Defense Health Care: Need for More Prescribing Psychologists Is Not
Adequately Justified (Letter Report, 04/01/97, GAO/HEHS-97-83).

The Military Health Services System (MHSS) has more psychiatrists than
it needs. As a result, GAO questions the military's plan to train
psychologists to prescribe drugs for mental conditions, such as
depression. MHSS needs no prescribing psychologists or any other
additional mental health care providers authorized to prescribe
psychotropic medications. Although the Defense Department (DOD) met its
goal of training psychologists to prescribe drugs, it faced many
difficulties in implementing the Psychopharmacology Demonstration
Project. MHSS never had a clear vision of the prescribing psychologists'
role, did not meet recruitment goals, and repeatedly changed the
curriculum. The program's total cost is about $6.1 million, or $610,000
per prescribing psychologist. GAO cannot conclude that the benefits
gained from training prescribing psychologists warrant the cost of the
program. Training psychologists to prescribe drugs is not justified
because MHSS has no demonstrated need for them, the cost is substantial,
and the benefits unclear.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-97-83
     TITLE:  Defense Health Care: Need for More Prescribing 
             Psychologists Is Not Adequately Justified
      DATE:  04/01/97
   SUBJECT:  Health care personnel
             Drugs
             Human resources utilization
             Health services administration
             Human resources training
             Medical education
             Mental health care services
             Cost effectiveness analysis
             Military personnel
IDENTIFIER:  DOD Military Health Services System
             DOD Psychopharmacology Demonstration Project
             
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Cover
================================================================ COVER


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

Prescribing Psychologists in DOD

(101494)


Abbreviations
=============================================================== ABBREV

  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. 

Letter
=============================================================== LETTER


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 medication\1

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. 

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


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

\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. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

The MHSS has more psychiatrists than it needs to meet its current and
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. 

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. 


   BACKGROUND
------------------------------------------------------------ Letter :2

The main mission of the MHSS, which spends more than $15 billion a
year, 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 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 conditions\5 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
schizophrenia\6 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 psychosocial\8 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. 

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 panel\9 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
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 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. 


--------------------
\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). 

\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. 

\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. 


   NUMBER OF MENTAL HEALTH CARE
   PROVIDERS IS ADEQUATE FOR
   READINESS REQUIREMENTS
------------------------------------------------------------ Letter :3

None of the services needs additional mental health providers capable
of prescribing medication to meet either current or upcoming medical
readiness requirements, according to our review of DOD's health care
needs.  Each service has more than enough psychiatrists, as well as
clinical psychologists, to care for its anticipated wartime
psychiatric caseload.  Given this surplus, spending resources to
provide psychologists with 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 for prescribing psychologists.  Table 1 shows
the number of MHSS psychiatrists each service has determined it
needs\11 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 Readiness
                              Requirements

                                                          FY      FY
                           FY 1995         FY 1996       1997    1998
                        --------------  --------------  ------  ------
                                Assign          Assign
Service                 Needed      ed  Needed      ed  Needed  Needed
----------------------  ------  ------  ------  ------  ------  ------
Air Force                   \a     129      \a     115      \a     107
Army                       205     226     205     219     198     228
Navy                       105     166     107     144     107     107
======================================================================
Total                       \a     521      \a     478      \a     442
----------------------------------------------------------------------
\a Number is not available. 



                                Table 2
                
                Psychologists by Service: Number Needed
                     and Assigned to Meet Readiness
                              Requirements

                                                          FY      FY
                           FY 1995         FY 1996       1997    1998
                        --------------  --------------  ------  ------
                                Assign          Assign
Service                 Needed      ed  Needed      ed  Needed  Needed
----------------------  ------  ------  ------  ------  ------  ------
Air Force                   \a     156      \a     165      \a     207
Army                       118     130     118     113     103      98
Navy                       135     157      92     117      92      92
======================================================================
Total                       \a     443      \a     395      \a     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 consultants\13 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 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. 


--------------------
\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. 

\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. 


   PDP'S IMPLEMENTATION FACED
   DIFFICULTIES
------------------------------------------------------------ Letter :4

Although DOD met the mandate to establish a demonstration project to
train military psychologists to prescribe psychotropic medication for
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'
      ROLE IN THE MHSS NOT CLEARLY
      DEFINED
---------------------------------------------------------- Letter :4.1

The PDP did not clearly define the role of prescribing psychologists
in the MHSS.  The ACNP's PDP evaluation panel noted in 1992 that the
project's goal "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 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 PARTICIPANTS
      WAS DIFFICULT
---------------------------------------------------------- Letter :4.2

DOD had difficulty recruiting PDP participants throughout the
project.  The 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

                                                        Gradua
                                                           ted  Curren
                                        Entere    Left    from  tly in
                                         d the     the     the     the
Year                                       PDP     PDP     PDP     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 CRITERIA
      WERE NOT SPECIFIED
---------------------------------------------------------- Letter :4.3

The MHSS established no formal candidate selection criteria for the
PDP.  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. 


      CURRICULUM REPEATEDLY
      CHANGED
---------------------------------------------------------- Letter :4.4

The duration, content, and sequencing of PDP training continued to
change 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
      PDP GRADUATES WERE DELAYED
---------------------------------------------------------- Letter :4.5

The first psychologists who completed the PDP faced delays of up to
14 months in getting prescribing privileges at the facilities where
they were 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
      PSYCHOLOGISTS UNRESOLVED
---------------------------------------------------------- Letter :4.6

The MHSS has not decided who should supervise prescribing
psychologists.  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 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. 


   PDP WAS COSTLY AND ITS BENEFITS
   ARE UNCERTAIN
------------------------------------------------------------ Letter :5

Even if the MHSS had a need for additional mental health care
providers to prescribe medication, the cost of meeting this need by
training clinical psychologists to prescribe drugs is substantial. 
Furthermore, although the 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
---------------------------------------------------------- Letter :5.1

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, FY 1991-98

                                                                Total
             Type of cost                 Training component    costs
--------------------------------------  ----------------------  ------
                                        Classr  Clinic  Procto
                                           oom      al     red
                                          year    year    year
--------------------------------------  ------  ------  ------  ------
PDP training expenses                   $1,650       0       0  $1,650
                                          ,420                    ,420
Student salary plus benefits (minus     844,06  333,15       0  1,177,
 productivity benefit)                       5       4             219
Supervisor lost productivity                 0  475,81  206,87  682,68
                                                     0       4       4
PDP training overhead cost                  \a      \a      \a  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. 

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 psychologist.\17 On the basis of these
assumptions, the total cost of lost faculty productivity due to
training the 10 graduates for 11.5 years\18 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. 


--------------------
\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. 

\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. 


      PERCEPTIONS OF PDP AND ITS
      BENEFITS DIFFER
---------------------------------------------------------- Letter :5.2

The PDP increased the number of MHSS mental health care providers who
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. 

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. 


      COST-EFFECTIVENESS OF PDP
      UNDETERMINED
---------------------------------------------------------- Letter :5.3

The cost-effectiveness of having MHSS psychologists prescribe
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. 



                                         Table 5
                         
                         Annual Life Cycle Costs of Selected MHSS
                         Providers Based on VRI's Cost Estimates

                    Yearly life cycle cost per full-time equivalent
                  ---------------------------------------------------
                                                                                 Required
Provider group    Accession  Training     Force  Retirement     Total         utilization
----------------  ---------  --------  --------  ----------  --------  ------------------
Psychiatrists       $23,470   $13,864  $112,697     $19,142  $169,173                  \a
Psychologists         1,134     3,766    66,155      15,849    86,905                  \a
Psychologists/       10,901     8,182    86,506      17,289   122,878                  \a
 psychiatrists
 (base case
 scenario)
Prescribing           1,218    29,296    71,979      17,735   120,227               92.6%
 psychologists
 (start-up case
 scenario)
Prescribing           1,218    17,197    71,979      17,735   108,128               59.0%
 psychologists
 (optimal case
 scenario)
-----------------------------------------------------------------------------------------
Note:  Estimates are expressed in 1996 dollars. 

\a Not applicable. 

Source:  VRI data. 

VRI estimated 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 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
                  ---------------------------------------------------
                                                                                 Required
Provider group    Accession  Training     Force  Retirement     Total         utilization
----------------  ---------  --------  --------  ----------  --------  ------------------
Psychiatrists       $23,470   $13,864  $112,697     $19,142  $169,173                  \a
Psychologists         1,134     3,766    66,155      15,849    86,905                  \a
Psychologists/       10,901     8,182    86,506      17,289   122,878                  \a
 psychiatrists
 (base case
 scenario)
Prescribing           1,218    32,611    71,979      17,735   123,542             101.85%
 psychologists
 (start-up case
 scenario)
Prescribing           1,218    26,196    71,979      17,735   117,127              84.01%
 psychologists
 (optimal case
 scenario)
-----------------------------------------------------------------------------------------
Note:  Estimates are expressed in 1996 dollars. 

\a Not applicable. 

Source:  VRI data. 

On the basis of our overhead and training cost estimates, PDP
graduates under the start-up scenario\23 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. 


--------------------
\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. 

\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. 


   CONCLUSIONS
------------------------------------------------------------ Letter :6

In DOD's mental health care system, the main function of prescribing
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 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. 


   RECOMMENDATION TO THE CONGRESS
------------------------------------------------------------ Letter :7

In the future, should prescribing psychologists be needed to meet
DOD's medical readiness requirements, the Congress should require DOD
to (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. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :8

In comments received March 26, 1997, in response to a draft of this
report, 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. 


---------------------------------------------------------- Letter :8.1

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; William Stanco, Senior
Evaluator; and Deena El-Attar and Gregory Whitney, Evaluators. 

Richard L.  Hembra
Assistant Comptroller General


SCOPE AND METHODOLOGY OF AN
EVALUATION OF THE PDP BY VECTOR
RESEARCH, INC. 
=========================================================== Appendix I

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. 


   COST-EFFECTIVENESS ANALYSIS
--------------------------------------------------------- Appendix I:1

To determine the relative cost-effectiveness of training and
employing prescribing psychologists relative to other DOD health care
providers, VRI 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, 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
      COST-EFFECTIVENESS ANALYSIS
------------------------------------------------------- Appendix I:1.1

The following are the main steps in VRI's 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 COSTS
------------------------------------------------------- Appendix I:1.2

VRI's estimates of the annual life cycle cost per FTE of various
types of 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 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. 


   FEASIBILITY ANALYSIS
--------------------------------------------------------- Appendix I:2

The objectives of VRI's feasibility analysis were to assess

  -- 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 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. 


OBJECTIVES AND METHODOLOGY OF OUR
EVALUATION OF THE PDP
========================================================== Appendix II

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. 

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. 


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

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


*** End of document. ***