UNDERSTANDING THE INFLUENTIAL, EXPANDING ROLE OF NPs …

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How Advanced Practice Providers Impact Clinical Care in the U.S. Healthcare System

UNDERSTANDING THE INFLUENTIAL, EXPANDING ROLE OF NPs & PAs

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2020


WHY MARKETERS TARGET NPs & PAs

NPs and PAs are providing significantly more patient-centered diagnostic, treatment and follow-up care to patients of all ages, in all types of practice locations. Job growth of 26%-31% is expected from 2018-2028 (87,000 new jobs) in primary care and at the specialty level, and particularly for NPs and PAs working in rural and medically underserved areas.1,2

• Increasing influence in a changing healthcare system beset by doctor shortages and expanded case load.• NPs and PAs handle 1.5 billion patient visits and write over 1 billion Rxs annually.• NPs and PAs rank among the top 10 fastest growing professions and best jobs in the U.S.

expected from 2018-2028

26%-31% Job growth

NPs and PAs make up 27% of the healthcare provider workforce, and equal nearly 44% of physicians in patient care.4 NPs/PAs accounted for 27% of retail Rxs, or $1 billion (see slides 22-23). In 2019, AAPA and AANP estimate these providers handled 1.5 billion patient visits.

The number of NP and PA encounters per Medicare beneficiary has increased 11% from 2017 to 2018 (and decreased 3% among primary care physicians). Medicaid fee schedules for NPs and PAs are increasing in 17 states as of 2017.3 Thus, more NPs/PAs are receiving payments from Medicare and Medicaid. Recent recommendations to increase direct billing by reducing “incident to” billing, and to collect specialty information from NPs and PAs will result in better oversight and reduced costs.

from 2017-2018

11%

Medicare beneficiary increased

Sources:1. Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, April 2020; U.S. News 1/7/2020.2. Larson EH, Andrilla CHA, Coultheard C, Spetz J. How Could Nurse Practitioners and Physician Assistants Be Deployed to Provide Rural Primary Care? Rural Health Research Center; 2016.3. The MedPAC Blog 2/15/2019; MedPAC 3/2020 Report to Congress; MacPAC State Medicaid Fee-for-Service Payment Policies.4. Direct Medical Data, April 2020 (NPs/PAs) and 5/25/2020 (MDs and DOs).

healthcare provider workforce

27%NPs & PAs make up

of retail Rxs

27%NPs & PAs

accounted for

physicians in patient care



The total number of licensed NPs/PAs (461,609) exceeds the number of primary care physicians in patient care (270,093).1

By 2032, the U.S. physician shortage is projected to be 121,000 in primary care and across many specialties2 and NPs/PAs will increasingly fill these gaps.

State-level reform of scope of practice, supervision, and delegation of authority for PAs and NPs has been growing (varies by profession and state).3 HHS 2018 recommendations called for states to broaden scope of practice laws for non-physician APRNs and PAs, among other allied health professionals.4

85% of consumers say they value nurses and physician assistants as an important source of healthcare information (up 5% since 2015).5

Sources:1. Direct Medical Data, April 2020 (NPs/PAs) and 5/25/2020 (MDs and DOs).2. Association of American Medical Colleges (AAMC) projections, 4/23/19.3. HealthLeaders, More States Pushing for Autonomy in Scope-of-Practice Battle, May 01, 2019.4. Reforming America’s Healthcare System Through Choice and Competition, 2018, pages 31-38. 5. MARS Consumer Health Study, 2019.

WHY MARKETERS TARGET NPs & PAs

• The number of NPs and PAs combined exceeds the number of PCPs.• Rapid growth of NPs and PAs (expected to continue) fills gaps left by physician shortages and increasing healthcare demand.


GROWTH FACTORS

Sources:1. Bureau of Labor Statistics, U.S. Dept. of Labor, Occupational Outlook Handbook, April 2020.2. U.S. Census Bureau, July 2019.3. Merritt Hawkins 2018 and 2019 Review of Physician and Advanced Practitioner Recruiting Incentives.

Employment of healthcare workers is projected to grow 14% from 2018 to 2028, adding about 1.9 million new jobs, more than any other group of occupations.

NPs and PAs are projected to increase more significantly, 26%-31% through 2028.1

Healthcare demands have increased with emphasis on preventive care and demand for services from an aging population as they live longer, more active lives than previous generations.1 April 2017 – March 2018 reflected the largest 12-month growth in demand recorded for NPs and PAs in recruiting assignments (this declined slightly April 2018 – March 2019).

53 million of the U.S. population is aged 65 or older.

Population is projected to grow to 78 million

by 2035.2

The CMS projects healthcare spending will grow at a 5.5% pace from 2017 to 2027 when it will reach $5.7 trillion, accounting for 19.7% of GDP.3

$ $$$ $The number of primary care physicians has been declining as existing physicians and recent graduates choose higher paying medical and surgical specialties and/or retire. The physician shortage is projected to be 121,900 by 2032, in part due to a 1997 Congressional cap on federal funding for GME residency programs leading to a gap in match rates according to the AAMC’s 2019 State Physician Workforce Data Book. The bipartisan Resident Physician Shortage Reduction Act of 2019 introduced in Congress provides Medicare support for an additional 3,000 new residency positions each year over the next 5 years.


Sources:1. Martsolf GR, Barnes H, Richards MR, et al. Employment of Advanced Practice Clinicians in Physician Practices. JAMA Intern Med. 2018 April. 2. Cody E. Who’s your prescriber now? Demand for NPs and PAs is booming, according to report. MM&M. 2018 June 20.3. https://www.cdc.gov/obesity/data/adult.html (accessed July 29, 2020).4. https://www.congress.gov/bill/115th-congress/house-bill/1284.5. Bipartisan Budget Act of 2018/Increasing Access to Quality Cardiac Rehabilitation Care Act of 2019.

Large employers (including the VA) and insurers are allowing greater access to NPs and PAs as a lower cost option. Value-based care has become a staple, such as Aetna’s retail healthcare MinuteClinics staffed by NPs.2 Despite increased NP/PA autonomy, over two-thirds of NPs and PAs who work with a physician bill at least a portion of care as “incident to” the collaborating physician. Direct care is therefore not always visible in the data, which may lead to the undercounting of NP/PA care and misattribution of this care to physicians. (AAPA, AANP and numerous other sources.) Congressional and professional association efforts are moving to increase direct billing/reimbursement of services.

$53% of primary care and multispecialty practices employ at least 1 NP or PA. A 22% increase from 2008 to 2016, among specialty practices.1 The Society of Hospital Medicine 2019 report noted 80% of hospital medicine groups employ NPs/PAs.

CMS rule changes of 11/15/19, effective 1/1/20, allow for all APPs, and corresponding students, who are paid under Medicare PFS, to document notes in a patient’s medical record which may be reviewed and verified by the billing professional.

Effective 1/1/19, the Medicare Patient Access to Hospice Act allowed PAs to manage and provide hospice care to terminally ill Medicare patients.4

Effective 1/1/24, PAs and other APPs will be allowed to supervise cardiac and pulmonary rehabilitation Medicare programs. Both Acts benefit medically underserved communities.5

The Obesity Medicine Association (OMA) offers NPs and PAs an opportunity to earn a certificate of Advanced Education in Obesity Medicine exclusively for PAs and NPs who wish to continue their obesity treatment education. CDC estimates 42% of middle-aged adults have this chronic, progressive condition.3

GROWTH FACTORS


SCOPE OF PRACTICE OVERVIEWNurse Practitioners

In addition to their NP preparation, 7% of NPs were educated as another type of APRN (clinical nurse specialist, certified nurse midwife, or certified registered nurse anesthetist).1 The National Organization of NP Faculties and the American Association of Colleges of Nursing has committed to move all entry-level NP education to the doctoral degree level by 2025, however a DNP is not currently mandatory to practice as an APRN.

• NPs act as primary-care providers performing the same tasks involved in examining, diagnosing, and treating patients as PCPs.

NPs are advanced practice, licensed, and independent nurses who work in a collaborative or supervisory setting with physicians and other NPs (75% work with other NPs).1 NPs work without physician involvement or may transition to independent practice as a primary care provider in about 27 states/territories (about 50%1); nine states require some portion of charts/records be reviewed/co-signed by a physician. The ratio of NP to physician involvement varies by state, from two to eight per MD.2 Details by state: http://scopeofpracticepolicy.org/practitioners/

Sources:1. AANP National Nurse Practitioner Sample Survey, 2018; NONPF.org; AACN.org.2. AMA, 2018 sourced via ThriveAP.com, Do NPs or PAs Have More Freedom? 4/30/19.

NPs have graduate degrees

95%NPs were educated as another type of APRN

7%NPs hold doctoral

degrees

18%


Sources:1. AANP National Nurse Practitioner Sample Survey, 2018; NONPF.org; AACN.org.2. Direct Medical Data April 2020.3. Federal Register, December 2016.

NPs hold prescriptive privilege in all 50 states, D.C., and Puerto Rico and nearly all (96%) NPs prescribe pharmacological agents to their patients and write an average of 20 scrips/day.1

NPs may prescribe, administer, and dispense Schedule III-IV controlled substances in all states and Schedule II in 45 states; six states do not allow prescribing of Schedule II. https://www.deadiversion.usdoj.gov/drugreg/practitioners/mlp_by_state.pdf

As of April 2020, there are 315,435 NPs.2 New NP graduates have been steadily increasing and the number of certifications have doubled from 2015-2019 (including multiple certifications); about 42% of NPs have been in practice less than 5 years.1 As of 2018, there were 7,039 DNP graduates and 32,678 students enrolled in DNP programs.

Department of Veterans Affairs (VA) permits three types of advance practice nurses (including NPs) working within the VA system, to practice at the top of their licenses independent of physician supervision, regardless of their state’s laws.3

SCOPE OF PRACTICE OVERVIEWNurse PractitionersSCOPE OF PRACTICE OVERVIEWNurse Practitioners


Sources:1. AAPA-PA Communications Guide, December 2018.2. Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Physician Assistants, April 2020.3. Direct Medical Data April 2020.

Today’s PAs collaborate with physicians, often as the lead on care coordination teams, and see patients in all settings without a physician present. Supervision is only referenced when required by legal and regulatory documentation (state or practice level); 47 states require supervisory or collaborative agreements with a physician. The ratio of PA to physician involvement varies by state, from two to seven per MD.1

States continue to expand the role of PAs. As team-based models of care become more widely used, and as insurance companies expand their coverage of PA service, PAs can perform more procedures. About 30 states have “adaptable supervision requirements” and where states do not determine scope of practice, it is determined on site:http://scopeofpracticepolicy.org/practitioners/

PAs are educated at the graduate level, with most PAs receiving a master’s degree or higher. To maintain licensure, PAs are required to recertify as medical generalists every 10 years and complete 100 hours of continuing medical education every 2 years.2 Certificates of Added Qualifications (CAQs) can be earned in seven specialties (NCCPA).

As of April 2020, there are 146,174 licensed PAs.3

require supervision

47 states

adaptable supervision requirement

30 states

licensed PAs

146,174

SCOPE OF PRACTICE OVERVIEWPhysician Assistants


Sources:1. AAPA.org, press release dated 2/9/2018.2. Final 2020 Physician Fee Schedule rule issued by the Centers for Medicare and Medicaid Services (CMS).

PAs must complete all pre-medical science courses and 3 years of prior healthcare experience (EMT, radiology, paramedic, nursing, respiratory tech) before enrollment in a training program.

PAs are licensed to prescribe in all 50 states, D.C., Puerto Rico, and Guam. PAs may prescribe, administer, and dispense Schedule II-V medications in 44 states; Schedule II in six states; and none in 1 state. Levels of controlled substances by state: https://www.deadiversion.usdoj.gov/drugreg/practitioners/mlp_by_state.pdf

Effective January 1, 2019, a Congressional law enabled PAs to provide hospice care and effective January 1, 2024, to supervise cardiac pulmonary rehab programs to Medicare patients.1

A CMS rule, 11/15/19, effective 1/20/20 aligns the ”supervision” of PAs to that of NPs, deferring first to state laws on PA scope of practice. In the absence of state law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA’s approach to working with physicians in furnishing their services to Medicare Part B patients.2

SCOPE OF PRACTICE OVERVIEWPhysician Assistants


NP PROFILE

• Average NP is female (92%), 47 years old, and has been in practice for 10 years.

Source:DMD, April 2020.

provide education

81%

have a National Provider Identifier

99.4%

certified, state-licensed NPs

315,435 There are more than 315,435 certified, state-licensed NPs; 99% have graduate degrees, 18% have doctoral degrees.

99.4% have a National Provider Identifier (NPI) - 83% are accepting Medicare and 80% are accepting Medicaid patients. 62% are directly credentialed with commercial insurance companies. NPs have full practice authority (do not have to work under the supervision of a physician) in 20 states. Remaining states require physician sign-off on certain care decisions.

81% provide education and counseling for most of their patients.

deliver primary care

69%

median base salary

$110,000

specialtytracks

850 NPs complete a formal educational specialty program beyond that of a registered nurse. Most training programs are either 4 years (BSN) or 2 years (ASN), followed by a 2-year master’s degree and certification in their specialty; there are 850 specialty tracks at 400 institutions.

Full-time NPs write an average of 20 prescriptions per day. 57% of NPs see at least three patients per hour, over 1 billion patient visits per year.

Median base salary for a full-time NP (35+ hours per week) is $110,000.

88% of NPs are certified in an area of primary care and 69% deliver primary care.


NP SPECIALTY BREAKOUT

Sources:1. POCN Data: July 2019 - June 2020.

9%

4%

4%4%

5%

51%

1%

2%

3%

2%

6%8%

NPs TYPICALLY SPEND 47% OF PRACTICE TIME ON PATIENT EDUCATION AND COUNSELING (PAs = 41%)1

NPs PRACTICE IN MORE THAN 70 SPECIALTY FIELDS AND MOST DESIGNATE A SPECIALTY. THE MAJORITY OF NPs PRACTICE IN THE FOLLOWING AREAS1:

PRIMARY CARE* DERMATOLOGY

OB/GYN

DIGESTIVE SYSTEM

ENDOCRINE AND METABOLISM

CIRCULATORY

PYSCHIATRY

ONCOLOGY

NERVOUS SYSTEMS

GENITOURINARY SYSTEMS

ORTHO/SURGICAL

RESPIRATORY


• Average PA is female (69.3%), 38 years old, and is in practice in primary care, surgical, and internal medicine subspecialties, and emergency medicine.

Sources:1. National Commission on Certification of Physician Assistants, Inc. (2020, April). 2019 Statistical Profile of Certified Physician Assistants: An Annual Report of the NCCPA.2. Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Physician Assistants, April 2020.3. ARC-PA Accreditation Standards for Physician Assistant Education©, http://www.arc-pa.org/wp-content/uploads/2019/11/Projected-Growth-as-of-11.6.2019.pdf.

Best Healthcare Jobs of 2020

#2

PAs work in one clinical position

84%

certified PAs

140,000More than 140,000 certified, and clinically practicing PAs collectively treat 9.5 million patients per week.1

The top 5 states (NY, CA, PA, TX, and FL) account for nearly 40% of all PAs.1 Overall, this workforce has grown 37% since 2013,1 and is projected to grow another 31% by 2028.2

84% of PAs work in one clinical position; work an average of 40 hours/week; see an average of 72 patients per week (over 400 million patient visits/year collectively). To supplement their earnings, 12% of PAs work in two or more clinical positions, adding 11 hours and 22 patients to their weekly case load.1

U.S. News and World Report ranked PA as #2 in the Best Healthcare Jobs of 2020. is required to maintain

certification

CME

average annual salary

$113,186

PAs have a master’s degree or higher

>77%

ARC-PA expects the 254 accredited programs today to grow to 304 by 2023.3 The accredited programs in the U.S. offer baccalaureate or masters degrees; eight post-graduate accredited programs. As of 2020, all programs must confer graduate degrees. More than 77% of PAs have a master’s degree or higher.1 Clinical rotations include all areas of medicine, primary care and family medicine, emergency medicine, obstetrics/gynecology, pediatrics, surgery, and a variety of subspecialties.

PAs are required to include their NPI number on all applications to enroll in Medicare and Medicaid programs and on all claims for payment submitted under those programs. Average annual salary for PAs is $113,186,1 an increase of 15% over the last 6 years.

Self-assessment CME and new practice improvement CME is required to maintain certification. The new 10-year process is divided into five 2-year cycles (100 hours every 2 years; 50 credits can be Cat 1 and/or Cat 2 with complete recertification every 10 years by passing the multiple-choice PANRE exam). Licensure is required by all states.1 Scope of practice varies by state.

PA PROFILE


Sources:1. POCN Data: July 2019 - June 2020.

PA SPECIALTY BREAKOUT

PAs TYPICALLY SPEND 41% OF PRACTICE TIME ON PATIENT EDUCATION AND COUNSELING (NPs = 47%)1

PAs PRACTICE IN MORE THAN 70 SPECIALTY FIELDS AND MOST DESIGNATE A SPECIALTY. THE MAJORITY OF PAs PRACTICE IN THE FOLLOWING AREAS1:

7%

3%

4%3%

15%

52%

3%

3%

1%

1%

6%2%

PRIMARY CARE*

DERMATOLOGY

OB/GYN

DIGESTIVE SYSTEM

ENDOCRINE AND METABOLISM

CIRCULATORY

PYSCHIATRY

ONCOLOGY

NERVOUS SYSTEMS

GENITOURINARY SYSTEMS

ORTHO/SURGERY

RESPIRATORY


Sources:Kantar Media, NP/PA 2019 Media Measurement Study, Profiling Data. Kantar Media, Med/Surg December 2018 MD/DO, Profiling Data.

AVERAGE PATIENTS SEEN/WEEK

90

80

70

60

50

40

30

20

10

0

PAs NPs MDs/DOs

112/week

5953

72

30

25

20

15

10

5

0

31/week

1714

29

PAs NPs MDs/DOs

IN OFFICE IN HOSPITAL


Source:Kantar Media, NP/PA 2019 Media Measurement Study, Profiling Data.

NP PRACTICE SETTINGS

HOSPITAL

PHYSICIAN GROUP, SINGLE-SPECIALTY

COMMUNITY/RURAL CLINIC

PHYSICIAN GROUP, MULTI-SPECIALTY

SOLO PHYSICIAN PRACTICE

NP PRACTICE

URGENT CARE CLINIC

LONG-TERM CARE FACILITY

CONVENIENT/RETAIL CARE CLINIC

OTHER

0% 5% 10% 15% 20% 25% 30% 35%



PHYSICIAN GROUP, SINGLE-SPECIALTY

HOSPITAL

PHYSICIAN GROUP, MULTI-SPECIALTY

SOLO PHYSICIAN PRACTICE

URGENT CARE CLINIC

COMMUNITY/RURAL CLINIC

LONG-TERM CARE FACILITY

CONVENIENT/RETAIL CARE CLINIC

OTHER

0% 5% 10% 15% 20% 25% 30%

PA PRACTICE SETTINGS


Source:Extrapolated from CDC/HHS, National Ambulatory Medical Care Survey, 2016: Tables 14 & 26 (Office Visits Only-NPs/PAs account for 6.35% of all office visits).

LEADING PRIMARY DIAGNOSES

TOTAL NP/PA VISITS: 56,153,000

AT OFFICE VISITS

5.4

4.7

4.6

4.4

3.6

3.3

2.9

2.5

2.3

2.3

2.0

1.5

1.4

1.4

1.0

MAJOR DISEASE CATEGORY

NUMBER OF VISITS IN MILLIONS

DISEASES OF THE RESPIRATORY SYSTEM

DISEASES OF THE MUSCULOSKELETAL AND CONNECTIVE TISSUE

DISEASES OF THE CIRCULATORY SYSTEM

SYMPTOMS, SIGNS, AND ABNORMAL CLINICAL AND LABORATORY FINDINGS, NOT ELSEWHERE CLASSIFIED

MENTAL, BEHAVIORAL AND NEURODEVELOPMENTAL DISORDERS

DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE

ENDOCRINE, NUTRITIONAL, AND METABOLIC DISEASE

DISEASES OF THE EYE AND ADNEXA

DISEASES OF THE GENITOURINARY SYSTEM

NEOPLASMS

INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES

DISEASES OF THE NERVOUS SYSTEM

DISEASES OF THE DIGESTIVE SYSTEM

DISEASES OF THE EAR AND MASTOID PROCESS

CERTAIN INFECTIOUS AND PARASITIC DISEASES


THERAPEUTICS PRESCRIBED BY NPs

Source:Kantar Media, NP/PA 2019 and 2018 Media Measurement Study, Profiling Data.

% OF UNIVERSE PRESCRIBING

ANTIBIOTICS, B/M SPECTRUM

ANTIHISTAMINES, SYSTEMIC

ULCER/GERD THERAPY

ANTIDEPRESSANTS

ANTIHYPERTENSIVES

ANTI-ANXIETY

BRONCHODILATORS, STEROID INHALANTS

DERMATOLOGICALS

NUTRIENTS & SUPPLEMENTS

BRONCHODILATORS, BETA AGONISTS, ORAL

BETA & ALPHA/BETA BLOCKERS

CHOLESTEROL/LIPID LOWERING AGENTS

SYNTHETIC NON-NARCOTIC ANALGESICS

ANTIVIRALS

DIABETES THERAPY, ORAL

ANTIARTHRITICS

GLUCOSE & OTHER TEST STRIPS

DIABETES THERAPY, INSULIN

ANTICOAGULANTS, ORAL

NARCOTIC ANALGESICS, NON-INJECTABLE

PROPRIETARY ANALGESICS

SEIZURE DISORDERS

CONTRACEPTIVES/ESTROGEN/PROGEST.

ALZHEIMER’S-TYPE DEMENTIA

PEDIATRIC VACCINES

87.0%

83.8%

81.6%

80.0%

79.7%

79.5%

78.8%

74.9%

74.7%

72.7%

72.4%

71.6%

68.2%

67.9%

66.6%

66.6%

61.7%

60.7%

55.8%

55.0%

53.1%

49.6%

47.7%

41.0%

29.7%

83.4%

74.4%

77.2%

72.9%

69.6%

74.1%

66.2%

67.6%

75.2%

62.1%

63.6%

60.5%

60.6%

62.0%

58.2%

51.9%

56.9%

54.9%

50.4%

54.0%

47.3%

40.2%

48.1%

31.4%

31.6%

2019 2018


Source:POCN Data: July 2019 - June 2020

TOTAL Rxs PRESCRIBED BY NPs

SSRI (SEL. SEROTONIN REUPTAKE INHIBITOR)

SEIZURE DISORDERS

HMG-COA REDUCTASE INHIBITORS

ACE INHIBITORS, ALONE

PROTON PUMP INHIBITORS

CONTRACEPTIVES, ORAL ESTROGEN-PROGESTOGEN

NEWER GENERATION ANTI-DEPRESSANTS

THYROID HORMONE, SYNTHETIC

BETA BLOCKERS

ANTIARTHRITICS, SYSTEMIC PLAIN

CALCIUM CHANNEL BLOCKERS

ANTI PSYCHOTICS, OTHERS

CODEINE AND COMBINATIONS, NON-INJECTABLE

ANALEPTICS

HORMONES, GLUCOCORTICOIDS PLAIN, ORAL

BIGUANIDES, ALONE

MUSCLE RELAXANTS,NON-SURG, W/O ANALGESIC

BETA AGONISTS, AEROSOLS

SNRI (SEROTONIN/NOREPI REUPTAKE INHIBIT)

BENZODIAZEPINES

26,378,148

22,190,711

21,943,764

13,857,935

13,776,370

12,673,835

12,415,080

12,291,555

12,221,457

11,437,697

11,311,731

10,778,691

10,535,200

10,483,557

10,282,568

10,180,595

9,363,937

9,220,023

8,677,905

8,015,185

TOP 15 THERAPEUTIC CLASSES - ACCOUNTS FOR 50% OF TOTAL Rxs/YEAR


Source:Kantar Media, NP/PA 2019 and 2018 Measurement Study, Profiling Data Media.

% OF UNIVERSE PRESCRIBING

ANTIBIOTICS, B/M SPECTRUM

ULCER/GERD THERAPY

ANTIHISTAMINES, SYSTEMIC

SYNTHETIC NON-NARCOTIC ANALGESICS

ANTI-ANXIETY

DERMATOLOGICALS

NARCOTIC ANALGESICS, NON-INJECTABLE

ANTIHYPERTENSIVES

NUTRIENTS & SUPPLEMENTS

BRONCHODILATORS, STEROID INHALANTS

ANTIVIRALS

BRONCHODILATORS, BETA AGONISTS, ORAL

BETA & ALPHA/BETA BLOCKERS

ANTIARTHRITICS

PROPRIETARY ANALGESICS

ANTIDEPRESSANTS

ANTICOAGULANTS, ORAL

CHOLESTEROL/LIPID LOWERING AGENTS

DIABETES THERAPY, ORAL

DIABETES THERAPY, INSULIN

GLUCOSE & OTHER TEST STRIPS

CONTRACEPTIVES/ESTROGEN/PROGEST.

SEIZURE DISORDERS

ALZHEIMER’S-TYPE DEMENTIA

PEDIATRIC VACCINES

84.6%

72.0%

71.1%

68.3%

65.1%

64.5%

64.2%

62.1%

62.0%

61.0%

59.4%

57.8%

56.4%

55.1%

54.9%

53.5%

52.6%

48.0%

46.7%

42.8%

41.1%

34.0%

33.9%

22.6%

19.3%

83.4%

77.2%

74.4%

60.6%

74.1%

67.6%

54.0%

69.6%

75.2%

66.2%

62.0%

62.1%

63.6%

51.9%

47.3%

72.9%

50.4%

60.5%

58.2%

54.9%

56.9%

48.1%

40.2%

31.4%

31.6%

2019 2018

THERAPEUTICS PRESCRIBED BY PAs


HMG-COA REDUCTASE INHIBITORS SSRI (SEL. SEROTONIN REUPTAKE INHIBITOR)

CODEINE AND COMBINATIONS, NON-INJECTABLE

ANTIARTHRITICS, SYSTEMIC PLAIN

SEIZURE DISORDERS

HORMONES, GLUCOCORTICOIDS PLAIN,ORAL

PROTON PUMP INHIBITORS

ACE INHIBITORS, ALONE

MUSCLE RELAXANTS, NON-SU RG, W/O ANALGESIC

THYROID HORMONE, SYNTHETIC

BETA BLOCKERS

BETA AGONISTS, AEROSOLS

CALCIUM CHANNEL BLOCKERS

BIGUANIDES, ALONE

CEPHALOSPORINS & RELATED

HORMONES,CORTICOIDS PLAIN,DERMATOLOGICAL

NEWER GENERATION ANTI-DEPRESSANTS

EXTENDED SPECTRUM MACROLIDES

CONTRACEPTIVES, ORAL ESTROGEN-PROGESTOGEN

ANGIOTENSIN II ANTAGONIST, ALONE

TOP 15 THERAPEUTIC CLASSES – ACCOUNTS FOR 49% OF TOTAL Rxs/YEAR

Source:POCN Data: July 2019 - June 2020

TOTAL Rxs PRESCRIBED BY PAs

9,505,862

8,354,452

8,297,036

7,905,013

7,257,769

6,669,968

6,331,927

5,871,706

5,617,678

5,331,758

4,924,986

4,473,863

4,431,191

4,117,974

3,669,563

3,662,350

3,594,625

3,384,495

3,376,497

3,319,166


VALUE OF NP & PA Rxs

• RESULT: NPs and PAs generate at least $1.081 billion in annual Rxs!1

Sources:1. Extrapolated from: IQVIA, National Sales Perspectives, 2019 via KFF.org based on Total Retail Prescriptions and Revenue; accessed 6/1/2020.2. Among physicians and Advanced Practice Providers. Redi-Data via KFF, March 2020; DMD April, May 2020.3. Kantar Media, 2019 NP/PA Media Measurement Study, Profiling Data.4. Direct Medical Data: physicians and NP/PAs only, MAT March 2019.

Nationally, NPs and PAs make up 27% of the healthcare provider workforce.2

Corresponding to over 27% of all U.S. dispensed retail prescriptions.4 This is up from 9% in 2010.1

NPs and PAs write an average of 68 Rxs per week.3

healthcare provider workforce


Rxs per week

68NPs & PAs write

dispensed retail prescriptions

27% Corresponding

to over

The expansion of prescribing authority is determined by each state and not limited to NPs/PAs. It has begun to expand, although limited, to other healthcare professionals such as psychologists, pharmacists, and naturopaths.

NPs and PAs combined wrote 1.007 billion retail prescriptions in 2019, up from 676 million in 2015.4 Rxs are underreported, as not all NPs/PAs are tracked, and non-retail is excluded.

120,318 PA prescribers wrote approximately 333.76 million retail Rxs in 2019.4

million retail Rxs

333.76PAs wrote

billion retail prescriptions

1.007NPs & PAs wrote

223,673 NP prescribers wrote approximately 673.5 million retail Rxs in 2019.4

million retail Rxs

673.5NPs wrote


Source:Direct Medical Data, MAT, March 2019.

RETAIL PRESCRIPTIONS WRITTEN BY NPs AND PAs continue to rise, reaching over 1B in 2018

1000

800

600

400

200

0

NPs

2016 2017 2018

PAs

Mill

ions



POCN REACHES NPs & PAs when pharmaceutical reps cannot

Prescribe a new drug as soon as it is released

9%

Prescribe a new drug after it becomes a standard drug

27%

Prescribe a new drug after a few others have tried it successfully

28%

Prescribe a new drug once it is in fairly common use

36%

• 41% do not see sales representatives.• 33% see sales representatives selectively.


Source:Kantar Media, Sources & Interactions 2019 - PA/NP Edition.

TOP SOURCES OF CLINICAL & PROFESSIONAL INFORMATION

PROFESSIONAL PORTALS (E.G., UPTODATE, MEDSCAPE, ETC.)

COLLEAGUES: PHYSICIANS

COLLEAGUES: NPS/PAS

CONFERENCES/SYMPOSIA/MEETINGS

CURRENT PROFESSIONAL JOURNALS: PRINT EDITION

MOBILE APPS: DRUG REFERENCE

WEBSITES: PROFESSIONAL PUBLICATIONS

CURRENT PROFESSIONAL JOURNALS: ONLINE/APP VERSION

REFERENCE PUBS: ONLINE

PROFESSIONAL ASSOCIATIONS

0 20 40 60 80 100

NPs PAs

IMPORTANCE

COLLEAGUES: PHYSICIANS

COLLEAGUES: NPS/PAS

PROFESSIONAL PORTALS (E.G., UPTODATE, MEDSCAPE, ETC.)

CONFERENCES/SYMPOSIA/MEETINGS

CURRENT PROFESSIONAL JOURNALS: PRINT EDITION

WEBSITES: PROFESSIONAL PUBLICATIONS

PROFESSIONAL ASSOCIATIONS

MOBILE APPS: DRUG REFERENCE

NEWSLETTERS: EMAIL

CURRENT PROFESSIONAL JOURNALS: ONLINE/APP VERSION

0 20 40 60 80 100

NPs PAs

REACH


PROFESSIONAL DIGITAL USE

Sources:1. Kantar Media, NP/PA 2019 Media Measurement Study, Website Usage.2. Kantar Media, Sources & Interactions 2019 - PA/NP Edition.

Nationally, NPs and PAs make up 27% of the 99% who use the internet for professional purposes an average of 12.8x per week1 for an average of 13 minutes per session.2

98% make prescribing decisions and 86% write Rxs using a digital platform.1

87% use smartphone/tablet for professional purposes.1

74% complete CME credits via a digital platform.1

use the internet for professional purpose

99%

use smartphone/tablet for professional

purposes

87%

write Rxs using a digital platform

86%

Consult internet-based resources on specific patient conditions more than 3.5x per week on average.1

96% read medical journal articles; 56% read digital versions; 79% read both print and digital.1

39% access webcasts/podcasts.1

access webcasts/

podcasts

39%

read both print and digital

79%

per week

3.5x Consult internet-based resources


Source:POCN NP/PA Marketing Receptivity Survey, “What NPs and PAs Want From Pharma Marketers.” January 2020.

DIGITAL SOURCES & INFO NEEDS

64%

TOP DIGITAL SOURCES FOR LEARNING ABOUT PRODUCTS OR TREATMENTS

36%

28%

20%

17%

15%

12% 47%

TOP FEATURES WANTED FROM A PROFESSIONAL ONLINE DESTINATION

69%

67%

65%

62%

CME

DISEASE KNOWLEDGE

CLINICAL PRACTICE (DOSING, ADMIN, PATIENT MGT.)

PATIENT ASSISTANCE PROGRAMS

PATIENT EDUCATION TOOLS

CO-PAY CARD, VOUCHERS

CLINICAL CASE STUDIES/PATIENT PROFILES

84%

69%

EMAIL COMMUNICATIONS

PRODUCT WEBSITE

MOBILE/TABLET APPS

SELF-GUIDED PROGRAMS

WEB PORTAL

DIGITAL WEBINARS W/RESPECTED SPEAKER

EHR (ELECTRONIC HEALTH RECORD)


NPs/PAs play an increasingly important role in clinical practice as primary care providers due to physician shortages, increased demands of an aging patient population, and healthcare needs of 318 million people with or without health insurance, in all types of practice locations.

NPs/PAs are on the front lines of providing efficient, comprehensive primary care treatment and actively prescribe across all therapeutic categories, representing a KEY INFLUENCE on the success of pharmaceutical and other healthcare products.

NPs/PAs are prolific prescription writers = MORE THAN 1 billion Rxs/year. Rate of growth could be 30% higher through 2028.

NPs/PAs are omnichannel users, accessing professional information through multiple platforms. Digital consumption is increasing.

• Access to profession information + increased patient access to NPs/PAs = improved patient communication & outcomes.

HIGHLIGHTING KEY FACTS!


WHAT THE FUTURE MAY HOLD

*Subject to state laws, hospital policies, and Medicaid programs.

DUE TO COVID-19

• The CMS waived restrictions (April 1, 2020) allowing Medicare patients in hospitals to be cared for by other HCPs including PAs, and allowed hospitals to hire PAs to increase workforce capacity and deal with patient surges.* Similarly, the Department of Veteran’s Affairs (VA) temporarily employed PAs in 157 facilities nationwide.

• HCPs can temporarily enroll in Medicare, including those who had previously opted-out for the required 2-year period.

• Expansion of the Accelerated and Advance Payment Program (emergency relief funds) ensured a substantially increased number of payments to Medicare Part A providers and Part B suppliers within days rather than weeks (to cover income losses and PPE expenses – funds must be repaid).

• As of 5/29/20, eight states waived or suspended physician supervision requirements or other select practice requirements of PAs. (AAPA.org)

THE CARES ACT (3/27/20)

• Permanently authorized NPs and PAs to order home healthcare services for Medicare patients (consistent with state law).

• Enabled televisits for new patients to be covered by Medicare (eliminating the need to have an established relationship with the patient). (IQVIA 4/29/20 study revealed a decline of 70%-80% in patient visits to physician offices, offset by a 25% increase in patient consultations by telemedicine. POCN’s COVID-19 study among NPs and PAs confirms increases in telemedicine and remote diagnoses, prescribing, and other virtual treatment interactions with patients).

• Temporarily authorized physicians and NPs to have face-to-face telehealth encounters to recertify hospice care and temporarily waived face-to-face visits between home dialysis patients and physicians, NPs, and PAs, during the crisis.

• Funded $100 billion to HCPs, hospitals, skilled nursing facilities, and the Indian Health Service.

waived or suspended physician supervision

requirements

8 states

to HCPs and suppliers

The Cares Act funded

$100 billion


Source:1. Reforming America’s Healthcare System Through Choice and Competition, 2018, pages 31-38.

Elimination of supervision

requirements

Increase in virtual, remote meetings

and events

Broaden scope of practice laws for

APRNs, PAs

A 2018 report from the U.S. Department of Health and Human Services, Department of Treasury, and Department of Labor, included recommendations for states to broaden scope of practice laws for APRNs and PAs, among other providers, to expand access to quality care.1

The increase in virtual, remote meetings and events (including major medical conventions), coupled with the heightened need for HCPs to stay up to date daily as a result of COVID-19, and supported by improved technical achievements, has accelerated the shift to digital media consumption. A “new normal” is likely to evolve. (See POCN’s COVID-19 survey for details on other changes/needs among NPs/PAs.)

Section five of an Executive Order to protect and strengthen Medicare, signed 10/3/19, could result in elimination of supervision requirements and lead to pay parity according to the nonprofit Practicing Physicians of America (practicingphysician.org).

WHAT THE FUTURE MAY HOLDOngoing Issues, Efforts, Impacts

In 2017, the AAPA’s new Optimal Team Practice policy advocates for PAs, physicians, and other healthcare professionals to work together to provide quality care without burdensome administrative constraints. It advocates for states to eliminate the legal requirement for a specific relationship between a PA and a physician or any other healthcare provider for a PA to practice to the full extent of their education, training, and experience; create a separate majority-PA board to regulate PAs or add PAs and physicians who work with PAs to medical or healing arts boards; and authorize PAs to be eligible for direct payment by all public and private insurers.

Federal and state healthcare policies, changes to the ACA, and new healthcare models, consolidation of health systems, growth of Federally Qualified Health Centers and urgent/convenient care clinics, mental health initiatives/needs, telehealth, and innovative advances will undoubtedly impact NP and PA providers.

MedPAC endorsed (9/13/19) that Section 6111 of the SUPPORT Act (substance abuse) be expanded to include APPs as covered recipients of Open Payments (from manufacturers and GPOs), beginning in 2021, reportable to CMS in 2022.

The Healthcare Workforce Resilience Act (proposed 5/8/2020) may permit up to 25,000 nurses - foreign trained or approved but delayed green card holders - to provide care in the U.S. subject to licensing requirements, background checks, etc.

PAs to be eligible for direct payment by

all public and private insurers

Section 6111 of the SUPPORT Act

(substance abuse) be expanded to include

APPs insurers

Changes to the ACA will undoubtedly

impact NP and PA providers

Documents

UNDERSTANDING THE INFLUENTIAL, EXPANDING ROLE OF NPs …