Pharma reps have visited NPs for over a decade, but all too often we forget a large section of HCPs in branded and awareness campaigns.  

Today, mid-level practitioners see a broader volume of patients than ever before. The reasons for this are legion: a physician shortage, an aging population, reduced RVU/reimbursement, and a P&L focus where efficiency and cost weighs highly on staffing.

Ironically, both nurse practitioners (NPs) and physician assistants (PAs) grew out of the first doctor shortages in the 1960s as “physician extenders” that owned more mundane diagnostic tasks. Now both mature professions, both have grown in the scope of their responsibilities though their outlooks are distinctly different.

For branded and awareness campaigns, it will be important going forward to get a handle on all things midlevel: when, where, and how patients interact with them; how they digest information; and what are the cultures like inside the professions.

Below, I’ve outlined a few takeaways from a previous study where a past role looked at how HCPs communicated vaccine information to the vaccine hesitant.

Physician Assistants

Most PAs operate with a similar mindset to physicians: they view patients and treatments clinically and with an element of a dispassionate scientific eye. Training is arduous. Most earn a three-year masters degree and add 2,000 or more clinical hours to complete their certification. They can prescribe in all 50 states, though what they can prescribe differs wildly from state to state (few can write Schedule IIs for instance).

While the state they practice n determines much of their lived reality, so does the health system they work in. Some systems deploy PAs as independently as possible, but others will provide a complex supervisory apparatus. Unlike NPs, they cannot set up an independent practice, so almost all behavior will be in part impacted by the full physicians they work for or with.

In a past project, we looked at ways PAs deal with vaccine hesitancy, and most relied on clinical language, MOA metaphors, and explaining safety metrics (often repeatedly) to patients. Their trust in the product and it’s scientific merit largely informed their outlook.

Messaging to PAs

• Targeting PAs is difficult. There are also fewer PAs (~95,000) than NPs (~325,000), which automatically means there are fewer opportunities for script lift.
• Most work in variations of higher physician oversight and may have less individual autonomy.
• For brands, it is critical to deliver high science, high trust information much as you would with physicians.
• In our studies, PAs report higher levels of dissent from patients around their medical judgement than physicians or NPs. Equipping PAs with their preferred information and treating them like well-informed partners will build better relationships with brand.
• PAs reported a high willingness to learn about disease states that they see often, opening them up to unbranded/awareness campaigns.

Nurse Practitioners

A friend recently said to me, “I got to my doctor, who is an NP.” That encapsulates much of the complexity in the NP space. In many instances, they have taken over as a primary point of care. Like PAs, they hold a masters (sometimes doctorate) but always begin life as registered nurses (RNs). As a result, their practices and culture reflect more closely to nurses than physicians.

Like PAs, NP licensing varies state by state, but crucially NPs can set up independent practices in many states. Their prescribing can be more restricted, and many even take on specialties like psychiatry and provide basic point of care and prescriptions.

Returning to our hesitancy study, NPs tended to rely more on timing and benefit. Their language and tactics often focused on care rather than clinical efficacy.  To sum it up, most say “It’s time for your shot. It will help you” rather than engaging in a more clinical discussion.

Messaging to NPs

• Targeting NPs can be difficult because of the variation in their practices. Knowing where patients interact will be critical to success.
• Depending on brand or disease state, it might be useful to segment them – say by specialty, independent, employed, or even community/academic. This will take a deep understanding of the disease state.
• NPs tend to focus more on markers that “get it done,” which mirrors much of the behavior seen in RNs.
• NPs almost unilaterally believe that advertising and outreach do not impact their judgment or behaviors with patients. Whether that’s statistically true or not, embracing messaging that is less “you should” and more “we know you know but …” in approach can help seed ideas and behavior without resistance.

The Future

The mid-level landscape is changing very quickly and promises to change even more in the future. In the wake of COVID-19, more discussion around a national model for NPs and PAs has circulated, but we’ve yet to see broad movement on that front. I believe it is coming. If NP-PAs each had uniform standards between states more similar to physicians, then targeting becomes significantly easier by removing some of the major geographical variation.

Second, brands should have urgency in making these adjustments in specific categories, like psychiatry and dermatology, where structural changes have emerged. In these two categories, low reimbursement rates and high investment by private equity have made cash payments much more common. Insurance-dependent patients now see more general and primary care practices for medication management in these fields – and those practices now have more PAs and NPs. (Similarly, PE investment in family med practices has seen more mid-levels taking on more patients in the name of profit).