Midlevel Healthcare Providers: An Untapped Prescribing Force

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Denise Myshko

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Billions of prescriptions — and millions of dollars — are being influenced by a group of individuals who go largely untapped when it comes to communications, outreach, and education. Nurse practitioners (NPs) and physician assistants (PAs) wrote 7.8% of U.S. prescriptions — 308 million from June 2009 through June 2010 — up 20.24% from the previous year, and these scripts are valued at $20.2 bilion (7.6% of prescriptions), according to IMS Health. The NP/PA Will See You Now The physician is just one of many key stakeholders important in the prescribing decision; in all 50 states NPs and PAs can examine and diagnose patients and prescribe therapies. And with more than an estimated 30 million new patients expected to enter the healthcare system in the coming year as a result of the Patient Protection and Affordable Care Act, pharmaceutical companies and their healthcare communications agency partners would be well-advised to start to address this growing sphere of key decision-makers. NPs and PAs are not new to the healthcare system. They have been part of the continuum for more than 40 years, but there is increasing recognition of the important role these healthcare providers play in clinical practice and patient care management. “There is a great benefit to successful practices having NPs and PAs in the office,” says Meaghan Onofrey, president of insights and analytics at Ogilvy CommonHealth. “There are financial incentives for practices to employ these midlevel providers. The office can see more patients without employing more physicians, who are more expensive from a salary and malpractice perspective. Our work has shown that NPs and PAs tend to have better training in communication, and often they have the ability to build rapport with patients more easily, resulting in better dialogue and outcomes.” NPs and PAs are in high demand as physicians face increasing pressure from payers to see more patients, says Mark Calabrese, VP and general manager of marketing solutions at Cegedim Dendrite. “The dynamics of the business model have changed; physicians need to see more patients,” he says. “Physicians’ offices, medical centers, and emergency rooms bring in these healthcare practitioners to lighten the load. The balance has nearly reached a tipping point; there are almost as many NPs/PAs seeing patients as there are physicians. Down the road, these professionals will probably become the primary provider of healthcare in the office setting.” Kathleen Nelson, Ph.D., senior VP, scientific officer at Vox Medica, agrees that reimbursement to and the time constraints on primary-care physicians have changed over the past 10 years and having NPs and PAs as the first line of care for patients has grown in popularity. “The practice of medicine is going to change to meet the demands entailed with primary care,” she says. “I can even envision a time when nurse practitioners and physician assistants might establish their own independent practices, with some back up from a physician, to meet these needs.” That could become a reality in the near term. In July, the Department of Health and Human Services announced it would provide $15 million for the operation of 10 nurse-managed health clinics to support education and training and to provide primary healthcare services to populations living in medically underserved communities. In addition, the healthcare reform law provides $250 million in investments intended to increase the number of healthcare providers and strengthen the primary-care workforce, of which $32 million of this new funding is specifically intended to support the development of more than 600 new physician assistants. On the Front Lines Mr. Calabrese says nurse practitioners and physician assistants are taking on direct patient care and are more responsible for diagnosis and treatment. “They’re going to develop their own cadre of pharmaceutical options and treatment modalities that they are most comfortable with and that work best for their patients,” he says. “They are also playing an important role in the dissemination of education to drive patient behavior change.” Because multiple healthcare stakeholders are coming together to manage a treatment regimen, NPs/PAs are increasingly becoming co-partners in the administration of drugs and other care options with a broad audience of patients, says Gaurav Kapoor, head of strategic marketing solutions at Indegene. “In my experience, nurse practitioners and physician assistants are increasingly becoming independent decision-makers for a majority of therapies related to primary care and internal medicine,” he says. “Because of the increased volume of patients and the changing health economic model in the United States, we view qualified NPs and PAs as being integral to physician practices and key influencers for patient prescriptions.” This well-educated, highly professional group of people has not had the recognition of their talents for a long time because they’ve been under the shadow of the physician, Dr. Nelson says. “I surmise that they have a tremendous amount of influence over prescribing,” she says. “They are on the front lines. They see drug reps, they make decisions about what drugs should be prescribed, and I think their influence hasn’t been adequately documented. In the future, those data will be forthcoming but there isn’t a huge body of data right now.” Melissa Hammond, managing director of Snowfish, agrees that it’s hard to know exactly the type or amount of influence nurse practitioners and physician assistants have over prescribing because the data aren’t accurate. “At first glance, it appears that this group doesn’t have much influence at all,” she says. But a survey of NPs and PAs by Snowfish contradicts this assumption. Snowfish surveyed more than 400 midlevel practitioners, who indicated they were writing an average of 50 prescriptions a week. Therefore, this group alone — representing fewer than 0.2% of the NP/PA universe — is writing more than 1 million prescriptions a year. Additionally, the NPs and PAs that Snowfish surveyed indicate that they write prescriptions without taking direction from a collaborating physician more than 76% of the time. The company estimates that about 99% of the prescription volume of midlevel practitioners is not being captured by data providers. Prescription for Success Ms. Onofrey says there is often confusion among her pharmaceutical clients. Some believe that the NP or PA is providing only a supporting role in the practice. “Oftentimes, these healthcare providers are overlooked by clients, but we’ve uncovered that PAs and NPs often have the same influence as a physician in a practice,” she says. “When pharmaceutical companies become involved with them and provide them with information and value-added services, NPs/PAs can be highly influential to the success of a product.” Dr. Nelson says there is a tremendous opportunity to develop brand loyalty if pharmaceutical companies have the vision to recognize NPs/PAs as an independent group that has a lot of influence on healthcare. Greg Barrett, VP of marketing at Daiichi Sankyo Inc. (DSI), agrees that this is a group that pharma traditionally has not spent a lot of time with. “But they are receptive when we provide them with meaningful, objective, and important data about our products and about disease states,” he says. DSI has made a commitment to connecting with this audience by providing unrestricted grants, through efforts of the field forces, and through medical and professional meetings. “We provided an unrestricted grant to the Preventive Cardiovascular Nurses Association so that it can develop materials to give its constituents to help educate patients,” Mr. Barrett says. “When we are able to provide resources to organizations such as PCNA, we are happy to do so because we know it will ultimately benefit patients.” The company also has a salesforce structure that allows representatives to focus on the entire group practice setting. “We employ a concept of the total office call,” Mr. Barrett says. “If a practice or doctor’s office has physicians, NPs, and PAs, we want our reps to be able interact with all of the individuals who are involved with providing quality healthcare to patients. We think this is the best way to communicate effectively about our products. It’s about creating the opportunity to have a good dialogue with the healthcare providers, whether they are physicians, nurse practitioners, or physician assistants.” Mr. Calabrese suggests that pharmaceutical companies begin to make investments to find out who and where these professionals are so sales reps and nonpersonal promotional efforts can be appropriately directed. “Because their focus takes a very patient-centric approach, NPs and PAs need education to help them manage their patients’ compliance,” he says. Ms. Hammond says nurse practitioners and physician assistants need to see case studies, patient profiles, and information about disease states to be able to adequately manage the variety of patients who may come through the door with a particular disease. “Just like with physicians, they need to receive solid facts about the drugs and postmarketing data, as well as information about side effects and trials,” she says. But Ms. Onofrey stresses it’s important not to simply take the physician-directed materials and put a different name on them. “This approach will not work,” she says. “Pharmaceutical companies have to cater to the unique needs of NPs and PAs. An NP in a neurology practice might be very different from a PA in a pediatric setting. As they do with physicians, pharmaceutical companies should segment these providers, get to know them, and understand their needs.” Ms. Onofrey says because script tracking is difficult, there are other avenues that should be considered for getting to know these practitioners. “Many of our clients are attending meetings where NPs/PAs are playing a bigger role,” she says. “There are several NP/PA organizations that are specifically dedicated to the fields that our clients are looking at, whether it be atrial fibrillation or epilepsy. There are a lot of different venues, from an educational standpoint, that our clients are able to tap into. There are definite benefits to taking a ground-up approach versus letting the script data control the interaction.” Mr. Kapoor says many pharmaceutical companies are exploring nontraditional methods of reaching out to nurse practitioners and physician assistants. “Campaigns involving the right mix of e-marketing, e-sampling, tele-detailing, and reduced personal contact have shown excellent results,” he says. “This is different from the traditional approach of detail-heavy campaigns that continue to be applied to physician audiences.” “Virtual vehicles, such as interactive tutorials, interactive case studies, and preceptorships, have been shown to increase knowledge and action with this and other audiences,” Mr. Kapoor adds. A Manhattan Research study found that almost 90% of nurses visited a pharma, biotech, or device corporate or product website in the past 12 months. Among corporate sites, Merck and GlaxoSmithKline are the most visited by nurses. Though the majority of nurses visit manufacturer websites, general professional medical websites have much higher retention rates among this segment. While a majority of nurses use social networking sites for personal reasons, few are visiting professional online communities. F PharmaVOICE welcomes comments about this article. E-mail us at feedback@pharmavoice.com. There are more than 75,000 Physicians assistants in the U.S. Source: American Academy of Physician ­Assistants “At first glance, it appears that as a group NPs and PAs don’t have much influence at all, but a survey of more than 400 midlevel practitioners, revealed they are writing an average of 50 prescriptions a week. We have found that a combination of factors determines influence.” Melissa Hammond Snowfish Nurse practitioners write an average of 19 prescriptions a day or about 556 million ­prescriptions annually and about 332 million medications were prescribed or recommended by Physician assistants. “The balance has shifted. The physician’s influence in the prescribing arena has in many ways decreased and the role of NPs and PAs has increased.” Meaghan Onofrey Ogilvy CommonHealth “With more personalized care plans coming into play to combat complex chronic diseases, NPs/PAs have become an integral part of disease management and patient support systems that drive positive health outcomes.” Gaurav Kapoor Indegene Nurse Practitioner Facts: n 96.5% of NPs prescribe medications and write an average of 19 prescriptions a day or about 556 million prescriptions annually n NPs hold prescriptive privileges in all 50 states, including controlled substances in all but three n 62% see three to four patients per hour; 12% see more than five patients per hour n 66% practice in at least one primary-care site; 31% practice in at least one nonprimary-care site (such as inpatient, emergency, surgical, or specialty practice); 20% practice in rural or frontier settings n About 8,000 new NPs were certified in 2008 n 92% of NPs maintain national certification; 88% have graduate degrees; 39% hold hospital privileges; 13% have long-term care privileges n The average NP is female (94.6%) and 48 years old; she has been in practice for 10.5 years as a family NP (49%) Physician Assistant Facts: n About 257 million patient visits were made to physician assistants; about 332 million medications were prescribed or recommended by PAs n All 50 states, the District of Columbia, and Guam authorize PAs to prescribe n 37.5% work in hospitals; 24.2% work in single-specialty physician groups; 11.2% work in multi-specialty physician groups; and 8.6% work in solo physician practices n Physicians may delegate to PAs those medical duties that are within the physician’s scope of practice and the PA’s training and experience n State medical and physician assistant practice acts and regulations generally allow physicians broad delegatory authority, which permits flexible, customized team practice n In facilities such as hospitals, PAs obtain clinical privileges through a system similar to the one used for physicians n With a projected growth of 39%, the Bureau of Labor Statistics predicts PAs will be the second-fastest growing health profession in the next decade (after home health aides); projected employment in 2018 is 103,900 Sources: American Academy of Nurse Practitioners. For more information, visit aanp.org. American Academy of Physician Assistants. For more information, visit aapa.org. “NPs and PAs are ­traditionally not a group that pharma companies have spent a lot of time with. But NPs and PAs are very ­receptive to an appropriate and meaningful ­engagement.” Greg Barrett Daiichi Sankyo How Industry May Offer Value to NPs/PAs: 1. Train sales representatives to understand the role of NP/PA. 2. Sponsor/support educational activities and in-services specifically focused to NPs/PAs. 3. Provide more sponsorship to NP/PA professional society meetings. 4. Don’t exclude NPs/PAs from signing for/accepting samples (when no other restrictions exist). 5. Fund lectures delivered by key opinion leaders who are NPs/PAs. 6. Recognize NPs/PAs in marketing materials, advertisements, and patient handouts when referring to the treating clinician (don’t limit to “ask your doctor”). Source: Snowfish LLC. For more information, visit ­snowfish.net. “The role of NPs and PAs allows more time for patients to ask ­questions, have questions answered, and learn about their disease state or treatment options.” Mark Calabrese Cegedim Dendrite “NPs and PAs have a tremendous amount of influence over prescribing. They are there on the front lines. They are the ones who see drug reps, and they make decisions about what drugs should be prescribed. “ Dr. Kathleen Nelson Vox Medica Top Prescription Drug Categories Written by NPs/PAs Estimates of Nurse Practitioner Prescription Writing NP Specialty Total Number Lower Rxs/Yr. Upper Rxs/Yr. Family Medicine 46,000 19,550,000 80,500,000 General Internal 18,000 7,650,000 31,500,000 Medicine Pediatrics 13,000 5,525,000 22,750,000 Source: Snowfish LLC. For more information, visit snowfish.net. There are about 140,000 ­practicing Nurse practitioners in the United States. Source: American Academy of Nurse ­Practitioners In this age of ever-increasing price pressure and cost control, the professional group of NPs and PAs offers a wonderful opportunity to provide quality healthcare at a reasonable cost,” says Greg Barrett, VP of marketing at Daiichi Sankyo. “Today, NPs and PAs are accredited professionals and many hold master’s degrees. This is a group qualified to provide quality healthcare.” Nurse practitioners are advanced practice nurses who provide healthcare services similar to those of a physician. NPs diagnose and treat a wide range of health problems. They have graduate education and clinical training beyond their registered nurse degrees. Physician assistants are graduates of an accredited PA educational program and who are authorized by the state to practice medicine with the supervision of a licensed physician. Physician assistants and nurse practitioners can prescribe in all 50 states; many states also allow them to prescribe controlled substances. Mark Calabrese, VP and general manager, marketing solutions, at Cegedim Dendrite, says NPs and PAs have become the primary triage and treatment point for patient care, and they take it upon themselves to make the time to consult with patients. “In many cases, the NPs and PAs are the first to treat the patient coming through the door, determining whether an illness can be handled in the office setting or if it requires a referral back to the physician for the next level of testing or procedure,” he says. “They try to help patients understand why they’re being prescribed a particular medicine, why it is so important to fill the prescription, and why treatment regimens are necessary. They try to instill in patients the importance of taking on some responsibility for the success of the treatment.” According to Manhattan Research, U.S. nurses believe they have considerable influence on patients’ health decisions and behavior. The Taking the Pulse Nurses v10.0 study found that more than 80% of nurses encourage patients to take advantage of health and condition websites and are significantly more likely than physicians to recommend these resources to their patients. The research is based on interviews with more than 1,000 U.S. nurses and PAs and focuses on the media and device preferences, professional resource mix, and digital behaviors and attitudes of these segments. Rep Access to Physicians Continues to Decline Obtaining access to busy physicians grew more difficult for pharmaceutical sales representatives in 2009, as the number of physicians willing to see most reps fell almost 20% and the number of prescribers refusing to see most reps increased by half. According to findings from ZS Associates’ spring 2010 AccessMonitor report, only about 58% of prescribers in 2009 were “rep-accessible,” defined by the report as meeting with at least 70% of the sales reps who called on them. This is down 18% from the year-earlier report that showed 71% of physicians as rep-accessible. At the same time, the number of “rep-inaccessible” prescribers — those who saw fewer than 30% of the reps who called on them — increased to 9% from 6% in the year-earlier survey. The report classified 33% of physicians as “rep-neutral,” meaning they see 31% to 69% of the reps who call on them. “Sales management should accept that reps can’t reach these doctors simply by telling them to try harder, “ notes Chris Wright, principal and leader of the pharmaceutical practice at ZS Associates. While physician access continues to decline, the influence of NPs and PAs in the decision-making process continues to increase. Executives from Snowfish say this group of midlevel practitioners are looking for added value from pharmaceutical companies. Those who responded to a Snowfish survey of more than 400 NPs and PAs indicated a number of ways that the industry could reach the NP/PA audience, including: training sales representatives to understand the role of the NP/PA; sponsor-supported educational activities and in-services specifically focused to meet the needs of NPs/PAs; more sponsorships provided to NP/PA professional society meetings; and funding lectures delivered by key opinion leaders who are NPs/PAs. A handful of participants indicated that they are not sampled as much as they would like. A few commented that some companies do not allow them to sign for samples, even when the physician is not available. This has been identified as a frustration point for these particular NPs/PAs. According to Melissa Hammond, managing director of Snowfish, one best practice for reaching the NP/PA audience is to focus on providing valuable education in the office setting. “Almost 90% of nurse practitioners are women, many have families and — just as with physicians — they may not have time to attend programs outside of the office,” she says. “Dinner meetings are the worst way to reach this audience. In-office education or online programs should become part of the strategy.” Mr. Wright says progressive pharmaceutical companies now recognize the need to be more precise and more efficient with their sales and marketing efforts. Many of these companies have responded by adopting a new salesforce deployment strategy called “differential resourcing.” F Nurse practitioners and physician assistants are a very significant audience and an ­important part of the healthcare equation. Expanding the Healthcare Equation “Managers must modify the call plan to connect best with each ­individual healthcare provider.” Chris Wright ZS Associates

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