A methodology for identifying behavioral health advanced practice registered nurses in administrative claims

Congress and many state legislatures are considering expanding access to telemedicine. To inform this debate, we analyzed Medicare fee-for-service claims for the period 2004-14 to understand trends in and recent use of telemedicine for mental health care, also known as telemental health. The study population consisted of rural beneficiaries with a diagnosis of any mental illness or serious mental illness. The number of telemental health visits grew on average 45.1 percent annually, and by 2014 there were 5.3 and 11.8 telemental health visits per 100 rural beneficiaries with any mental illness or serious mental illness, respectively. There was notable variation across states: In 2014 nine had more than twenty-five visits per 100 beneficiaries with serious mental illness, while four states and the District of Columbia had none. Compared to other beneficiaries with mental illness, beneficiaries who received a telemental health visit were more likely to be younger than sixty-five, be eligible for Medicare because of disability, and live in a relatively poor community. States with a telemedicine parity law and a pro-telemental health regulatory environment had significantly higher rates of telemental health use than those that did not.

Only a small proportion of individuals with a substance use disorder (SUD) receive treatment. The shortage of SUD providers, particularly in rural areas, is an important driver of this treatment gap. Telemedicine could be a means of expanding access to SUD treatment. However, several key regulatory and reimbursement barriers to greater tele-SUD use exist, and both the Congress and the states are considering or have recently passed legislation to address these barriers. To inform these efforts, we describe how tele-SUD is currently being used. Using 2010–2017 claims data from a large commercial insurer, we identify characteristics of tele-SUD users and examine how tele-SUD is being used in conjunction with in-person SUD care. Despite a rapid increase in tele-SUD over the period, we find low use rates overall, particularly relative to the growth in tele-mental health. Tele-SUD is primarily being used as a complement to in-person care and is disproportionately used by those with relatively severe SUD. Given the severity of the opioid epidemic, the low-rates of tele-SUD use that we observe represent a missed opportunity. As availability of tele-SUD is expanded, it will be important to monitor closely which tele-SUD delivery models are being deployed and their impact on access and outcomes.

The use of nurse practitioners (NPs) in primary care is one way to address growing patient demand and improve care delivery. However, little is known about trends in NP presence in primary care practices, or about how state policies such as scope-of-practice laws and expansion of eligibility for Medicaid may encourage or inhibit the use of NPs. We found increasing NP presence in both rural and nonrural primary care practices in the period 2008–16. At the end of the period, NPs constituted 25.2 percent of providers in rural and 23.0 percent in nonrural practices, compared to 17.6 percent and 15.9 percent, respectively, in 2008. States with full scope-of-practice laws had the highest NP presence, but the fastest growth occurred in states with reduced and restricted scopes of practice. State Medicaid expansion status was not associated with greater NP presence. Overall, primary care practices are embracing interdisciplinary provider configurations, and including NPs as providers can strengthen health care delivery.