Non-Doctors Now Handle 40% of Antipsychotic Scripts in Medicare

A growing proportion of antipsychotic prescriptions for older adults were written by nonphysician clinicians, reflecting shifts in the mental health care workforce and prescribing practices, cross-sectional data showed.

From 2013 to 2023, antipsychotic prescription claims for Medicare Part D beneficiaries written by psychiatrists and primary care physicians (PCPs) declined annually by 3.2% and 2.6%, respectively (P<0.001 for both).

Prescriptions from advanced practice registered nurses (APRNs) and physician assistants (PAs), however, rose by 11.8% (P<0.001) each year, reported researchers led by Youngran Kim, PhD, of the University of Texas Health Science Center at Houston, in JAMA Network Open.

Over the decade, the proportion of prescriptions decreased for psychiatrists (from 48.4% to 32.4%) and PCPs (from 33% to 23.8%) but nearly tripled for APRNs and PAs, jumping from 13.8% to 39.6%.

“These shifts were associated primarily with the expanding number of prescribing APRNs and PAs rather than an increase in the mean number of claims per clinician,” Kim and co-authors wrote.

“These findings highlight workforce changes in mental health and the expanding role of nonphysician clinicians in managing patients receiving antipsychotics, particularly in areas with limited psychiatrist availability,” they added.

The shift comes at a time of a “critical shortage of psychiatrists,” which may be insufficient to meet current needs, Kim and colleagues noted. Psychiatrists have the highest Medicare opt-out rate of all specialties — around 8% — further tightening the bottleneck for older patients seeking care.

“This combination of workforce contraction and Medicare nonparticipation may have shifted much of the responsibility for prescribing and managing psychotropic medications to other clinician groups,” Kim’s team explained. “In contrast, APRNs and PAs have increasingly taken on these prescribing roles. Psychiatric mental health nurse practitioners, who have specialized training and certification, may help offset workforce shortages and play a growing role in managing psychiatric needs among older adults.”

The study didn’t stratify prescribers by care setting, but the researchers suggested the findings may reflect the expanding role of APRNs and PAs in nursing homes, a setting where antipsychotics are more frequently used. Prior research showed that roughly 15% of Medicare enrollees in nursing homes over age 75 received an antipsychotic versus 3% of community-dwelling adults. A recent HHS Office of Inspector General report also indicated that some nursing home staff overdiagnosed dementia patients with schizophrenia so they could prescribe antipsychotics and make patients easier to manage.

The shift from physicians to APRNs in prescribing for nursing home patients shouldn’t be a concern, James Goodwin, MD, of the University of Texas Medical Branch at Galveston, argued in an accompanying commentary.

Nursing home residents treated by APRNs “have better outcomes than those treated by physicians because almost all APRNs who treat nursing home patients work full time in those facilities, while most physicians who treat nursing home residents are only occasional visitors,” he explained.

Based on the study data, it remains unclear whether nonphysician clinicians were more or less likely to prescribe antipsychotics than their physician counterparts, Goodwin noted. “There is also little information about the prescription itself, such as days’ supply, whether it was prescribed for a short period or longer duration, and whether it was to be taken only as needed or daily,” he added.

Kim and co-authors acknowledged these limitations, and said future research should stratify prescribing by care setting (community vs nursing home), mode of care delivery (in-person vs telehealth), prescription type (new vs refill), and practice model (independent vs team based).

The researchers used the CMS Medicare Part D Prescribers by Provider and Drug dataset from 2013 to 2023. In 2023, about 77% of Medicare beneficiaries were enrolled in Part D. Prescriptions for first-generation and second-generation antipsychotics were identified.

During the study period, total antipsychotic claims rose from 22.4 million to 24.1 million, but trailed behind the rapid growth of Medicare Part D enrollment (35.7 million to 51.9 million). Consequently, the rate of antipsychotic claims dropped from 0.63 to 0.46 per enrollee.

Nationwide shifts toward nonphysician-led mental health care were seen in both rural and urban areas. Rural areas had larger shifts from PCPs to APRNs and PAs, while urban areas had larger shifts from psychiatrists to APRNs and PAs.

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