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Health Affairs Editor-in-Chief Alan Weil interviews Michael Barnett from Harvard University’s T.H. Chan School of Public Health to discuss Michael and coauthors recent research on assessing trends in the supply of mental health care practitioners, including psychiatrists and nurse practitioners serving Medicare enrollees.
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FULL TRANSCRIPT
Alan Weil
Hello and welcome to A Health Podyssey. I’m your host, Alan Weil. The United States is in the midst of a mental health crisis. Almost a quarter of adults with a mental illness report that their mental health needs are not being met. Now, one factor in the crisis is the limited health professions workforce available to treat mental health conditions.
Is there a growing group of mental health professionals who can help meet the need for mental health services? That’s the topic of today’s episode of A Health Podyssey. I’m here with Michael Barnett, Associate Professor in the Department of Health Policy and Management at Harvard University’s T.H. Chan School of Public Health. Dr. Barnett and coauthors published a paper in the September 2022 issue of Health Affairs, assessing trends in the supply of mental health care practitioners, including psychiatrists and nurse practitioners serving Medicare enrollees.
They found that between 2011 and 2019, the number of psychiatrists serving the Medicare population decreased. But the number of nurse practitioners increased. In today’s episode, we’ll talk about these findings and whether psychiatric mental health nurse practitioners can help fill the gap in health professions capacity in the United States. Dr. Barnett, welcome to the program.
Michael Barnett
Thank you for having me.
Alan Weil
I’m really looking forward to talking about this paper. This is such an important topic, and we know that we don’t have enough people trained to meet the needs of the mental health needs of the population. So you’re really much more knowledgeable in this area than I am. Can you just give me the, sort of, overall landscape? What do we know about the need for mental health services in the United States and whether or not we’re able to meet those needs?
Michael Barnett
Yeah, this is obviously such an important issue. I imagine that almost anybody listening to this podcast has family members or themselves have experienced how hard it is to actually get access to mental health care and just how ubiquitous it is. One thing we know is that since 2020, since the pandemic started, the share of U.S. adults that have reported symptoms of anxiety or depression, depending on kind of when you look and what data you use, has probably at least doubled, maybe even tripled or more.
And that’s in the setting of a situation where before the pandemic, we had a big problem already that only a small fraction of people with mental illness who needed treatment actually received it or saw a health care professional. And even though we don’t specifically look at the issue of addiction in this particular paper, it’s even worse for that particular problem, which is also a growing public health need in the country and has been for many decades.
So the situation before the pandemic was really quite dire and then when we went into the pandemic, the demand for these services probably doubled, at least, with no change in supply. If anything, actually a decrease in the supply of mental health professionals who are in the workforce and available to treat.
Alan Weil
There are a lot of different kinds of professionals who can treat different aspects of mental illness and mental distress. I’m sure we can’t get into all of it here, but can you just give me a sort of a thumbnail, who does what? What kinds of professionals are capable of providing, what sorts of services?
Michael Barnett
Yeah, so like in every realm of health care, there are many, many different professionals. It’s definitely much more than, say, physicians and nurses. In mental health, as a primary care doctor myself, I’d be remiss to not-if I didn’t point out-that actually primary care providers are the most common professional treating mental health conditions, certainly with prescriptions in the U.S.
However, of course, primary care doctors are not solely treating mental health conditions and have quite a bit on their plates otherwise. And they’re not mental health specialists, even though many of them are very well equipped to treat common, you know, mild to moderate symptoms of common health, mental health issues. But when you need specialty care, we can generally divide the group into prescribers and non-prescribers and we focus on prescribers in this paper and that’s basically-two and-I’ll say two and a half professionals.
There’s of course psychiatrists who are doctors who specialize in mental health. And this paper we look at this emerging professional category who call themselves psychiatric mental health nurse practitioners and they are nurse practitioners who really function as psychiatrists in their professional care. The same way nurse practitioners, who are primary care clinicians, will function as primary care, counterpart primary care physicians.
In a few states, five states, actually, psychologists can in fact prescribe, but actually they’re not doing that much prescribing right now. We don’t know a ton about exactly what they do, but it just shows you actually how dire the mental health shortage is that in several states they’ve actually empowered this entirely different group to prescribe. And then in the non-prescribers we have of course psychologists I mentioned and social workers as well as mental health counselors. And they provide therapy, talk therapy and lots of other different kinds of therapy like cognitive behavioral therapy or CBT.
Alan Weil
Well, let’s jump into what you found, because it’s pretty striking, given the shortage we have of personnel. Tell us the overall findings with respect to prescribers and the trends in who’s treating Medicare enrollees.
Michael Barnett
I was very surprised by our findings too. I knew to expect that, you know, in almost every one of these workforce papers will be look at nurse practitioners or physician assistants. We know that this is an exploding workforce that’s grown enormously in the past two decades. And what I was surprised by for this group, which we call PMHNPs is that their number grew, more than doubled, grew by 162%. Where during the same period, and this is the part which has been reported in other literature, but it was particularly disheartening in the context of looking at Medicare. That there was actually a 6% decrease in the number of psychiatrists who were treatingany Medicare patients. And then also, just in terms of the volume of work that they were doing, there was actually a nearly one third drop in just the volume of psychiatrist visits. That were happening over this period with Medicare BENES. And this is before the pandemic. So we know that actually this even further undermines the mismatch between supply and demand among anyone in Medicare after the pandemic.
Luckily, because the psychiatry NP workforce doubled during this period, they actually offset that decrease in visits so that it wasn’t quite as bad. So that the total number of visits available that happens with a mental health prescriber dropped by about 10%. But still, that’s a drop in a set of care that we know is in great demand and was, if anything, increasing pre-pandemic and now it exploded since 2020.
Alan Weil
So you have this growing health profession workforce in a subset of the workforce that’s growing. You looked at who they’re treating and what sorts of care they’re providing. Can you tell me like who? Is it your average Medicare enrollee who’s treated by PMHNP?
Michael Barnett
As far as we can tell, the types of patients that were treated by NP mental health specialists were pretty similar to the ones treated by psychiatrists. This is you know, it’s a perennial question in health services research, kind of comparing the nature of practice of NP’s to psychiatrists, because there’s always concerns about, you know, whose turf is what. And you know, are nurse practitioners, psychiatrists or nurse practitioners and physicians providing equivalent care or how can we compare them?
We found that psychiatrists were more likely to treat patients with more mental health conditions, so more complex than nurse practitioners. And also they were much more likely to be located in urban areas, which is consistent with what we know about physicians really are, if anything, kind of getting depleted out of rural areas. And that gap is being filled by non physicians like nurse practitioners, MPA’s, or physician assistants.
Alan Weil
I want to talk some more about these urban rural differences and get into some of the policy factors associated with practice. We’ll cover those topics after we take a short break. And we’re back. I’m speaking with Dr. Michael Barnett about trends in mental health care delivery in Medicare between 2011 and 2019. Before the break, we were talking about the growing role of this group that he refers to as psychiatric mental health nurse practitioners.
Before the break, you noted the urban rural split in the practice for psychiatrists. What are you seeing in terms of the urban rural split for these nurse practitioners?
Michael Barnett
The differences between psychiatrists and nurse practitioners taking care of mental health in the rural and urban areas in the U.S. is quite dramatic. What we found is that there are about half as many psychiatrists per 100,000 enrollees in Medicare in rural areas as there were in urban areas. While on the other hand, there are actually about equal numbers of mental health nurse practitioners in rural and urban areas, which means that there are proportionally way more nurse practitioners actually over time than there are psychiatrists.
And actually what we find is that by 2019, there are basically as many nurse practitioners, per 100,000 people. Particularly in states that have full scope of practice for nurse practitioners, as there are psychiatrists. So there are parts of the country where if you want to see a mental health prescriber, you’re more likely to be able to find a nurse practitioner than a psychiatrist.
Alan Weil
That’s a pretty dramatic finding. And you just referenced scope of practice as the topic of long standing interest in health care. As a policy journal, this is one of the few levers that people actually can pull around workforce. Maybe if could you say a little more about the, first of all, what role that plays and how scope of practice might relate to the availability of services for people? Particularly in areas that might have a harder time attracting a psychiatrist.
Michael Barnett
I agree, Alan. That scope of practice has been a major controversy for quite a while now and actually shows no signs of slowing down. What we mean by scope of practice is really the extent to which non-physician prescribers like nurse practitioners or physician assistants. So in this case, really what we’re talking about is nurse practitioners. The extent to which they’re able to have completely independent practice without any supervision or other layers of approval necessary for them to physically put up a shingle and just operate their own office the same way a physician with the same level of the same type of specialty would practice.
And there are quite a number of varied regulations across the country that put various limitations on whether nurse practitioners need to be supervised by a physician or put in a certain number of hours of supervised work before they’re able to practice independently. And we don’t need to get into all of that. But what we did do in this particular paper is we looked at states where basically there are no restrictions on entities being able to prescribe and just practice on their own. Versus states where there are some level of restrictions such that they can’t really just go into that state, move there and just open up their own shop.
It’s been a fairly consistent finding that in states with full scope of practice, there are more nurse practitioners and they practice more independently, not surprisingly. We find a parallel of that in our particular study and we think it’s particularly notable because of just how profound this mental health supply demand gap is and the fact that this is one of the few situations where we find that actually in this specialty care environments, right?
This is specialty care, that we have more NP’s in a lot of areas in the country than psychiatrists. And to my knowledge, this is really the first situation where we’ve seen an example of this kind of shift in the workforce.
Alan Weil
You know, your study focused on Medicare data. I do just wonder if I could ask you whether you think these findings generalize to the broader population or how both the demand side and the supply side might differ for people who aren’t on Medicare relative to the folks you were focused on.
Michael Barnett
My guess is that the findings we have here would be broadly similar, actually, in other insured populations. The exception, of course, is I think, among those with private insurance, which of course, is going to be the most generous. My guess is that this disparity between psychiatrist and nurse practitioners might not be quite as stark, that they might be more, that there are many more psychiatrists who are accepting private insurance and continuing to do so.
But I think the gap is so profound that, you know, there’s also many access problems among those with private insurance because many people have limited networks. And there are also quite a few psychiatrist who only take cash and don’t accept any kind of insurance, actually. So I don’t think this would be the case in every specialty across every geography, but I think we are likely to see the same pattern when people look at this pattern and other data sets, which I’m sure will be happening in the next year or two.
Alan Weil
Other than scope of practice, which we’ve already talked about. Are there other policy implication out of this work or your broader research in this area that might be of interest?
Michael Barnett
I think there are a couple of policy areas that this can also inform. So one policy area also concerns telemedicine. And we know from my prior work and the work of others that mental health is, you know, the quote unquote sort of killer app in a way for telemedicine, because there’s no physical exam inherently necessary in the interaction between a mental health specialist and a patient.
And so quite a lot of mental health care pre- and post- pandemic is actually happening by telemedicine. And it also seems that nurse practitioners are particularly adept at adopting this new technology before the pandemic, as well as after the pandemic. So I do wonder in rural areas where actually, even if you have, say, more nurse practitioners than you do psychiatrists, there are many people who could still live quite a ways away from actually being in-person as the nurse practitioner that actually took that policy to facilitate telemedicine access might be even more effective in those areas and that nurse practitioners might be able to further extend their reach given their adoption of telemedicine.
We don’t know for sure yet, and that’s a question that our group is going to be actively looking into. But I think that this is, as we debate the future of telemedicine policy, after the public health emergency for COVID 19 evaporates and then the telemedicine policy landscape changes, this is one area to watch closely. Another policy implication, I think, is also one of the other levers we have in affecting the workforce is the extent to which we provide incentives for clinicians to relocate to rural areas or to provide subsidies for training and for training of nurses and other certificates after nurses graduate from their doctorates.
And I think that the trends that we observed imply that we might have more, we might get more bang for our buck. Investing in the psychiatric nurse practitioner workforce to encourage them to move to rural areas than psychiatrists who have been in a decades long exodus away from rural areas that have the largest mismatch between demand and supply.
Whereas NP’s are actually increasingly going to those areas, we may have leverage to further increase that. The growth in that workforce by targeting that particular provider population.
Alan Weil
Well, those all seem like areas ripe for additional work and policy activity. I am curious as we wrap up here, putting this in the broader context of the increasing role of physician assistants and nurse practitioners, is there just a sort of a sea change here in terms of who’s getting care and who’s providing care as we shift services away from physicians?
And this is just sort of one part of a much broader phenomenon. Or do you think the findings you have here are are quite specific to mental health?
Michael Barnett
I’d say that there certainly has been a sea change over the past 2 to 3 decades in the rise of non-physician providers like nurse practitioners and peers. I think one unique aspect of the mental health angle in our paper is that, is just kind of, how closely matched the supply and availability of NP’s are compared to psychiatrists in certain parts of the country.
And whereas, we still have a situation that even though nurse practitioner and PA’s, those workforces have grown enormously in other areas, they are still dwarfed by the size of the physician workforce. That’s providing, say, primary care across the country. But they’re very rapidly growing. And so I do think this is part of a sea change where given the, you know, the supply bereft status of mental health is particularly relevant there.
But part of the reason we’re seeing the scope of practice debates continuing to flare in interprofessional conflict between, for example, the AMA and nursing organizations is because I think the sea change is very threatening to the status quo of the current health care system, and it’s still uncertain, you know. What is optimal for public policy, for population health, for spending and for customer satisfaction, and on how people get health care.
But it is probably one of the largest changes I would say, in the health care system that is going to be evolving over the next decade.
Alan Weil
Well, that’s really fascinating. It’ll be interesting to see. I’ll be able to turn to you and colleagues for insights as those trends evolve. Dr. Barnett, thank you so much for the work, for explaining it, for helping us understand this important issue and today for being my guest on A Health Podyssey.
Michael Barnett
Thank you so much for having me, Alan. It was a pleasure.
DOI: 10.1377/hp20220912.248830
