Advanced Practice Providers Extend Patient Access to Mental Healthcare

Two studies published in the September 2022 issue of Health Affairs give credence to the expanded scope of practice for advanced practice providers, like nurse practitioners and physician assistants, asserting NPs and PAs help extend patient access to mental and behavioral healthcare.

Particularly, the studies, which were sent to journalists, indicated that APPs can help expand patient access to care in mental and behavioral health, an area in which care access is stymied by provider shortages.

The first study, completed by researchers from Harvard University and the University of Pittsburgh, indicated that psychiatric mental health nurse practitioners (PMHNPs) filled the growing gap in psychiatrists.

Using Medicare fee-for-service claims data, the researchers found an overall 6 percent drop in the number of psychiatrists delivering mental healthcare between 2011 and 2019.

That decrease in practicing psychiatrists coincided with an 11.5 percent decrease in the number of mental healthcare visits per 100 beneficiaries, regardless of practitioner type. In 2011, there were 27.4 mental health visits per 100 beneficiaries every year, but by 2019 there were only 24.2 visits.

The researchers indicated that the drop in mental health visits was driven by a decrease in visits with psychiatrists, specifically. Between 2011 and 2019, the number of visits to psychiatrists per 100 beneficiaries decreased 29 percent, from 24 visits to 17.

It was the growth in PMHNPs that kept patient access to mental healthcare from being as bad as it could have been, the data demonstrated. During the study period, the number of PMHNPs treating Medicare beneficiaries grew by 162 percent.

Overall, the number of PMHNP visits per 100 beneficiaries grew 111.3 percent from 3.4 to 7.2 visits annually. The growth of PMHNPs and the patients who visited with them offset the decrease in psychiatrist visits.

These findings indicate that advanced practice providers, like PMHNPs, are effective in closing the gap created by a physician shortage, the researchers said. However, they acknowledged that establishing full practice authority for PMHNPs is a fraught argument.

“A frequent question raised in any study of physician and NP practice is the quality of care and clinical scope that each type of professional can provide for a given population,” they pointed out. “To our knowledge, there is no evidence directly comparing the quality of care of PMHNPs versus psychiatrists.”

“However, this is still a polarizing topic where NPs and physicians have diverging viewpoints, particularly when it comes to scope-of-practice policies,” the researchers added. “Further research is needed to examine any differences in quality of care or health outcomes for the treatment provided by PMHNPs versus other clinicians.”

A second study also published in the latest issue of Health Affairs found that advanced practice providers could help fill in gaps in medication-assisted treatment (MAT) for opioid use disorder.

Ample evidence has emerged indicating stark gaps in MAT care. Due in large part to a dwindling workforce licensed to administer MAT, and authorized providers not taking on a full patient panel, many who need buprenorphine as part of MAT are going without.

This latest study from the University of California San Francisco revealed that advanced practice nurses (APNs) and physician assistants (PAs) with a so-called X-waiver—the authorization to administer buprenorphine or methadone as a part of MAT—were helpful in filling those care gaps.

The researchers obtained Drug Enforcement Agency data about clinicians registered with an X-waiver between the second quarter of 2018 and the first quarter of 2021. The team also assessed how many patients clinicians were authorized to see per their registration—30, 100, or 275.

During the study period, the number of all clinicians with registered with waivers increased, indicating a growth in the number of providers able to treat patients needing MAT.

That growth in available providers was also driven greatly by the number of clinicians shifting their authorizations from 30-patient panels to 100-patient panels. Particularly, advanced practice nurses and PAs drove the shift from small- to medium-sized panels, the data showed.

“APNs accounted for the largest contribution to treatment capacity growth during the pandemic. Multiple studies have found that the extension of waivers to APNs and PAs improved access to buprenorphine, particularly in rural communities,” the researchers said.

Moreover, APNs and PAs were more likely to actually prescribe buprenorphine or methadone as part of MAT compared to their physician counterparts and to treat folks on Medicaid.

Like the Harvard/U Pitt researchers, the UCSF authors pointed out the regulatory barriers keeping some states from leaning on advanced practice providers to expand access to MAT. Some scope of practice laws require physician oversight of APNs and PAs, which the UCSF researchers said could slow the pace at which these clinicians can treat patients and obtain authorizations to administer MAT.

As care gaps continue to loom, the UCSF researchers suggested a second look at health policy.

“It has been estimated that more than 2.2 million people needed opioid use disorder treatment in 2019, but only one in four received it,” they concluded. “Policy and practice leaders need to support growth in the buprenorphine-prescribing workforce and to facilitate clinicians prescribing to the maximum level allowed.”