New policies and legislation related to health care reform mean that control over treatment selections may also shift within different markets. For professionals creating a clinical pathway for a disease state, it is important to understand the various stakeholder biases in real-world contexts, so that appropriate prompts may be integrated into the pathway in order to achieve the best outcomes.
The answer to the question “who controls treatment selection” has been shifting along with health care reform, but this change has not impacted every treatment or market in the same way. Stakeholders, including payers, patients, prescribers, health systems, and specialty pharmacy providers (SSPs), have their own priorities that should be considered. Treatment selection will vary greatly based on the insurer’s position, disease state, health systems, and patients. Some situations will see the traditional insurer controlling what is dispensed, while other situations may have the patient or prescriber in control. Another variable is how the specific market is structured, because insurers control different aspects of the prescription channel such as prescribers, health systems, and SSPs.
Directing treatment preferences will first require an in-depth understanding of the stakeholders who truly control the treatment selection. Given the rapid change in payments, delivery systems, and treatment options, staying on top of these changes is vitally important. Once the controlling party is identified, there needs to be an appreciation of the factors that influence each segment regarding their selection of a preferred treatment—what is the basis of their preference for one treatment over another (Table 1). In most situations, the selection is primarily based on financial and clinical outcomes as they relate to accountable quality measures. This information can be embedded into clinical pathways in order to drive stakeholders to the best treatments that will achieve their objectives.
Payers
One would initially think that insurers, by virtue of their strong influence as payer, are always the primary controller of treatment selections. After all, it generally follows that he who has the gold (the payer) makes the rules. However, in many situations, payers are not involved in controlling treatment selection. For example, in specialty areas, such as oncology or hemophilia, insurers historically have not been heavy-handed in directing selection. In these areas, the control shifts to other stakeholders because of the insurer’s limited involvement. Also, with the use of stand-alone treatment options, there is no opportunity for payers to limit utilization, so their influence is limited. This is also the case where treatment selection preference does not change expenditures from a payer standpoint, so, again, their need to influence selection is limited.
Health Systems
Health care reform legislation places greater financial risk on health systems through accountable care organizations and bundled payment arrangements. As a result, health systems are increasing their control by identifying preferred treatments. The selection of these preferred products is based on a product’s ability to assist health systems with achieving the outcomes for which they are being held accountable.
Prescribers
Historically, prescribers have been the focus of treatment pull-through efforts before any other stakeholder. Prescribers’ priorities for treatment selection typically center on superior clinical outcomes and reduction in practice administrative burden. With buy and bill (where the physician practice purchases the treatment and bills for it) as opposed to white bagging (insurance pays the pharmacist directly, so the physician does not benefit from the specific treatment), prescribers have greater influence in what is used, because they are the buyers under buy and bill models. They have less influence under white bagging, since, under this model, the medication is billed and paid directly through the insurer while the treatment is sent to the physician’s office for administration. Because of the increase in availability of specialty treatments, white bagging has increased, which has resulted in greater influence of SPPs.
Specialty Pharmacy Providers
As SSPs offer services for patients, providers, and insurers by streamlining the treatment delivery process and smoothing out the challenges in health care delivery and financing. SPPs are utilized through open or limited distribution—open channel meaning that the drug is available through any SPP as opposed to a limited distribution system. Because of their relationship with patients and prescribers, these SPPs have the ability to direct patients to specific treatments based on their contracts and incentives with the pharmaceutical manufacturer. The funds from these contracts provide the foundation for supportive services that are often critical to patients suffering from these conditions.
Patients
As high-deductible or catastrophic insurance plans increase, the financial risks for patients are increasing as well. Because of these increased stakes, patients will have a greater voice in what treatment they receive. Indeed, many prescriptions are abandoned at the pharmacy counter because patients are unwilling to commit their personal funds to purchase those prescriptions. Once abandoned, these prescriptions could be shifted to less expensive options that patients consider to be of more value. Ensuring that patients appreciate the value of the treatment is critical to their selection.
Conclusion
It is helpful for providers to be aware of the various biases at work in a range of contexts and for each different stakeholder. By utilizing the knowledge of each party’s priorities and bias within care delivery, providers can integrate prompts and options along a pathway in order to achieve the best outcomes.
