaii in 1997,
                        psychologists seeking authority to prescribe would have to pass a
                        standard examination. Legislation proposed in Missouri would require the
                        development of a specified formulary of drugs for certified prescribing
                        psychologists.


                        None of the services needs additional mental health providers capable of
Number of Mental        prescribing medication to meet either current or upcoming medical
Health Care Providers   readiness requirements, according to our review of DOD’s health care
Is Adequate for         needs. Each service has more than enough psychiatrists, as well as clinical
                        psychologists, to care for its anticipated wartime psychiatric caseload.
Readiness               Given this surplus, spending resources to provide psychologists with
Requirements            additional skill does not seem justified.

                        Each of the three services has a model and procedures to determine the
                        number of specific types of health care providers needed to support its
                        MHSS medical readiness mission. These are based on the types and number
                        of casualties anticipated under a wartime scenario. About one out of eight
                        casualties would involve combat stress, according to an Army official.10
                        Caring for combat stress requires skill in (1) diagnosing combat stress,
                        including the ability to distinguish it from neurological or other
                        psychological disorders with like signs and symptoms, and (2) treating a
                        range of severity levels of combat stress. Psychologists have many but not
                        all of the skills necessary to treat combat stress and are therefore
                        included, along with psychiatrists, in the services’ staffing of those who
                        treat anticipated wartime casualties. Psychologists cannot be substituted
                        for psychiatrists, however. Even if trained to prescribe drugs,
                        psychologists are not as equipped as psychiatrists to distinguish between
                        actual combat stress and certain neurological disorders that appear to be
                        combat stress. Psychiatrists are also better able to treat more severe or
                        complicated combat stress cases.

                        The services have separate requirements for psychiatrists and clinical
                        psychologists. None of the services has a separate readiness requirement

                        10
                          Stress is the internal process of preparing to deal with events or situations referred to as “stressors.”
                        Stress involves physiological reflexes such as increased nervous system arousal, release of adrenaline
                        into the bloodstream, change in blood flow to different parts of the body, and the like. Stress also
                        involves emotional responses and the automatic perceptual and cognitive processes for evaluating an
                        uncertainty or a threat. Combat stressors are those occurring during combat-related activities, whether
                        from enemy action or other events or situations. They may arise from a soldier’s own unit, leaders, and
                        mission demands or from the conflict between mission demands and a soldier’s home life.



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                                     for prescribing psychologists. Table 1 shows the number of MHSS
                                     psychiatrists each service has determined it needs11 and the number
                                     assigned or on board for fiscal years 1995 through 1998.12 Table 2 shows
                                     the number of clinical psychologists each service has determined it needs
                                     and the number assigned for fiscal years 1995 through 1998.

Table 1: Psychiatrists by Service:
Number Needed and Assigned to Meet                          FY 1995                       FY 1996                 FY 1997         FY 1998
Readiness Requirements               Service            Needed          Assigned     Needed        Assigned          Needed          Needed
                                                                    a                          a                              a
                                     Air Force                               129                          115                             107
                                     Army                   205              226          205             219             198             228
                                     Navy                   105              166          107             144             107             107
                                                                    a                          a                              a
                                     Total                                   521                          478                             442
                                     a
                                         Number is not available.



Table 2: Psychologists by Service:
Number Needed and Assigned to Meet                          FY 1995                       FY 1996                 FY 1997         FY 1998
Readiness Requirements               Service            Needed          Assigned     Needed        Assigned          Needed          Needed
                                                                    a                          a                              a
                                     Air Force                               156                          165                             207
                                     Army                   118              130          118             113             103              98
                                     Navy                   135              157            92            117              92              92
                                                                    a                          a                              a
                                     Total                                   443                          395                             397
                                     a
                                         Number is not available.



                                     As these tables show, the MHSS has at least as many uniformed
                                     psychiatrists and clinical psychologists as it needs to meet its current and
                                     upcoming readiness requirements. Our discussions with psychiatry
                                     consultants13 to the Surgeons General of the three services confirm the
                                     picture these numbers portray, and testimony of DOD officials at
                                     congressional hearings is consistent with the views expressed by these
                                     consultants. At a March 1995 Senate Armed Services Committee hearing,
                                     the Assistant Secretary of Defense for Health Affairs stated that on the
                                     basis of DOD staffing guidelines, the MHSS has no shortage of active-duty

                                     11
                                       The Air Force could not provide the number of psychiatrists or psychologists needed to meet its
                                     readiness requirements for fiscal years 1995 through 1997. The Air Force Surgeon General, however,
                                     stated in 1995 that his service had a surplus of psychiatrists.
                                     12
                                      Projections of readiness requirements are available for all the services only through fiscal year 1998.
                                     Officials from each of the services, however, have observed that as the size of the military declines,
                                     MHSS readiness requirements for psychiatrists beyond fiscal year 1998 should stay the same or
                                     decline.
                                     13
                                       These are officials in each branch of the service who represent specific types of health care providers
                                     in that branch.


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                                 physicians in general. The Navy Surgeon General also testified at this
                                 hearing that the Navy has no shortage of psychiatrists. In addition, an
                                 official from the DOD Office of Health Affairs said that DOD has a surplus of
                                 psychiatrists.

                                 Although training psychologists to prescribe medication enables them to
                                 perform functions they do not normally perform, it does not give them all
                                 the skills needed to enable them to substitute for psychiatrists.
                                 Furthermore, the MHSS’ current staffing level of psychiatrists and
                                 psychologists is more than enough to meet its readiness requirements for
                                 caring for psychiatric cases without adding to some psychologists’
                                 capabilities. Therefore, the MHSS seems to have no current or upcoming
                                 need for psychologists who may prescribe drugs.


                                 Although DOD met the mandate to establish a demonstration project to
PDP’s Implementation             train military psychologists to prescribe psychotropic medication for
Faced Difficulties               mental illness, the PDP implementation faced several problems. Some of
                                 these problems have been resolved. The problems include

                             •   the lack of a clearly defined purpose for prescribing psychologists in the
                                 MHSS,
                             •   difficulty recruiting the desired number of participants per class,
                             •   unspecified participant selection criteria,
                             •   repeated changes in the classroom curriculum,
                             •   delays in granting prescribing privileges, and
                             •   unresolved issues involving supervision.

                                 The lack of precedent and experience with authorizing psychologists to
                                 prescribe medication, according to some officials at locations where PDP
                                 participants are stationed, is partly to blame for some of these problems.
                                 These include delays in granting prescribing privileges and disagreements
                                 over the extent of supervision.


Prescribing Psychologists’       The PDP did not clearly define the role of prescribing psychologists in the
Role in the MHSS Not             MHSS. The ACNP’s PDP evaluation panel noted in 1992 that the project’s goal

Clearly Defined                  “to train psychologists to issue appropriate medication under certain
                                 circumstances” was “rich with ambiguities.” The project was structured
                                 and revised periodically without specifying the (1) prescribing
                                 psychologists’ duties and responsibilities, (2) types of clinical settings or
                                 facilities their skills would be best suited for, (3) types of psychotropic



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                                   medication psychologists would be qualified to prescribe, and (4) level of
                                   supervision they would require. In September 1995, after the project had
                                   operated for 4 years, the ACNP panel suggested that DOD define clearly how
                                   PDP graduates could be used; this did not take place.



Recruiting PDP                     DOD  had difficulty recruiting PDP participants throughout the project. The
Participants Was Difficult         recruiting goal, which was not met, was six psychologists for each PDP
                                   class. Since the project started in 1991, 13 psychologists have participated.
                                   Seven have completed it. Three have dropped out, and three are expected
                                   to finish their clinical experience in June 1997 (see table 3). Those who
                                   dropped out did so for various reasons: One left the military. Another
                                   enrolled in the medical school at USUHS. The third left because of
                                   dissatisfaction with the program.

Table 3: Status of Psychologists
Entering the PDP                                                                              Graduated
                                                                      Entered      Left the     from the Currently
                                   Year                               the PDP         PDP           PDP in the PDP
                                   1991                                      4            2           2            0
                                   1992                                      0            0           0            0
                                   1993                                      2            1           1            0
                                   1994                                      5            0           4            1
                                   1995                                      2            0           0            2
                                   Total                                    13            3           7            3

                                   Because the PDP did not attract enough military psychologists, the program
                                   was opened to civilian clinical psychologists willing to enter the military.
                                   Two of the five PDP participants who began the program in 1994 were
                                   civilians who joined the military to participate in the PDP. Finally, only two
                                   psychologists entered the PDP in 1995.


Candidate Selection                The MHSS established no formal candidate selection criteria for the PDP.
Criteria Were Not Specified        Four classes of candidates had entered the PDP before prerequisites for
                                   participation were first addressed in February 1995. At that time, the PDP
                                   Advisory Council recommended that a candidate for the PDP (1) be on
                                   active duty, in good standing as a psychologist, and have an active state
                                   license to practice clinical psychology; (2) have a minimum of 2 years of
                                   active-duty experience as a clinical psychologist in one of the uniformed
                                   services; (3) agree to meet the service’s payback obligations for
                                   postdoctoral training; and (4) volunteer for the program.




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Curriculum Repeatedly        The duration, content, and sequencing of PDP training continued to change
Changed                      after the project began. Originally, PDP training was intended to last for 2
                             years and consist of both course work and clinical experience during each
                             year. An additional year of clinical experience was added for the first class
                             after it began the program, however, because the participants were not
                             receiving enough clinical experience. Subsequent classes received 2 years
                             of training as originally planned: the first dedicated exclusively to course
                             work at USUHS, the second, to clinical practice.

                             In addition, the curriculum content and sequencing of the courses changed
                             after the project began. Courses such as neuroscience and
                             psychopharmacology were added, while others were dropped. In 1995, the
                             ACNP panel noted that the curriculum for those who started the PDP in 1994
                             was “markedly different” from the curriculum for participants who started
                             the PDP in 1991. The panel said at that time that the curriculum needed to
                             be thought through more thoroughly, using the final scope of practice and
                             formulary as a starting point. The panel also noted that assessing the
                             adequacy of the curriculum was difficult because it changed frequently.
                             The panel saw a need for a well-organized, structured approach to the
                             design of courses as well as the selection of participants. It recommended
                             at that time that unless the MHSS addressed these concerns satisfactorily,
                             the project should end.


Prescribing Privileges for   The first psychologists who completed the PDP faced delays of up to 14
PDP Graduates Were           months in getting prescribing privileges at the facilities where they were
Delayed                      assigned possibly due to the facilities’ lack of experience with this type of
                             provider. Two recent graduates, however, received privileges within 2
                             months of arriving at their facilities. In each of these cases, PDP officials
                             visited the facilities where these psychologists had been assigned to
                             explain the project and training and provide information about the
                             graduates to facility officials. Facility officials cited these visits as helpful
                             in resolving their concerns about psychologists’ prescribing privileges.


Supervision of Prescribing   The MHSS has not decided who should supervise prescribing psychologists.
Psychologists Unresolved     In 1994, the MHSS decided that after prescribing psychologists had
                             completed their clinical year, they would spend the next year practicing
                             under a psychiatrist’s supervision. The MHSS originally anticipated that
                             these psychologists would ultimately function independently. All of the
                             PDP graduates, however, continue to practice under the supervision of a




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                                       psychiatrist, and whether they will ever prescribe independently is
                                       unclear.

                                       The PDP Advisory Council’s February 1995 scope of practice statement,
                                       which has been used as guidance for allowing prescribing privileges for
                                       some PDP graduates, states that prescribing psychologists should prescribe
                                       psychotropic medication only under the direct supervision of a physician.
                                       According to the Advisory Council that developed this statement, PDP
                                       graduates’ prescribing practice should be closely supervised. These
                                       psychologists should then gradually be permitted to practice under less
                                       supervision as they demonstrate their competence.


                                       Even if the MHSS had a need for additional mental health care providers to
PDP Was Costly and                     prescribe medication, the cost of meeting this need by training clinical
Its Benefits Are                       psychologists to prescribe drugs is substantial. Furthermore, although the
Uncertain                              PDP produced additional providers who can prescribe and some facilities
                                       have reported positive experiences with them, determining the PDP’s
                                       cost-effectiveness is impossible at this time.


Cost of PDP                            The total cost of the PDP will be about $6.1 million through the completion
                                       of the proctored year for those currently in the program—or about
                                       $610,000 per psychologist who completes the program (see table 4).

Table 4: Estimated Cost of PDP by
Training Component and Type of Cost,                                                      Training component
FY 1991-98                                            Type of cost               Classroom          Clinical     Proctored Total costs
                                                                                       year            year           year
                                       PDP training expenses                     $1,650,420                 0              0 $1,650,420
                                       Student salary plus benefits (minus
                                       productivity benefit)                         844,065        333,154                0     1,177,219
                                       Supervisor lost productivity                          0      475,810        206,874        682,684
                                                                                              a              a              a
                                       PDP training overhead cost                                                                2,584,199
                                       Total cost                                                                               $6,094,522
                                       Notes: These estimates assume that the three current PDP participants will complete the clinical
                                       portion of the project in June 1997 and their proctored year in 1998.

                                       Estimates as expressed in 1996 dollars.
                                       a
                                           Not available by component.




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On the basis of our previous estimates of the cost of a USUHS medical
education,14 we estimate that the cost of the classroom training for PDP
participants provided by USUHS was about $110,028 per participant per
year. Most of this amount consisted of faculty cost and costs for operating
and maintaining USUHS. The remainder included the cost of research,
development, testing and evaluation, military construction, and other
miscellaneous costs. Our estimate of total cost for PDP training includes
the cost of 12 classroom years of training for 10 PDP graduates as well as 3
years of training for three psychologists who dropped out of the program.

Our estimates of psychologists’ salaries while participating in the PDP are
based the assumption that those entering the project would receive a
salary of $56,071 during their first year in the PDP, $57,571 during their
second year, and $58,985 during their third year.15 Student salaries totaled
$844,065 during the classroom training portion of the PDP, according to our
estimate. This included the salaries of 11 participants for 1 year of
classroom training each, 3 of whom ultimately dropped out of the PDP, and
2 participants for 2 years each.

Because PDP participants treated patients during their clinical and
proctored years, we reduced our salary estimates for these years by a
productivity factor representing the time they spent treating patients. We
used a productivity factor of 50 percent for the clinical year and
100 percent for the proctored year.16 On the basis of these productivity
factors, total participant salary costs for the clinical portion of the PDP
were $333,154, according to our estimates. This accounts for one
participant who dropped out approximately halfway through the clinical
year and another who received an additional year of clinical training.

To estimate faculty and supervisor salaries for the PDP for the clinical and
proctored years, we assumed that one faculty member per psychologist
would devote 40 percent of his or her time per clinical year of training.
Likewise, we assumed that during the proctored year, one supervisor
would spend 20 percent of his or her time supervising each prescribing



14
   Military Physicians: DOD’s Medical School and Scholarship Program (GAO/HEHS-95-244, Sept. 29,
1995).
15
 This is derived from VRI’s DOD salary information for its cost-effectiveness and feasibility study
(May 17, 1996).
16
  PDP participants and their supervisors generally agreed on the basis of their experience that
participants spent about half their time in the clinical year and all of their time in the proctored year
treating patients.



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                             B-276291




                             psychologist.17 On the basis of these assumptions, the total cost of lost
                             faculty productivity due to training the 10 graduates for 11.5 years18 of
                             clinical training was $475,810, according to our estimate; the total cost of
                             lost supervisor productivity was $206,874 for 10 participants for 10
                             proctored years of practice. The lost productivity cost is based in each
                             case on an annual salary of $103,437.19

                             Total PDP overhead cost was $2.58 million, according to our estimate.20
                             This included the cost of the evaluation contracts ($1.75 million) and
                             personnel support costs ($830,000) for a PDP Director and a Training
                             Director for fiscal years 1992 (when the PDP began) through 1998, when
                             those currently in training are expected to complete their proctored year.
                             Also included in overhead costs are smaller amounts for invited lecturers,
                             travel and per diem expenses, supplies, and other miscellaneous expenses
                             during this time.

                             If the PDP had attracted a total of 24 participants and all of them had
                             graduated, the cost would have been about $365,000 per prescribing
                             psychologist. In addition, the cost per graduate would have been about
                             $94,000 less than this if the project had progressed beyond the
                             developmental stage and external evaluations could have been
                             discontinued. After operating for 7 years, however, the project was only
                             able to attract about half the number of participants considered optimal
                             and had not progressed beyond the stage for which external evaluations
                             were needed.


Perceptions of PDP and Its   The PDP increased the number of MHSS mental health care providers who
Benefits Differ              may prescribe drugs to treat certain mental conditions. This may reduce
                             psychiatrists’ workloads. Psychiatrists, psychologists, and primary care
                             physicians, however, have different opinions on the effect of allowing
                             psychologists to prescribe drugs on the quality of mental health care and
                             collaboration among these providers.



                             17
                               These proportions are based on discussions with psychiatrists who supervised PDP participants in
                             their clinical and proctored years. They generally agreed they had devoted 20 and 40 percent of their
                             time, respectively, per year to supervising participants.
                             18
                              This includes 1 year of clinical training for nine graduates, 2 years for one graduate, and 1/2 year for
                             one participant who dropped out of the PDP halfway through the clinical year.
                             19
                              This is the cost of the average fiscal year 1996 annual salary and benefits of all DOD psychiatrists as
                             estimated by VRI in its cost-effectiveness and feasibility study of the PDP.
                             20
                               This is based on overhead costs contained in PDP annual reports produced by the Army and costs
                             reported by VRI in its cost-effectiveness and feasibility study of the PDP.
                             Page 14                                         GAO/HEHS-97-83 Prescribing Psychologists in DOD
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As a result of the PDP, seven psychologists are prescribing medication at
DOD military facilities, and three more are expected to complete clinical
training in the summer of 1997 and receive prescribing privileges some
time after that. The first three participants are seeing mainly patients who
require medication, and one of these temporarily filled a vacancy created
by the departure of a psychiatrist.

Having prescribing psychologists on staff has certain benefits to facilities
where they are assigned. One of these facilities had been experiencing
unusually heavy psychiatrist workloads because it did not have enough
psychiatrists to fill all its psychiatry positions. In the interim, this facility
specifically requested a prescribing psychologist to fulfill some of the
responsibilities of a psychiatrist, reducing the psychiatry workload.
Another prescribing psychologist temporarily saw the patients of a
psychiatrist who transferred to another facility until the facility brought in
another psychiatrist.

VRI obtained perceptions of the PDP by surveying MHSS psychiatrists,
primary care physicians, and psychologists about the possible effects of
allowing psychologists to prescribe medication.21 The most frequent
responses to the survey’s open-ended questions about the potential benefit
of this practice were that it would (1) increase the number of mental
health care providers in the MHSS and (2) reduce psychiatrists’ workloads.
The most frequently noted limitation to allowing psychologists to
prescribe medication was their perceived lack of knowledge about
medicine, physiology, and adverse drug interactions and effects.

Survey results also indicated that psychiatrists, psychologists, and primary
care physicians differed about whether adding prescribing psychologists
to the MHSS was beneficial. Most psychologists responded that training
psychologists to prescribe would improve the quality of mental health care
in the military. Conversely, most psychiatrists believed quality of care
would decline. Furthermore, psychiatrists thought this would undermine
their working relationships with MHSS psychologists; most primary care
physicians responded that this would improve their collaboration with
psychologists. Most psychologists agreed that the authority to prescribe
would enhance their collaboration with MHSS primary care physicians. But
as far as their collaboration with MHSS psychiatrists was concerned, about
half the psychologists believed this would improve such collaboration; the
other half thought it would interfere with it.


21
  See app. I for a detailed description of this survey.



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Cost-Effectiveness of PDP   The cost-effectiveness of having MHSS psychologists prescribe
Undetermined                psychotropic medication is unclear at this time. Determining the
                            cost-effectiveness of this effort would require information on the
                            (1) proportion of the time remaining in the military that prescribing
                            psychologists would have to perform functions that psychiatrists would
                            normally perform and (2) extent to which having psychologists prescribe
                            medication would result in fewer psychiatrists in the MHSS. The results of
                            analyses designed to predict the relative cost-effectiveness of training and
                            employing psychologists to prescribe compared with other providers with
                            this authority differ depending on the cost estimates used. VRI’s analysis
                            concluded that the PDP would prove cost-effective under certain
                            circumstances. Additional analyses using different cost estimates,
                            however, suggest that the PDP would not be cost-effective under these
                            same circumstances.

                            VRI found that the annual life cycle cost of a prescribing psychologist was
                            potentially lower than that of a psychiatrist-psychologist combination,
                            which is typically required to treat an MHSS patient with a mental condition
                            requiring medication. As table 5 indicates, VRI’s analysis accounted for
                            acquisition costs (the cost of recruiting people into the military), training
                            costs, basic and special pay and benefits (such as housing allowances),
                            health care costs, risk management expenses (for potential malpractice
                            claims), and retirement costs. It assumed various pay levels for different
                            types of providers at different stages in their military careers as well as for
                            different career lengths. It also assumed that PDP enrollees would enter the
                            project after 6 years as DOD clinical psychologists.




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Table 5: Annual Life Cycle Costs of Selected MHSS Providers Based on VRI’s Cost Estimates
                                         Yearly life cycle cost per full-time equivalent
Provider group              Accession          Training          Force          Retirement               Total            Required utilization
                                                                                                                                                    a
Psychiatrists                  $23,470          $13,864        $112,697             $19,142         $169,173
                                                                                                                                                    a
Psychologists                    1,134             3,766         66,155               15,849           86,905
Psychologists/
psychiatrists (base case
                                                                                                                                                    a
scenario)                       10,901             8,182         86,506               17,289          122,878
Prescribing psychologists
(start-up case scenario)         1,218           29,296          71,979               17,735          120,227                                 92.6%
Prescribing psychologists
(optimal case scenario)          1,218           17,197          71,979               17,735          108,128                                 59.0%
                                         Note: Estimates are expressed in 1996 dollars.
                                         a
                                             Not applicable.

                                         Source: VRI data.



                                         VRIestimated the annual life cycle cost of prescribing psychologists given
                                         two scenarios, a start-up case scenario and an optimal case scenario. To
                                         predict the conditions under which the PDP would be cost-effective, VRI
                                         compared the annual life cycle cost of a prescribing psychologist under
                                         the start-up scenario with the life cycle cost of what it refers to as the
                                         “base” scenario. It used the start-up scenario rather than the optimal
                                         scenario because the former accounts for the nonrecurring, fixed (or
                                         start-up) costs actually associated with developing and implementing the
                                         PDP.22 The base scenario is the annual life cycle cost of the current
                                         psychiatrist-psychologist combination required to treat MHSS mental health
                                         care patients who need medication.

                                         Given the difference in annual life cycle costs between the base and the
                                         start-up scenarios, VRI predicted that the PDP would be more cost-effective
                                         than the base scenario if PDP participants in the start-up period functioned
                                         as prescribing psychologists, rather than traditional clinical psychologists,
                                         for more than 92.6 percent of their time remaining in the military. For this
                                         estimate, VRI assumed that (1) each PDP class would have three
                                         psychologists, (2) prescribing psychologists would be supervised for the
                                         remainder of their military service, (3) supervisory costs after the
                                         proctored year would amount to 5 percent of a physician’s annual salary

                                         22
                                           The optimal scenario represents a modification of the start-up scenario. It assumes the PDP is
                                         operating in a long-term, steady state, so start-up costs are excluded and the recurring costs of
                                         supplies and training are set at levels that represent long-term efficiency. It also assumes the optimal
                                         class size of six participants.



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                                         B-276291




                                         per prescribing psychologist per year, and (4) prescribing psychologists
                                         would remain in the military an average of 10.2 years after completing the
                                         PDP.


                                         The validity of VRI’s predictions about the circumstances under which the
                                         PDP would be cost-effective depends on how realistic VRI’s cost estimates
                                         are as well as the other assumptions it used to estimate the annual life
                                         cycle cost of MHSS psychiatrists, psychologists, and prescribing
                                         psychologists. Some of VRI’s estimates were based on scant MHSS
                                         experience in training and employing psychologists to prescribe.
                                         Information about the PDP’s overhead cost that we collected after VRI
                                         completed its work, for example, indicated that overhead cost was lower
                                         than originally thought. Also, VRI’s estimate of the cost of training at USUHS
                                         was lower than our estimate of the cost of this training.

                                         For a more realistic prediction of the circumstances under which the PDP
                                         would be cost-effective, we asked VRI to redo its analysis, replacing its
                                         estimate of $2.89 million for total overhead cost during the start-up period
                                         with an updated estimate of $2.58 million. We also asked VRI to substitute
                                         the $39,969 it used per participant per year for PDP classroom training and
                                         related overhead with $110,028, our estimate of the per student per year
                                         cost of USUHS training, which includes training overhead. See table 6 for
                                         the results of this analysis.


Table 6: Annual Life Cycle Costs of Selected MHSS Providers Based on Our Estimates of Overhead and Training Costs
                                         Yearly life cycle cost per full-time equivalent
Provider group              Accession          Training          Force       Retirement           Total         Required utilization
                                                                                                                                   a
Psychiatrists                  $23,470          $13,864        $112,697          $19,142      $169,173
                                                                                                                                   a
Psychologists                    1,134             3,766         66,155            15,849       86,905
Psychologists/
psychiatrists (base case
                                                                                                                                   a
scenario)                       10,901             8,182         86,506            17,289      122,878
Prescribing psychologists
(start-up case scenario)         1,218           32,611          71,979            17,735      123,542                       101.85%
Prescribing psychologists
(optimal case scenario)          1,218           26,196          71,979            17,735      117,127                        84.01%
                                         Note: Estimates are expressed in 1996 dollars.
                                         a
                                             Not applicable.

                                         Source: VRI data.




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              B-276291




              On the basis of our overhead and training cost estimates, PDP graduates
              under the start-up scenario23 could not be cost-effective because they
              would have to function as prescribing psychologists more than
              101.85 percent of their time remaining in the military. This prediction is
              based on the same assumptions that VRI made about PDP class size,
              prescribing psychologists’ supervision, supervisory costs, and prescribing
              psychologists’ remaining time in the military.


              In DOD’s mental health care system, the main function of prescribing
Conclusions   psychologists is to care for patients with certain types of mental
              conditions that require certain psychotropic medications. According to
              DOD’s needs assessments, the MHSS has more psychiatrists to care for these
              patients than needed to meet medical readiness requirements. Therefore,
              the MHSS has no current or upcoming need for clinical psychologists who
              may prescribe medication. In addition, the cost of producing 10
              prescribing psychologists was substantial. Regardless of the cost, spending
              resources to produce more providers than the MHSS needs to meet its
              medical readiness requirement is hard to justify.

              The PDP has demonstrated that training psychologists to prescribe drugs,
              which increased the number of MHSS providers with this skill, reduced
              psychiatrists’ workloads in some cases. A potential benefit of the PDP,
              therefore, is the savings associated with prescribing psychologists
              delivering some of the services that psychologists in conjunction with
              psychiatrists have traditionally provided. These savings result because a
              prescribing psychologist can deliver this care with lower personnel-related
              costs than the combination of a psychologist and a psychiatrist.

              To realize these savings, however, DOD must (1) use a prescribing
              psychologist to treat patients who normally would have been treated by a
              psychiatrist and a psychologist and (2) replace higher priced providers in
              the MHSS with prescribing psychologists. Otherwise, the PDP cannot save
              DOD money. Even if the 10 prescribing psychologists from the PDP do, in
              certain situations, function as psychiatrists, the PDP is still not guaranteed
              to save money. Although prescribing psychologists cannot totally replace
              psychiatrists, DOD does not account for the introduction of prescribing

              23
                Again, annual life cycle cost per prescribing psychologist under the start-up rather than the optimal
              case scenario was used to predict the cost-effectiveness of prescribing psychologists. The optimal case
              scenario assumes the PDP is training six psychologists per class and operating in a long-term, steady
              state in which start-up costs associated with project development, such as the cost of external
              evaluations, are not incurred. The start-up scenario better represents the PDP, therefore, because it
              did not train six psychologists per class and did not reach a steady state. In addition, costs associated
              with the PDP’s development were incurred throughout the project.



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                    B-276291




                    psychologists in the MHSS when determining its readiness needs for
                    psychiatrists. Therefore, it is uncertain whether DOD will reduce its
                    readiness requirement for psychiatrists in response to shifting some of a
                    psychiatrist’s functions to a prescribing psychologist.

                    Concerning the PDP’s implementation, DOD has demonstrated that it can
                    train clinical psychologists to prescribe psychotropic medication, and
                    these psychologists have shown that they can provide this service in the
                    MHSS. The implementation faced several problems, however, that persisted
                    for the PDP’s duration.

                    Given DOD’s readiness requirements, the PDP’s substantial cost and
                    questionable benefits, and the project’s persistent implementation
                    difficulties, we see no reason to reinstate this demonstration project.


                    In the future, should prescribing psychologists be needed to meet DOD’s
Recommendation to   medical readiness requirements, the Congress should require DOD to
the Congress        (1) clearly demonstrate that the use of those MHSS psychologists who have
                    been trained to prescribe has resulted in savings, (2) clearly define a
                    prescribing psychologist’s role and scope of practice in the MHSS compared
                    with other psychologists and psychiatrists, (3) design a curriculum
                    appropriate to this role and scope of practice, and (4) determine the need
                    for and the level of supervision that prescribing psychologists require.


                    In comments received March 26, 1997, in response to a draft of this report,
Agency Comments     the Assistant Deputy Assistant Secretary of Defense (Clinical Affairs)
                    stated that, on the basis of the methodology employed in this study, DOD
                    has no objections to its results and recommendations. Department
                    officials did provide a few technical corrections to the report. We modified
                    the report as appropriate.


                    Copies of this report will also be sent to other interested congressional
                    committees and the Secretary of Defense. Copies will also be made
                    available to others upon request. This report was prepared under the
                    direction of Stephen P. Backhus, Director, Veterans’ Affairs and Military
                    Health Care Issues, who may be reached at (202) 512-7101 if you or your
                    staff have any questions or need additional assistance. Other major
                    contributors to this report include Clarita Mrena, Assistant Director;




                    Page 20                           GAO/HEHS-97-83 Prescribing Psychologists in DOD
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William Stanco, Senior Evaluator; and Deena El-Attar and Gregory
Whitney, Evaluators.




Richard L. Hembra
Assistant Comptroller General




Page 21                         GAO/HEHS-97-83 Prescribing Psychologists in DOD
Contents



Letter                                                                                              1


Appendix I                                                                                         24
                        Cost-Effectiveness Analysis                                                24
Scope and               Feasibility Analysis                                                       26
Methodology of an
Evaluation of the PDP
by Vector Research,
Inc.
Appendix II                                                                                        28

Objectives and
Methodology of Our
Evaluation of the PDP
Tables                  Table 1: Psychiatrists by Service: Number Needed and Assigned               8
                          to Meet Readiness Requirements
                        Table 2: Psychologists by Service: Number Needed and Assigned               8
                          to Meet Readiness Requirements
                        Table 3: Status of Psychologists Entering the PDP                          10
                        Table 4: Estimated Cost of PDP by Training Component and Type              12
                          of Cost, FY 1991-98
                        Table 5: Annual Life Cycle Costs of Selected MHSS Providers                17
                          Based on VRI’s Cost Estimates
                        Table 6: Annual Life Cycle Costs of Selected MHSS Providers                18
                          Based on Our Estimates of Overhead and Training Costs




                        Abbreviations

                        ACNP      American College of Neuropsychopharmacology
                        DOD       Department of Defense
                        FTE       full-time equivalent
                        MHSS      Military Health Services System
                        PDP       Psychopharmacology Demonstration Project
                        USUHS     Uniformed Services University of Health Sciences
                        VRI       Vector Research, Inc.


                        Page 22                        GAO/HEHS-97-83 Prescribing Psychologists in DOD
Page 23   GAO/HEHS-97-83 Prescribing Psychologists in DOD
Appendix I

Scope and Methodology of an Evaluation of
the PDP by Vector Research, Inc.

                         In September 1995, DOD contracted with Vector Research, Inc. (VRI) to
                         conduct an evaluation of the PDP. The Assistant Secretary of Defense for
                         Health Affairs requested this study to obtain an evaluation of the PDP that
                         was independent of those performed by the American College of
                         Neuropsychopharmacology. VRI’s study was to

                     •   assess the relative cost-effectiveness of training psychologists to prescribe
                         medication and having them deliver this service in the Military Health
                         Services System (MHSS),
                     •   identify impediments to integrating prescribing psychologists into the
                         MHSS, and
                     •   evaluate the potential roles and functions of prescribing psychologists in
                         DOD.


                         To accomplish the first objective, VRI compared the annual life cycle cost
                         of various types of MHSS mental health care providers with the annual life
                         cycle cost of a prescribing psychologist. To address the remaining two
                         objectives, VRI conducted what it referred to as a feasibility analysis of the
                         PDP. VRI issued a report on this work on May 17, 1996.



                         To determine the relative cost-effectiveness of training and employing
Cost-Effectiveness       prescribing psychologists relative to other DOD health care providers, VRI
Analysis                 compared its estimate of DOD’s average annual life cycle cost of a
                         prescribing psychologist with its estimate of this cost for clinical
                         psychologists, psychiatrists, physicians specializing in internal medicine,
                         and physicians specializing in family practice. It calculated these costs on
                         the basis of three scenarios:

                     •   the “base” case scenario, which is the status quo, a combination of
                         psychologists and psychiatrists, with no prescribing psychologists in the
                         MHSS;
                     •   the “start-up” case scenario for prescribing psychologists, which had all
                         the same elements of the base scenario but accounted for the introduction
                         of prescribing psychologists into the MHSS; and
                     •   the “optimal” case scenario for prescribing psychologists, which
                         represented a modification of the start-up scenario.

                         Costs in the start-up scenario included the nonrecurring, fixed costs
                         associated with the PDP development and initial implementation as well as
                         other costs for the PDP that VRI also believed would diminish or disappear
                         in the long run. The optimal scenario represents the PDP in a long-term,



                         Page 24                            GAO/HEHS-97-83 Prescribing Psychologists in DOD
                         Appendix I
                         Scope and Methodology of an Evaluation of
                         the PDP by Vector Research, Inc.




                         steady state, during which no recurring costs associated with start-up and
                         optimal class size would accrue. In this scenario, VRI set the cost of
                         supplies and training to levels that indicate long-term efficiency.


Steps in the             The following are the main steps in VRI’s cost-effectiveness analysis:
Cost-Effectiveness
Analysis                 1. Calculate life cycle costs for active-duty military psychiatrists, family
                         practitioners, internists, and clinical psychologists; then calculate the cost
                         per full-time equivalent (FTE) for each of these by dividing their respective
                         life cycle cost by their respective expected length of service (length of
                         service minus unproductive time while in training).

                         2. Calculate life cycle costs for prescribing psychologists using actual and
                         anticipated costs for a PDP sized at six and at three psychologists per class;
                         and then, under both the start-up and base scenarios, calculate the cost
                         per FTE for prescribing psychologists assuming that they (1) serve as
                         clinical psychologists before entering the PDP and (2) after which they
                         prescribe psychotropic medication.

                         3. Calculate the cost per FTE for the combination of clinical psychologists
                         and psychiatrists that could be replaced by a prescribing psychologist.

                         4. Compare the annual life cycle cost per FTE of prescribing psychologists
                         under start-up and optimal scenarios with the cost per FTE of the
                         psychologist-psychiatrist combination.


Calculating Life Cycle   VRI’sestimates of the annual life cycle cost per FTE of various types of
Costs                    providers accounted for the cost of acquiring each type of provider,
                         training costs, “force” costs, and retirement costs associated with each.
                         Acquisition cost is DOD’s cost of recruiting someone into the military.
                         Training costs include the cost of providing DOD-sponsored training to
                         military health care providers. Force costs cover basic pay and
                         allowances, special pay, miscellaneous expenses, and health care benefits
                         of health care providers during their active-duty careers. Finally,
                         retirement costs include the cost of retirement pay and retiree health care
                         benefits.

                         VRI’s overall estimates of the annual life cycle cost per FTE for different
                         health care providers were based on a number of cost estimates and
                         assumptions about these four cost categories that varied somewhat by



                         Page 25                                GAO/HEHS-97-83 Prescribing Psychologists in DOD
                           Appendix I
                           Scope and Methodology of an Evaluation of
                           the PDP by Vector Research, Inc.




                           provider and scenario. Following are the major assumptions VRI made
                           when calculating life cycle cost for prescribing psychologists:

                       •   For cost savings to be realized, the introduction of prescribing
                           psychologists into the MHSS reduced FTEs for psychiatrists or other
                           physicians.
                       •   PDP participants had at least 6 years of experience as clinical psychologists
                           when they entered the PDP.
                       •   The PDP lasted 3 years—1 year for classroom training, 1 year for clinical
                           experience, and 1 year for proctored practice.
                       •   Each PDP class had three or six psychologists.
                       •   PDP participants required 40 percent of a faculty member’s time during
                           their clinical year of training and 20 percent of a faculty member’s time
                           during their proctored year, which took time from faculty members’
                           patient care.
                       •   After completing the PDP, graduates were able to “safely and effectively”
                           prescribe medication and were assigned to “utilize their new prescription
                           skills along with their clinical psychology skills to treat patients that
                           otherwise would have had to be treated by physicians for their mental
                           health care.”
                       •   PDP participants continued to practice as prescribing psychologists for the
                           rest of their military career.
                       •   Prescribing psychologists required supervision amounting to 5 percent of a
                           psychiatrist’s time for the rest of their military career.
                       •   PDP graduates posed no more of a malpractice risk to DOD than any other
                           mental health providers delivering the same treatment to the same types of
                           patients.
                       •   PDP graduates did not receive special pay otherwise paid to psychiatrists
                           and other physicians in the military.
                       •   Pension rates were based on an average service time for military
                           pensioners of 22.5 years as determined by a DOD actuarial study.


                           The objectives of VRI’s feasibility analysis were to assess
Feasibility Analysis
                       •   the barriers to employing prescribing psychologists in the DOD health care
                           system and
                       •   how prescribing psychologists would be used in the DOD health care
                           system.

                           To address the first objective, VRI conducted two surveys. It conducted
                           telephone interviews of about 400 DOD health care providers, including



                           Page 26                                GAO/HEHS-97-83 Prescribing Psychologists in DOD
Appendix I
Scope and Methodology of an Evaluation of
the PDP by Vector Research, Inc.




psychiatrists, primary care physicians, psychologists, and social workers
to obtain their views on the PDP. This survey measured their awareness of
the PDP, attitudes toward allowing psychologists to prescribe drugs,
participant training, and ultimate ability of psychologists to prescribe
medication. VRI also surveyed DOD medical beneficiaries to determine their
awareness of the relative scope of practice of psychiatrists and
psychologists and the PDP and to measure their attitudes toward allowing
psychologists to prescribe drugs.

To address its second objective, VRI reviewed DOD medical regulations,
records of the PDP Advisory Council, and military health care utilization
data and interviewed PDP graduates and officials familiar with the PDP. VRI
acknowledged that its conclusions about the use of prescribing
psychologists were “conjectures” because of DOD’s lack of experience with
prescribing psychologists.




Page 27                                GAO/HEHS-97-83 Prescribing Psychologists in DOD
Appendix II

Objectives and Methodology of Our
Evaluation of the PDP

                  The objectives of our evaluation were to

              •   assess the need for prescribing psychologists in the Military Health
                  Services System (MHSS),
              •   provide information on the implementation of the PDP, and
              •   provide information on the PDP’s cost and benefits.

                  To address the first objective, we used the need for MHSS psychiatrists as a
                  proxy for the need for prescribing psychologists because psychiatrists are
                  the only mental health care providers with full prescribing authority for
                  which the military determines a readiness need. To assess the need for
                  additional MHSS psychiatrists, we reviewed the Army, Navy, and Air Force
                  methods for determining the number they need to fulfill their medical
                  readiness mission and the results of their determinations. We compared
                  the number of psychiatrists each branch of the service determined it
                  needed, both now and in the future, with the number each currently has.

                  To collect information on the PDP’s implementation, we reviewed many
                  documents, annual reports, and assessments of the project. These
                  included periodic evaluations conducted by the American College of
                  Neuropsychopharmacology under contract to DOD and others done by the
                  Army Surgeon General’s blue ribbon panels as well as the Army’s annual
                  reports on the PDP.

                  We based our estimate of the PDP’s cost on (1) information on cost in the
                  Army’s annual reports on the PDP, (2) our estimates of the cost of training
                  provided by the Uniformed Services University of the Health Sciences
                  (USUHS),24 and (3) estimates of military salaries and benefits and the
                  productivity of PDP participants and their supervisors found in Vector
                  Research, Inc.’s (VRI) cost-effectiveness analysis of the PDP. This cost was
                  calculated in constant 1996 dollars.

                  To identify the qualitative benefits of the PDP, we interviewed all PDP
                  participants who completed the PDP and others at the facilities where they
                  were practicing and representatives of the American Psychiatric
                  Association and the American Psychological Association. We reviewed
                  articles that addressed the advantages and disadvantages of allowing
                  clinical psychologists to prescribe medication. We also examined the
                  results of a VRI survey of DOD health care providers that collected
                  information on providers’ perceptions of PDP’s benefits.

                  24
                     Military Physicians: DOD’s Medical School and Scholarship Program (GAO/HEHS-95-244, Sept. 29,
                  1995).



                  Page 28                                     GAO/HEHS-97-83 Prescribing Psychologists in DOD
           Appendix II
           Objectives and Methodology of Our
           Evaluation of the PDP




           To determine what cost savings or quantitative benefit, if any, might be
           realized by enabling clinical psychologists to prescribe medication, we
           reviewed VRI’s cost-effectiveness analysis of the program done under
           contract to DOD.25 We compared the results of this analysis with those of a
           subsequent analysis VRI did at our request using different assumptions. In
           this subsequent analysis, VRI replaced its original assumptions on the
           number of participants and level of supervision with information we had
           collected about actual program experience. It also replaced its USUHS
           training cost estimates with our estimates noted above.




           25
             See app. I for a description of VRI’s survey and cost-effectiveness analysis.



(101494)   Page 29                                         GAO/HEHS-97-83 Prescribing Psychologists in DOD
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