Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD – Chief Medical Officer
February 26, 2018
New policies and legislation related to health care reform mean that control over prescription drugs selections may also shift within different markets. For providers and provider groups creating clinical protocols 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 protocol in order to achieve the best outcomes. Drug selection will vary greatly based on the insurer’s position, disease state, health system, and patient. In addition, stakeholders like payers, patients, prescribers, health systems, and specialty pharmacy providers, each have their own priorities that should be considered. Some situations will see the traditional insurer controlling what is dispensed, while other situations may have the patient or prescriber in control. For example, an insurer will have drug and related medical expenses as a high priority while patients are seeking quality of life and low out-of-pocket costs. Prescribers have a keen eye on revenue, patient volume, quality measures, and buy-and-bill options while health systems are targeting accountable outcomes and total cost of care. And finally, specialty pharmacy providers gain their income from the cost of treatment plus the rebate dollars. While the overarching priority is to provide the right treatment for the right patient, sometimes, as you can see, each stakeholder’s biase may influence their decisions.

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