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Availability of Behavioral Health Providers and Services in Rural Areas, with Holly Andrilla

Date: March 7, 2023
Duration: 27 minutes

Holly AndrillaAn interview with Holly Andrilla, Deputy Director of the WWAMI Rural Health Research Center. Andrilla provides us with an overview of several data briefs she recently published detailing rural availability of psychiatrists, psychologists, psychiatric nurse practitioners, social workers, and counselors, as well as recent developments in access to medication for opioid use disorder (MOUD).

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Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. This is an episode about distribution of rural behavioral health services.

Today I'm talking to Holly Andrilla, deputy director of the WWAMI Rural Health Research Center. Thank you for joining us, Holly.

Holly Andrilla: Thank you for having me.

Andrew Nelson: In general, rural areas consistently tend to suffer from greater disparities in healthcare availability than urban areas do. And this is certainly true for behavioral health services, the same as any other kind of care. Behavioral health caregivers can include psychiatrists, psychologists, psychiatric nurse practitioners, social workers, and counselors. And last fall, you published a series of data briefs focusing on changes in the distribution of each of these providers between 2014 and 2021. Can you tell us what some of the changes you found during that time that were either positive or negative in terms of rural access?

Holly Andrilla: I can talk about the supply of the providers, and there are other issues that play into access; for example, insurance status. But, in terms of the supply of the behavioral health workforce, it has had some positive things and some negative things. Professions that require more training have tended to not have as big of increases. So, for example, the supply of psychiatrists per 100,000 population. And we do that to standardize, so that somebody doesn't say, “Well, of course, urban places have more, they have more people.” So it's all population adjusted. The supply of psychiatrists has actually declined over time. It declined pretty substantially from 25 years ago, and it has not increased and decreased slightly over the last 10 years.

And rural areas have fewer psychiatrists than urban areas. And then if you look within rural areas, there's a lot of variation, as well. And so, the smaller the place, not surprisingly, the lower the number per population of psychiatrists. About 70% of rural counties don't have even a single psychiatrist, and that's compared to about 25% of urban counties. So there's lots of places where that service is just absolutely not available. Now, some of the other professions have seen increases. The supply of clinical psychologists has increased. We don't have data going back quite as far for psychologists as we did for psychiatrists, but it's increased since 2014 by about 25%. It's not exactly 25%. It's a little more in urban places and a little less in rural places, but comparable. And then again, not quite half of rural counties don't even have one clinical psychologist.

And so if you're a person that lives in those places, then your access to care is really limited. We've seen huge increases in the number of psychiatric nurse practitioners in both rural and urban places. It's more than doubled the supply in both. And that really is largely due to the explosion of the supply of nurse practitioners in general. We've seen lots of new nurse practitioner training programs, and we've seen nurse practitioners really step up and they have been a big care provider in rural areas. And they've been great in that way. Social workers have also increased in the last 10 years, but still, rural places only have about 60% the supply of urban places. So although it's increasing, it's increasing in urban too. And so the rural-urban disparity has persisted.

And then the within-rural disparity has persisted. And then the other thing that I think is really fascinating about not just the behavioral health workforce, but really about the health workforce in general, is the geographic variation that you see across the country. There are certain census divisions that just have a lot more providers, even in their rural areas. And so I would say the Northeast tends to be the best supplied. And then you see some of the census divisions in the South are typically, not absolutely for every type of provider, but they have a lower supply. They're more challenged, and their rural areas are especially more challenged.

And counselors have increased as well. I mean, psychiatric nurse practitioners have had the largest percentage increase, recently, but they were very rare to begin with. And so although there's been a big percentage increase, we can't solve the problem that way alone.

There's lots of different kinds of counselors that we looked at and counted. All of those were included in our counts of counselors. And we were consistent across time in terms of how we counted. So the differences that we saw weren't due to just different kinds of counselors being counted, if that makes sense.

Andrew Nelson: Sure. I got you. Of course, not all rural residents that take advantage of behavioral health services require treatment from all of the different types of providers you studied. Can you talk a little bit about the kinds of progression of treatment that you might see with patients in need of more advanced care, like, for example, starting with a counselor and then being referred to some other type of behavioral health provider, like a psychiatric nurse or a psychologist?

Holly Andrilla: Well, sort of, I can, and the reason I say that is we're looking at using the national provider database. So these are people that bill insurance, basically. So it's not a comprehensive list because not everybody that provides services bills themselves, for one. And it isn't claims data, although we have done some looking at claims data. In a rural place, nurse practitioners and family physicians provide a big amount of behavioral healthcare, because they're the people that exist here. You can't have a psychiatrist or a psychologist providing care if there aren't any there. But they may then refer a patient for treatment for more specialized treatment. And even that has been challenging because a lot of that specialized treatment doesn't exist in rural places.

Now, you've heard lots and lots of things about how the pandemic, how hard it's made things. But one thing that the pandemic did that I think is a positive is it caused the government to loosen up rules about telehealth. And so it allowed people to get more care via telehealth, and it's been quite successful. And I think some of those changes, we're going to see persist. They're not going to roll everything back, I don't think. And so when you allow a rural person to get care via telehealth, then of course that expands the number of provider types that are available to them and decreases their travel time and so on and so forth. So that might be a way that we see services expand for rural populations.

Andrew Nelson: Definitely. Obviously telehealth services becoming more accessible is great. It's allowed people a much greater degree of access to important services. Another group of providers that you studied were social workers. Can you talk a little bit about the range of services social workers can provide, and how getting help from them can be destigmatized?

Holly Andrilla: Well, I mean, a key service that they can provide is healthcare navigation and figuring out what services people need and how to connect them to that. And I think that's a really undervalued service. I think people don't fully realize how difficult it is for patients to figure out what is the next step. So I think that social workers do such a broad range of services, really, depending on the needs of the patient, but also the setting that they're working in. I mean, lots and lots of physician offices now include a social worker that helps patients navigate what's the next service that they need. Like I said, like a healthcare navigator. And then of course, there's people that are in challenge situations where social workers are brought in to try and connect them with services. So I think that everything that a social worker does is much broader than probably what most people envision and certainly probably more than I'm even aware of.

Andrew Nelson: According to the CDC, in 2020 more than 90,000 people died from a drug overdose. Most of those were the result of opioid use. You mentioned an important support mechanism for people working through substance dependency problems you actually don't have a lot of information about; specifically groups like AA and NA and so forth. Can you talk a little bit about why you actually don't have very much data about that form of support?

Holly Andrilla: Those communities are pretty amazing. And I really didn't know much about them until I got involved in this work. And now I've met lots of people that are in recovery that use either AA, which is the Alcoholics Anonymous groups, or NA, which is Narcotics Anonymous. My understanding is there are not as many NA groups as AA groups. AA groups are in every town, every city, you can go to an airport and there'll be a meeting, and they provide support for people in recovery. And they're absolutely fantastic. However, one of their tenets is that anonymous part, they provide support to people, and what they do is confidential and they will not identify themselves in any way with, for example, media in any way, as part of their commitment to people being able to get help anonymously. And so, although they are a key component, we just don't have a lot of data on them. I think a lot of treatment facilities connect patients — if you do an inpatient treatment course, which is very often 30 days, then those facilities connect people with the AA and NA meetings, for ongoing support as they're in their recovery. So they're just absolutely vital to providing recovery support for people.

Andrew Nelson: For sure. Last week when we were setting up this interview, we talked a little bit about buprenorphine, which is a medication that's been effective in treatment of opioid use disorder. But until very recently, it could only be prescribed with a waiver from the DEA. Can you tell us what that process was like, and how it's changed recently?

Holly Andrilla: Yeah. It's sometimes referred to as MAT, which is short for Medication Assisted Treatment, or sometimes it's referred to as MOUD, which is Medication for Opioid Use Disorder. That is now more common than MAT. But it is a medication that originally was authorized under the Drug Addiction Treatment Act of 2000, that allowed physicians, but only physicians, to prescribe buprenorphine for opioid use disorder after they had got a waiver from the Drug Enforcement Administration, the DEA, and they had completed eight hours of training. And just the fact that people had to complete another eight hours of training was a barrier. Of course, these are all trained physicians that can prescribe opiates, but they couldn't prescribe this medication.

And in 2016, the Comprehensive Addiction and Recovery Act passed. And in that legislation, there was a demonstration project to sort of say, “What if we expanded the ability to prescribe to nurse practitioners and physician assistants, because there's this big shortage, would that help?” And so they did that. And very quickly, that was determined to be very successful. And so that demonstration part of that project was taken away and it was made permanent, and NPs and PAs could then get a waiver to prescribe buprenorphine. And those were still subject to the rules of individual states, the scope of practice. So nurse practitioners in particular have different rules as to how they can practice, that are dependent on their state. And so you saw some variation there, whether they had to have a physician agree to supervise them or, different states have different rules.

But actually, for rural populations, nurse practitioners were a big help, a big boost, to the supply of providers — and physician assistants as well. And then there have been several other steps of legislation that have expanded the access to be able to prescribe a waiver further. In subsequent years, 2018 had the Support Act, and then just this year, about a month or two ago, the DEA waiver was abolished. And so now anybody that can prescribe Schedule III drugs can prescribe buprenorphine subject to, still, their state scope of practice laws. But the idea with this removal of, it's sometimes referred to as the X waiver, is to expand access. Now, what will be very interesting to see, and we will be tracking it, is how do the numbers of prescriptions written for these medications change? The DEA waivers that people had allowed people to treat 30 patients at a time with the initial waiver.

And then after you had done it successfully for a period of time, you could apply to treat a hundred patients at a time. And then if you met some certain criteria, you could expand that up to 275. Now, with the waiver being removed, I believe that there is still a limit to how many patients you can treat simultaneously, but I'm not expert on all those restrictions yet. But we will be looking to see, “Does this expand the number of prescriptions?” Because although when we were looking at the number of waivered providers, we were also looking at how many people were actually using it. Because what we found is that people would get a waiver, but then they would not use it, or they would use it for a very small number of patients. And so the treatment supply wasn't really what we thought it was. It was less than that. That was like the maximum potential we could calculate, but, but what was actually being prescribed was much less than that.

The most recent time that we actually looked at the supply of waiver providers, there were still more than half of small and remote rural counties that did not have a single waiver provider. It has definitely increased over time, and the largest increase has been nurse practitioners. They have answered the call there and really got wavered in, in large numbers.

Andrew Nelson: Until very recently, there were some areas where you just didn't have access to buprenorphine at all, and now any location that has access to an NP or a PA, they can get it, right?

Holly Andrilla: Or a physician? Well, so what I would say is you couldn't get it in your community. And so for example, we did a study and looked at how far people had to travel to get medication treatment and it might be an hour drive. When we talked to all these people that weren't prescribing, they weren't using their waiver, we asked them, “Why aren't you using this? What, what are the barriers for you?” And we had different people give us different reasons, and there was concerns about people misusing the drug or selling it because it has a street value. And there were concerns about people's clinics or offices becoming an attraction, a magnet for drug addicts, and they didn't want to have that. But we also talked to providers that were successfully using their waiver, and we said, “How did you overcome these common barriers?”

And they had a lot of tips and ideas for how people that wanted to prescribe this could do that, and they did phenomenal things. For example, there was a woman that lived and worked in Montana, and when she was going to be coming to town, she texted patients and literally saw them in the parking lot of Walmart, to save them what would otherwise be a two and a half hour drive to connect with her. So people were sort of solving or trying to help patients get this care in creative ways. But, yeah, you're right, there were places where people live where in their community, they couldn't get care, they couldn't get that prescription written. So they then are traveling long distances, which of course is expensive, both in terms of time and money, and it's hard enough to be in recovery without then having all these additional barriers. So we're hoping that the telehealth and we're hoping that the expanded number of providers will improve access to treatment for people.

Andrew Nelson: It seems like we've seen in the last few decades, especially, expanding the range of services that NPs and PAs are allowed to provide is especially beneficial to more rural areas.

Holly Andrilla: Yeah, that's true. And quite frankly, you don't need a physician for lots of things. Lots of care that physicians are providing can be provided by a nurse practitioner or a physician assistant. Certainly physicians have more training. There's no question about that. And there's certainly some things that you definitely want to see a physician for, but there is a big role for nurse practitioners and physician assistants, and I think in particular in rural places that don't have physicians, I think it's fantastic that these other clinicians are stepping up and helping fill that gap.

Andrew Nelson: So certainly with increasing the availability of buprenorphine, there's a lot of potential to help a lot of people. Are there any other avenues of treatment or support that you've seen that have proven to be especially effective, especially for rural folks?

Holly Andrilla: The issue that you have with buprenorphine is that there are people that don't want to use medication for treatment. And so those people are going more for cognitive behavior therapy and so forth. And the NA and AA groups are providing support. I think the data says that the best chance for recovery from opioid use disorder is medication treatment. But there are certainly people that are on medication treatment for a period of time and gradually tapered off and then are part of these other NA and AA communities or getting behavioral healthcare. And so there's lots of people working on this in lots of different ways. I met a guy sitting on the plane who happened to be a therapist from Alaska, and he was doing culturally sensitive treatment for Alaskan Natives suffering from substance use disorder. And he had a lot of really interesting things to say about how he was approaching it. And so there's lots of roads to recovery, thankfully.

I think one thing that is important for everybody to be aware of is, it doesn't care what your economic status is, what race you are, any of that. This is an equal opportunity disease. And lots of people now know somebody because, as you say the number of overdose deaths, it's actually over a hundred thousand per year. That's a lot of people. So people know somebody now that has died of a drug overdose. And we're working really hard to reduce the stigma of getting care, because that has been a huge impediment for people reaching out for care, for people allowing care to be provided, compassionately in their communities. And so stigma is a thing that we're working really hard to try and help communities address and educate people about substance use disorder.

Andrew Nelson: Yeah. How are people going about destigmatizing getting that kind of help? Obviously for some people there can be a reluctance to admit that there's a problem, at least that there's a problem they need someone else's help with.

Holly Andrilla: People that have substance use disorder definitely have a hard time. It's hard to reach out for help. It's hard to admit even to yourself, “Hey, I'm, I'm addicted to this medication or this drug.” I think that's true for alcoholics as well. So certainly, that's a problem. But there's also people in the communities that think that they could just stop if they wanted to or they think poorly of a person because they have substance use disorder. And I would remind listeners that there are plenty of people that are addicted to opioids because they took a prescription medication as prescribed and developed addiction and really had to work hard to get over it. Since we're on a podcast, you can search and there's lots of TED talks where people tell their stories. And I think learning about people that have the stories of people with substance use disorder is one way to destigmatize it, because you realize that could be me. That person didn't do anything different than what I might have done, and yet they now are battling this really horrific medical condition.

Andrew Nelson: Yeah, I suppose that's something that's true regardless of the environment someone lives in, whether it's a rural environment or a more urban one. Are there any concerns you have in particular about the future of access to behavioral health services or, or conversely, you mentioned telehealth, that's made a big positive difference. Are there any other technological or societal changes that make you really excited about the future of behavioral health services?

Holly Andrilla: Well, I think that the culture is allowing people to, I will say, admit or recognize and seek help. And I think that's huge. People are starting to realize it's okay to need mental health services or behavioral health services. I think the pandemic exacerbated anxiety and depression for many people. Certainly we saw a big explosion in the number of overdose deaths, and those are, we say, deaths of despair. I think as we've learned that people have realized, “Oh, people do need to be able to get services.” So that, I think, is a good first step. I think that our training programs for these different provider types are just inadequate.

And we have seen that in rural places for a long time. Rural places have done with a smaller workforce for years and years. It's a persistent problem that's hard to solve because you have to have enough people that are trained, and they get paid better in an urban place. There's other opportunities maybe for their family members, maybe their spouse. That's a challenge for rural places. You see that with nursing right now everywhere, right? That people can't get enough nurses and to train a nurse takes somebody that has those skills, and they don't have enough training programs and they don't pay them enough to make them, people want to be nurse faculty.

So I feel concerned, but I feel that we're moving in the right direction in terms of the acknowledgement of the need for mental health services and mental healthcare and behavioral health services. And I do feel like the next generation is much more accepting of that. And I think they're much more compassionate to their peers, quite frankly that suffer from substance use disorder than say, my generation. So I feel good about that.

Andrew Nelson: It seems like with some of the issues that we're trying to find solutions to, not only can younger people maybe be more open to getting help, there can be less of a stigma there. In some cases there are just more things that we're able to identify as problems now that have solutions. There's less of a mindset that you just have to power through something or just kind of walk it off, when there are in fact a lot of services that have never been more accessible for people that do need that help.

Holly Andrilla: Yeah. One of the diseases that is often sort of coupled together with substance use disorder or opiate use disorder is diabetes. And nobody says to diabetics, “Oh, just power through. You don't need your insulin.” They don't. It's a chronic progressive disease, which is the same. Diabetics control that in different ways, and people with substance use disorder are in recovery in different ways. And I think it's important to provide all those options for people and respect that people make different treatment choices. That will be the way I think that we get the most people into recovery.

The thing that I found really positive was when I was talking to those providers that were successfully providing treatment, how optimistic they were and how positive the experience of providing care for opioid use disorder had been for them. Some of them said it had been the highlight of their medical training, that they had really seen families put back together, and that that was really rewarding. And I think that, that, for me, it was probably my favorite work we've done because it was positive because it was like, here are people that are actually in the trenches, and it's a positive experience for them. And so, and I wanted to tell their stories because I wanted them to be an inspiration to other people to join in the care. I get that people don't want to do this as their only kind of care that they do. I understand lots of people want a broad scope of practice, especially family docs. That's why they chose the profession they did. But it, but a part of it, if we all kind of did our bit, then I felt like we could make a bigger dent in it.

Andrew Nelson: There's kind of like an interesting analogue there, I think. On the one hand, we have people that need help, that need treatment, and they see that other people need help and have gotten help, gotten better. So that makes it less scary for them. But on the provider side, you have more and more positive stories of success and breakthroughs that can be kind of encouraging to them as well. As you said, a lot of them aren't going to want to provide that kind of care exclusively. But those kinds of stories can be a source of encouragement to them as well. Especially for providers that are finding themselves spread really thin, as a result of an overall shortage. But that's good to hear. I think a lot of people will find that encouraging.

Holly Andrilla: Yeah. I mean, the other thing that I think that people should find encouraging is the attention that this is getting paid for by the federal government. I mean, the Rural Communities Opioid Response Program, which is sometimes referred to as RCORP, has funded hundreds and hundreds. I mean, I think it's close to 600 community rural communities, to increase their treatment of opioid use disorder and methamphetamine treatment and helping moms that are addicted, which will subsequently help their children. So, I mean, they've spent more than a half a billion dollars on it. It's a big focus area. And I think quite frankly, that's an ongoing area of focus from the previous administration. So, I think that's good that we've figured out, “Hey, this is adversely affecting our communities and our families, so let's attack it.” So I think that's good.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke with Holly Andrilla, Deputy Director of the WWAMI Rural Health Research Center. Look in our show notes for more information about her work, and visit for all things pertaining to rural health.