In Many Ways, Industry Payments to NPs, PAs Competitive With Physicians

The first analysis of Open Payments data for advanced practice clinicians (APCs) revealed strong industry interest in establishing relationships with these providers that, in some respects, is on par with doctors.

Overall, physicians made far more money from industry in 2021: $1.87 billion, compared with $121 million for APCs, reported Parth Modi, MD, MS, of the University of Chicago, and colleagues in JAMA Network Open.

But when looking specifically at the median payment amounts and median number of payments — a proxy for interactions with industry — they found that the playing field became more level. Median total payment for doctors was $167, and $117 for APCs, and the median number of “interactions” was four for both groups.

“We know from social psychology research that even small amounts can influence behavior,” Modi told MedPage Today. “It may be that the number of interactions per year is more relevant, potentially.”

The CMS Open Payments database was established in 2010 under the Physician Payments Sunshine Act, which first reported data from 2014. Initially, only payments to physicians were required to be reported, but the database expanded to include APCs — nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists, clinical registered nurse anesthetists (CRNAs), certified nurse midwives, and anesthesiologist assistants — for the first time in 2021.

The data for this analysis became available in June and included 412,000 physicians and 232,000 APCs.

“We know from 8 years now of research using Open Payments data for physicians that almost every study has suggested there is an association between payments and physician behavior, whether that’s prescribing, editorial positions, choice of medical devices, and so on. It also leads to higher-cost prescribing,” Modi said.

“We thought it was important, given that we know that APCs, especially NPs and PAs, are a very quickly growing part of the healthcare workforce, and we wanted to understand if these things are similar for them,” he added.

The $121 million earned by APCs in 2021 accounted for 6% of the nearly $2 billion total, and among these providers, NPs earned the most ($79 million), followed by PAs ($39 million) and CRNAs ($2 million).

While the figures overall seem heavily skewed toward physicians, Modi said that doesn’t tell the whole story, explaining that physicians were far more likely to have ownership and stock payments.

“We see physicians who are inventors or have created a device or have intellectual property or an ownership stake in these businesses,” he said. “The data are skewed by these large-ticket items to physicians. So we also reported the medians, which are much more resistant to the big outliers. And they’re not that different” between doctors and APCs.

Indeed, Modi and team found that the most common payments to both physicians and APCs were for food and beverage (91% and 97%, respectively).

For APCs, industry spent $69 million on food and beverage, $32 million on services other than consulting, and $8 million on consulting fees.

Adriane Fugh-Berman, MD, of Georgetown University in Washington, D.C., who has long scrutinized physician-industry relationships, said in an email to MedPage Today that industry focuses its marketing efforts “on whoever controls the market share.”

Today, one in four prescriptions in the U.S. is written by an advanced practice nurse (APN) or PA, she noted.

Industry “has taken notice, recruiting NPs and PAs as key opinion leaders, funding their conferences, and in general using all the same tactics they use to woo physicians,” she said. “Although physicians have become more wary of drug reps and industry offerings, APNs and PAs are behind in terms of this awareness.”

Modi and team also found that states with the most restrictive scope-of-practice laws were associated with a 16.3% lower total value of payments to APCs compared with states with the least restrictive laws (incidence rate ratio 0.84, 95% CI 0.75-0.93, P=0.001).

“The greater value of payments to APCs who practice in states with the least restrictive scope-of-practice laws suggests that industry payments may be related to clinician autonomy,” they wrote.

While the findings appear consistent with other literature suggesting that industry payments influence the prescribing practices of doctors, Modi warned that they are preliminary and that there’s “a lot more work to be done” in terms of understanding the influence of industry payments on APCs.

“I wouldn’t say the influence is the same. We don’t know that yet,” he said. “But certainly the exposure to marketing efforts appears to be similar for physicians and APCs.”

His group is planning follow-up studies looking at whether the payments to APCs influence prescribing habits, as they do for physicians.