The Effects Of The Comprehensive Addiction And Recovery Act Of 2016 On Nurse Practitioner And Physician Assistant Buprenorphine Prescribing In Medicaid

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In America’s urgent opioid crisis, too few people are receiving treatment. While opioid use disorder (OUD) medications are effective and save lives, access to these medications is limited and inequitable. Barriers to broader treatment access range from stigma to regulatory restrictions. One major barrier is the limited number of health care providers who are trained, authorized, and willing to prescribe buprenorphine—a drug shown to be effective in treating OUD by blocking the euphoric effects of opioids, reducing cravings, and helping to sustain recovery. Only a small fraction of health care providers write buprenorphine prescriptions for treating OUD, and many counties do not have an authorized provider. However, in an analysis by IMPAQ International funded by the Medicaid and CHIP Payment and Access Commission (MACPAC), we saw promising signs that efforts to increase prescriber availability are working.

A major driver of this positive development was the Comprehensive Addiction and Recovery Act of 2016 (CARA). Among its sweeping provisions, CARA sought to address the clinician gap by empowering eligible nurse practitioners (NPs) and physician assistants (PAs) to become qualified prescribers of buprenorphine to treat OUD.

We explored prescribing trends after CARA became law by analyzing retail pharmacy claims data from July 2017 to June 2018. We found that the number of buprenorphine prescribers increased by 12 percent during this one-year period. NPs and PAs made up nearly one-fifth of all buprenorphine prescribers, and NP and PA prescribing increased rapidly over the study period. During the year, the number of patients receiving buprenorphine prescriptions for OUD increased 6 percent. Medicaid beneficiaries exhibited the highest treatment increases. About 40 percent of patients with buprenorphine prescriptions had at least one prescription paid by Medicaid, and 15 percent of Medicaid beneficiaries received buprenorphine prescriptions from NPs and PAs. Medicaid beneficiaries were also more likely to receive buprenorphine treatment from NPs and PAs than patients with other payment types.

Benefits Of Buprenorphine In Tackling OUD

Buprenorphine is one of three medications approved by the Food and Drug Administration (FDA) to treat OUD in combination with counseling and psychosocial support. An advantage of medication-assisted treatment (MAT) with buprenorphine is that it can take place in an office-based setting, rather than in an opioid treatment program or supervised facility (as required for alternative OUD treatments such as methadone). Therefore, expanding access to buprenorphine-based treatment is a crucial way to provide more options for OUD treatment. This is especially critical for the Medicaid population because these individuals have a higher rate of OUD than privately insured individuals, yet often have fewer treatment settings available to access care.

Legislation Aimed At Increasing The Number Of Clinicians Authorized To Treat OUD

To address the national crisis of opioid misuse and overdose fatalities, several federal and state policy efforts have sought to increase the number of health care providers who can provide OUD treatment, including MAT with buprenorphine. In 2016, CARA authorized qualified NPs and PAs to receive a Drug Addiction Treatment Act of 2000 (DATA) waiver from the Substance Abuse and Mental Health Services Administration. These waivers were previously restricted to physicians. Per CARA, NPs and PAs who completed the required training and application were authorized to prescribe buprenorphine for up to 30 patients concurrently in the first year, subject to applicable state laws. One year after the initial waiver approval, these providers could request an increase in prescribing limits, which would allow them to treat up to 100 patients. As illustrated in exhibit 1, NPs and PAs could begin waiver training and applications in November 2016. The first waivers for NPs and PAs were approved in February 2017.

Exhibit 1: Timeline of DATA waiver expansion to NPs and PAs

Source: Authors’ analysis.

Assessing The Effects of CARA 2016 On Buprenorphine Prescribing Patterns

While data are available on the number and geographic distribution of waivered NPs and PAs, we know little about the buprenorphine prescribing patterns of these newly waivered providers. We wondered about the amount of uptake of buprenorphine prescribing by NPs and PAs; how NP and PA prescribing trends compare with those of physicians; and how many patients were treated, and how many of them were Medicaid beneficiaries.

To study these effects, IMPAQ analyzed a year of data from the Symphony Health Integrated Dataverse (IDV^®), which included anonymized patients claims data from retail pharmacies covering July 2017–June 2018. IDV^® captures data on more than 90 percent of US retail pharmacy fills. We analyzed prescription patterns for those buprenorphine medications that are FDA-approved for treating OUD (as opposed to formulations approved for pain) and available in pharmacies.

It is worth noting that this study did not assess prescribing by certified nurse-midwives, clinical nurse specialists, and nurse anesthetists because the SUPPORT for Patients and Communities Act passed after our analysis, which gave these specialists the ability to prescribe. We also did not analyze buprenorphine treatment administered directly in emergency departments or other health care facilities.

Are NPs And PAs With New Authorization To Prescribe Buprenorphine Prescribing It?

Our study showed that NPs and PAs increasingly prescribed buprenorphine each quarter during the study period. Of the 37,380 practitioners who prescribed buprenorphine between July 2017 and June 2018, 13 percent were NPs (4,828) and 6 percent were PAs (2,099). Exhibit 2 shows the increase in the percentage of all buprenorphine prescribers who were NPs and PAs. Just four months after NPs and PAs began prescribing buprenorphine, there were 1,889 NPs and 909 PAs prescribing. By the end of our one-year study period, the number of NPs increased by almost 80 percent to 3,377, and the number of PAs increased by almost 50 percent to 1,353. By comparison, the number of physician prescribers started higher but grew more modestly, from 20,812 to 21,754 (4.5 percent).

Exhibit 2: Proportion of NPs and PAs among all practitioners prescribing buprenorphine

Source: Authors’ analysis.

Are More Patients Gaining Access To Buprenorphine Treatment?

In the year we studied, we found more than 10 million pharmacy claims for buprenorphine associated with more than 900,000 patients. Around 600,000 patients received treatment each quarter, increasing 6 percent over the year.

Most patients (97 percent) received at least one buprenorphine prescription from a physician. Twelve percent of the patients received at least one buprenorphine prescription from an NP or PA, either instead of or in addition to prescriptions from physicians. Interestingly, 74 percent of patients who received a buprenorphine prescription from an NP or PA also received a prescription from a physician.

The number of patients receiving buprenorphine prescriptions from NPs increased sharply from 17,821 in the third quarter of 2017 to 50,317 in the second quarter of 2018, a 182 percent increase. There was also a substantial increase in the number of patients receiving buprenorphine prescriptions from PAs—a 242 percent increase from 8,559 to 20,734. In contrast, the number of patients receiving buprenorphine prescriptions from physicians over this period increased by only 2 percent.

Medicaid Beneficiaries More Likely To Receive Treatment From NPs And PAs

With state Medicaid programs covering a variety of OUD treatment services including inpatient and outpatient treatment, prescription drugs, and rehabilitation services, Medicaid is playing a pivotal role in addressing the opioid crisis. About 60 percent of practitioners who prescribed buprenorphine during the year prescribed to Medicaid beneficiaries. As noted above, about 40 percent of patients in our study had at least one buprenorphine prescription fill paid by Medicaid. Their number increased by 12 percent over the year, which is twice as much as the increase for patients with other payer types. This increase suggests that previously reported rapid growth in OUD treatment for Medicaid beneficiaries continues.

The number of Medicaid beneficiaries receiving buprenorphine prescriptions rose for all prescriber types over the year; however, the increase was particularly pronounced among advanced practitioners. For example, the proportion of NPs among practitioners prescribing buprenorphine to Medicaid beneficiaries nearly doubled during the study period, from 7.2 percent to 13.6 percent. As a result, 15 percent of Medicaid beneficiaries received buprenorphine treatment from an NP or PA at some point during the study period, which is higher than the proportion for all patients (12 percent).

Regression analysis adjusting for patients’ sex, age, state, and prescriber’s rural or urban location confirmed that Medicaid beneficiaries were more likely to receive buprenorphine prescriptions from an NP or PA than patients covered by Medicare or commercial insurance, or those who paid in cash. In rural areas, the proportion of Medicaid beneficiaries receiving prescriptions from NPs and PAs was only slightly higher at 16 percent (defined as non-metropolitan counties) compared to urban areas at 15 percent.

Prescribing Patterns And State Policies

In addition to federal efforts to promote OUD treatment, states are using a range of financing and workforce policies to expand access to MAT. Our study considered one major area of state policy variation—NP prescriptive authority for buprenorphine. Some states allow NPs to prescribe buprenorphine for OUD independently, while others require physician oversight, at least for a certain period. In our study, states with full independent NP prescriptive authority had a higher proportion of NP and PA prescribers than states with limited NP prescriptive authority (25 percent versus 16 percent). In interpreting this finding, we caution that states are enacting multiple policies to address the opioid epidemic, and our study did not assess the interrelationship between NP prescriptive authority and other policies.

Moving Forward

Our study shows promising increases in the number of patients receiving buprenorphine-based treatment, especially for Medicaid beneficiaries. Buprenorphine prescribing activity from NPs and PAs has increased rapidly since CARA became law. We expect that these increases will continue in light of the SUPPORT Act provisions that extend waiver eligibility to additional practitioner types and increase the waiver limit for certain qualified practitioners in the first year. However, granting authority to prescribe buprenorphine, regardless of clinician specialty, is only one of many efforts to ensure access to treatment. Many previous reports noted that providers may not become waivered or do not begin prescribing even if they are waivered because of perceived burdens of waiver requirements, lack of patient demand, and challenges with institutional support and reimbursement. Tackling these challenges requires continued efforts to address stigma and conceive new delivery approaches to help people with OUD access care.

Authors’ Note

The research underlying this blog post was completed with support from MACPAC. The findings, statements, and views expressed are those of the authors and do not necessarily represent those of MACPAC. We would like to thank Ilene Harris, Karishma Desai, Thiyagu Rajakannan, Erin McMullen, Kate Kirchgraber, and Nevena Minor for their work on this research.