Getty Images/iStockphoto Physician assistants and nurse practitioners have asked the Michigan Legislature to update the state’s mental health code, written in 1974, to add PAs and NPs to the list of designated practitioners.
Physician assistants and nurse practitioners have asked the Michigan Legislature to fix a glaring hole in the state mental health code: no mention of PAs, NPs and other advanced practice providers in the list of designated mental health practitioners.
Michigan’s mental health code, written in 1974, was developed in the early days of advanced practice providers, when access to care was plentiful, PAs and NPs had more limited licenses and insurance reimbursement was cost-plus to whatever profit was desired.
Senate Bill 191, which redefines mental health professionals to include advanced practice providers, has passed the Michigan Senate and is awaiting hearings and a vote in the state House. It is sponsored by Sen. Curtis VanderWall, R-Ludington, chair of the House health policy committee, and all 15 members.
The bill would authorize several other things, including allowing advanced practice providers to conduct physical examinations, authorize seclusion and restraints and complete first clinical certificates to refer patients to a psychiatrist for further evaluation. Only a psychiatrist is able to make a second certification for involuntary hospital admission. The bill does not change that requirement.
For example, if a patient becomes aggressive toward others or has to be physically stopped from hurting him or herself, nurses can temporarily apply restraints — but a provider order has to be written within 30 minutes and the patient has to be examined in person within an hour, said Dr. Laura Hirshbein, a psychiatrist and medical director in the adult psychiatry unit at Michigan Medicine in Ann Arbor, in a letter of support for the bill.
“If the only provider available (in an inpatient unit) is a PA or an NP, the nurses have to release the patient — even if he takes a swing at other patients,” Hirshbein wrote. She added if the patient were on a medical floor, a PA or NP could legally order restraints because that setting is governed by the public health code that recognizes advanced practice providers.
The Senate Fiscal Agency, which analyzed the bill, concluded it would have no fiscal impact on state government even with a possible increase in mental health services. However, it could result in additional regulatory expenses as advanced practice providers would be monitored as mental health providers.
Thadd Gormas, executive director with the Michigan Academy of Physician Assistants, said SB191 is “pretty basic legislation” because the current code is outdated. More designated mental health providers are needed in the state’s overwhelmed healthcare system, he said.
Thadd Gormas
“This creates parity in the mental health code. PAs and NPs both practice in every mental health setting in Michigan, but are not listed as mental health providers,” Gormas said. “They deserve to be recognized.”
At a recent Senate hearing, several psychiatrists testified in support of the bill, Gormas said.
However, the Michigan Psychiatric Society, the Michigan State Medical Society, Disability Rights Michigan, Autism Alliance of Michigan and Arc of Michigan opposed the bill.
Mark Reinstein, a longtime mental health executive who testified for the Michigan Psychiatric Society, said the bill doesn’t significantly expand mental health access. He argued the bill should require advanced practice providers to have post-graduate certification in mental health and minimum hours of mental health training.
“Lastly, instead of curtailing the use of restraint and seclusion, a goal for everyone in the mental health community, SB 191 simply adds a host of new people, some of whom won’t be qualified, to the list of those who can do authorizations, exams and orders,” said Reinstein in a letter to the Senate health policy committee in March.
The Michigan State Medical Society said it supported the bill’s intent to reduce mental health treatment delays. But it objected to allowing additional healthcare providers to order the use of restraints and seclusion and provide initial certifications for involuntary holds and admissions.
“This legislation could be a vehicle to require or encourage state-licensed mental health facilities to adopt evidenced-based best policies and training protocols that lessen the need for restraints and seclusion and provide a safer environment for both residents and staff,” MSMS said in a statement to Crain’s.
“Expanding the number of healthcare professionals who can engage in these processes without altering fundamental practices will not improve the delivery of behavioral healthcare or clinical outcomes,” MSMS said.
The bill’s more than 18 supporters include the Michigan Osteopathic Association, the Michigan Society of Addiction Medicine, the Michigan Health and Hospital Association, the Michigan Academy of Family Physicians, the Michigan Nurses Association and the Michigan Association of Health Plans.
John McGinnity, director of the PA Medicine Department at Michigan State University, said PA students get the same training in psychiatry as osteopathic students.
“Let PAs use their training. There is a huge shortage of mental health providers. It is a common sense approach,” he said.
McGinnity said he believes some professional physician organizations are simply trying to protect their turf by using the lack of training argument. “I don’t see this as a threat to physicians,” he said.
Michigan Medicine Marc Moote
Marc Moote, chief physician assistant at Michigan Medicine in Ann Arbor, said updating the mental health code is critically important for patients.
“What Michigan residents need is access to mental healthcare as it is at a crisis level,” Moote said. “Nationally and in Michigan we need more capable, qualified and educated providers for our patients. We hire psychiatrists, but we have seen reimbursement challenges more for PAs and NPs than for physicians in that space.”
While Gormas said code changes wouldn’t require advanced practice providers to receive additional reimbursement for mental health services they provide, several PAs told Crain’s they believe the code changes could expand what credentialed PAs do because they could be directly reimbursed by payers for those uncovered services.
Samantha Danek, a hospital-based PA who also is chair of MAPA’s legislative committee, said she believes hospitals don’t hire as many advanced practice providers in mental health units because of reimbursement restrictions.
“Right now there is a three-month wait to be seen as a new mental health patient. Hospitals are businesses and they will hire you if you can generate revenue,” Danek said. “Certain services PAs provide in mental health aren’t reimbursed.”
For example, PAs are not reimbursed in some cases for an initial psychiatric evaluation and also for therapy that includes smoking, anxiety, depression and sleep problems.
“While we can’t say for sure that amending the mental health code would alleviate these access issues for patients, it will likely help,” Gormas said.
Sarang Patel, a PA who co-owns two mental health clinics with seven employed PAs, said his clinics face some reimbursement challenges, but the clinics continue to provide whatever service a patient requires.
“Changing the code can increase access at hospitals,” Patel said. “There are certain things related to the mental health code when it comes to billing in outpatient areas that could help us continue to bill properly that would sustain access to care in rural areas.”
Patel said more health insurers recognizing reimbursement for PAs in clinics could help expand the types of services they provide.
“If we run into any billing issues with therapy or medication management, we don’t go back to the patient and not provide the care, we just provide it and bite the bullet,” he said.
Blue Cross Blue Shield of Michigan, which reimburses advanced practice providers for certain mental health services, declined an interview request.
In a statement, Priority Health in Grand Rapids said reimbursing PAs for mental health services is a difficult question to answer because of various complications. “The complexity crosses lines of business, employers’ choices in plan design, as well as state and federal guidance,” said Priority.
Still, Dr. Jim Forshee, Priority’s chief medical officer, said updating the mental health code is a good thing. He questioned, however, the section of the bill that allowed advanced practice providers to order restraints in psychiatric units.
“We at Priority support these kinds of initiatives and thoughtful legislation because the demand for psychiatric services is so high,” said Forshee, who started out as a PA before going to medical school. “This is something we support, having increased access for patients in the state.”
In a statement, Priority Health said when NPs and PAs are billing in office settings and not credentialed as a network provider, they would bill under the collaborative arrangement of the physician, using the same mental health codes in the payers’ fee schedule.
But if NPs and PAs are billing in an office setting using their own credentials, Priority said they would pay at the advanced practice providers rate.
Forshee the COVID-19 pandemic has brought mental health access to an even higher level of needs. He said advanced practice providers could be used more to provide mental health telemedicine services as part of a mental healthcare team approach.
“We’ve not seen an expansion of the actual services available in a significant way,” he said. “Making it available digitally, which is something that we’ve done here at Priority Health, will give members online access to resources.”
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