- NPs and PAs play a growing role in dermatology specialty care.
- From 2013 to 2022, the prescribing intensity for biologics for dermatologic conditions grew at a faster rate among advanced practice clinicians (APCs) versus physician dermatologists.
- Dermatology-specific APC prescribers in Medicare increased more than twofold -- from 2,707 to 6,819 -- during the study period.
The share of medication spending attributable to physician associates/assistants (PAs) and nurse practitioners (NPs) for newer biologics to treat dermatologic conditions has tripled over the last decade, researchers reported based on Medicare Part D prescription data.
In 2013, advanced practice clinicians (APCs) accounted for 10.2% of the costs for newer therapies prescribed for psoriasis, atopic dermatitis, and other conditions treated in dermatology specialty care, a percentage that grew to 31.2% by 2023. Costs for these drugs associated with APC prescribing ballooned from $24 million (of $236 million total) to $744 million (of $2.39 billion total).
Total costs in Medicare Part D associated with prescriptions for these drugs from APCs increased at an annual clip of 46.3%, as compared with 25.5% for physician dermatologists, reported Arash Mostaghimi, MD, of Brigham and Women's Hospital, and Edward Kong, PhD, of Harvard Medical School, both in Boston.
"These increases were partly accounted for by faster growth in the number of dermatology-specific APCs relative to physician dermatologists," wrote Mostaghimi and Kong in JAMA Dermatology.
The number of dermatology-specific APC prescribers in Medicare Part D increased from 2,707 to 6,819 during the study period, while the number of physician dermatologists increased from 10,048 to 11,208, representing annual increases of 10.8% and 1.2%, respectively. By 2022, APCs accounted for 38% of prescribing clinicians in dermatology specialty care.
While overall prescribing intensity increased at similar rates between APCs and physician dermatologists during the study, the intensity of specialty medication prescribing -- the cost per prescriber-year for these newer biologics -- increased at a faster annual rate for APCs (32% vs 24% for the physicians).
"Our findings may have relevance for APC training, particularly regarding education on evidence-based prescribing and cost considerations," according to the study authors.
APCs are a growing part of the dermatology workforce, with an estimated 6,000 PAs and 6,000 NPs now providing dermatology specialty care, and the study raises questions regarding their scope of practice, how they can provide high-value care, and how they are educated, according to an accompanying editor's note.
"Clear delineations of the APC scope of work in dermatology may help inform curriculum development for their initial and continuing professional education," wrote Ivo Abraham, PhD, RN, of the University of Arizona in Tucson, and colleagues. "Given the low density of dermatologists in rural regions, policy initiatives of adding APCs to the rural workforce may mitigate this disparity and improve access to dermatologic care."
They noted that NPs and PAs could also help improve access to underserved populations.
"While the distribution of APCs underscores their growing role in dermatology, their patient care responsibilities, clinical outcomes, and healthcare utilization should be evaluated systematically," added Abraham and co-authors.
For their study, Mostaghimi and Kong used the Centers for Medicare & Medicaid Services (CMS) Physician and Other Supplier Public Use File, examining over 94 million prescription drug claims from 9,918 dermatology-specific APCs and 14,830 physician dermatologists.
From 2013 to 2022, overall drug costs associated with dermatology-specific APC prescribing increased from $140 million to $952 million (23.7% annual increase), as compared with $627 million to over $2 billion for physician dermatologists (13.8% annual increase). Spending for dermatology-specific biologics associated with physician dermatologist prescriptions increased from $212 million to $1.64 billion. All figures were reported in 2022 U.S. dollars.
The proportion of APCs who prescribed any dermatology specialty drug increased from 11.3% in 2013 to 40.9% in 2022. For physician dermatologists, the share rose from 18.2% to 47% during the study period.
Study limitations included the exclusion of clinicians not included in the CMS dataset, that drug rebate information was not available, that prescription appropriateness was not assessed, and that new prescriptions versus refills could not be evaluated.
Disclosures
The study was funded by an award from the National Institute on Aging.
Mostaghimi disclosed relationships with hims & hers, AbbVie, Sun Pharma, Pfizer, Lilly, Boehringer Ingelheim, Legacy Healthcare, Q32 Bio, and Astria Therapeutics. Kong had no disclosures.
Abraham reported owning stock in Matrix45, which has received contract funding from Coherus, ITM Radiopharma, Celltrion, G1 Therapeutics, European Commission, Eastern Research Group, CMR Institute, Mylan/Biocon, MorphoSys, Sanofi, GSK, Syndax Pharmaceuticals, Disc Medicine, Jenner & Block, Fish & Richardson, Hueston Hennigan, and Rakoczy Molino Mazzochi Siwik. Abraham is also the editor in chief of the Journal of Medical Economics. Co-authors of the editor's note included JAMA Dermatology editors.
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