Biopharma marketers have been consumed – you might say even a little obsessed – with reaching MDs and DOs. For years, physicians have ranked at or near the top of the list of industry’s most coveted customers.
But nurse practitioners and physician assistants, despite not commanding quite the same level of attention as their professional counterparts, are quietly catching up to them in both prescribing and patient volume. And, given strides they’ve made during the COVID-19 pandemic, industry may want to reassess that attentional imbalance.
“Pharma is in a bubble,” said Dave Mittman PA, DFAAPA, a past president of the American Academy of PAs (AAPA). “And the bubble is, physicians are everything. That bubble busted a while ago, and no one really looked at the new bubble. Maybe it took COVID for that to happen.”
Over the last five months, NPs and PAs have benefited from a broadened scope of practice, as many states have eased supervision requirements that had tethered them to doctors. Governors in eight states suspended or waived certain practice requirements for PAs in response to the COVID-19 pandemic, per the AAPA. Some 22 governors did the same for NPs, according to the American Academy of Nurse Practitioners (AANP).
In some of the hardest-hit states where legislative collaboration/supervision requirements were removed, NPs and PAs left their normal practice settings and pitched in everywhere from testing and ICUs to urgent care and ERs.
To the extent that the pandemic has, in essence, been a grand experiment in independence, it’s one which the clinicians say they passed with flying colors.
COVID is “an opportunity for nurse practitioners to show we did just fine without [such legislative constraints]. So give it up,” said Angela Golden, DNP, FAANP, a past president of the AANP.
Ditto for PAs. “What PAs want,” said Mittman, “is, we don’t want anyone else in our legislation.”
To that end, the pandemic has merely accelerated what had already been an ongoing trend in many states and territories for NPs and PAs to operate autonomously, even if it hadn’t been legislated.
“Elimination of supervision requirements has been the goal for NPs for many years,” said Golden, “and we’ve been steadily progressing that through the states.” In 28 states and Washington, DC, NPs had already been authorized to directly provide primary care services much like a doctor, and in most cases without physician oversight.
The PA profession is also moving in that direction, although it’s not as far along. In most states, PAs are still required to have a supervisory or collaborative agreement with a physician in order to practice.
These rules vary. Some states have a supervisory language requirement, meaning that a physician has to be within a certain number of miles or agrees to do a certain number of chart reviews. In other states, it’s nothing more than a piece of paper in the clinician’s drawer saying that the physician will collaborate when the NP or PA needs them to.
“Those are the [requirements] that, in my opinion, are the silliest,” said Golden, “because my professional responsibility is to collaborate with other healthcare providers when the patients need it. I don’t need a law; that’s a professional responsibility.”
The rules, put in place decades ago, do not reflect current realities, clinicians say. For instance, if the PA or NP is volunteering at a disaster site in another state, a physician may be unwilling to maintain the agreement, rendering the PA or NP unable to practice. In that case, the legislative requirements can be a barrier to access to care.
Moreover, at the time the requirements were enacted, more doctors owned their own practices, and PAs and physicians would often go into practice together. “They could really work as an amazing team,” recalled Mittman.
Today’s physician is more likely to be employed by someone. Notwithstanding the fact that medicine is now a team sport, “What happens to the [PA-physician] relationship? It’s gone,” said Mittman. “I’m just another peg to fill a hole, and so is the physician next to me and the NP next to her. It’s all, ‘We need you to see patients.’ There’s not that, ‘You rub my back, I’ll rub your back.’”
All of which is why PAs and NPs have been seeking to break free of these constraints and modernize. In fact, a reimagining of the healthcare workforce had been underway long before COVID, driven by, among other things, the shift to value-based payment and the triple aim of better care and patient satisfaction at lower cost.
The rise of retail clinics, often staffed by NPs or PAs, has been but one byproduct of a transforming health system and a consolidation of the provider, payer and PBM landscape. The $69 billion CVS-Aetna merger of 2018, for example, was spurred in part by a desire by CVS to leverage its 1,100 MinuteClinics to greater effect among Aetna’s members.
Now, both NPs and PAs prescribe more pharmacologic agents in some therapeutic areas and rival doctors in the number of patients seen. Many are becoming eligible for direct reimbursement from private insurers, as well.
In March, when Health and Human Services Secretary Alex Azar encouraged governors to lift the oversight requirements on clinicians, not every state took him up on the offer. California was one that resisted, and it’s been reported that the Golden State is likely to maintain supervision constraints, due largely to its powerful doctors’ lobby.
Even in those states that did waive rules, others say, a permanent easing shouldn’t be a foregone conclusion. Some physician groups, for instance, are withholding judgment until the COVID contributions of NPs and PAs can be properly assessed.
“For us, it’s not as simple as ‘We did this for the public health emergency; let’s just make it permanent,’” said Shawn Martin, EVP/CEO, American Academy of Family Physicians. “The right approach is to really evaluate what was positive and build on those things, but not necessarily just create pathways in areas where maybe it wasn’t a positive impact for patients and the healthcare system.”
Overall, the AAFP’s approach is that every member of the team – whether they be an NP, PA, nurse or physician – is valuable. But not interchangeable. “We should stop viewing them as a replacement strategy – like PAs and NPs can replace physicians,” Martin said. “The point is for physicians to do the things that they’re uniquely available and capable of doing based upon education and training throughout the team, and that the team is unified in its approach to providing comprehensive patient care.”
To that end, AAFP supports a vision of the primary care team with a physician leading the way. “Our official policy is that primary care teams should be inclusive,” said Martin. “Everybody should contribute to the betterment of patient care, but the primary care team is led by a physician.”
Not surprisingly, that view doesn’t sit well with Golden. “I personally will never be an advocate that says a physician must lead a team,” she said. What resonates more with NPs is the belief that the ultimate leader for patient care is the patient, a position affirmed by the American College of Cardiology (ACC), and that “We are a partner with the patient,” she noted.
Golden, who runs a family practice as well as a separate practice specializing in the treatment of obesity, voiced nothing but “the greatest respect” for her physician colleagues and their integral role in patient care.
At the same time, NPs “don’t go in and do surgery or cardiovascular interventions,” she said, “but to say that I can’t do family practice without a physician being part of that team is ludicrous. The research is very clear that that is not true.”
Then again, she acknowledged, “There are times you just find a point where you say, ‘OK, let’s respect each other and understand that we may not be able to come to an agreement on this.’”
Martin, too, acknowledged that such arguments at the organizational level are often a lot different than the realities at the practice level. “Our members are out there collaborating everyday with NPs, PAs, pharmacists and others, and it’s working quite well,” he said. “The disagreements at the organizational level tend to get amplified, but the reality on the ground is that a lot of really good practices have figured this out already.”
One of the biggest hurdles PAs have faced in working to change legislation at the state level is the misperception that PAs are literally “assistants” to physicians, despite the fact that in primary care their function is anything but.
This misperception may also have colored pharma’s approach to providing medical information, education and other resources to PAs and NPs. There are now 290,000 NPs in the country and 160,000 PAs. Given their growth and all the changes in their scope of practice, industry may need to change its approach.
The clinicians had some very pointed advice, which we’ll run in the print version of this feature, slated for MM&M’s October edition.
Editor’s note: The views of Dave Mittman and Angela Golden are their own and do not reflect the opinions of the AAPA or the AANP.