Scott A. Flanders, MD

Health plans have a significant role to play in managing antibiotic use. By that, I mean all health plans — those serving commercial populations and those serving Medicare and Medicaid members.

Beyond paying for care, health plans provide financial incentives to ensure that providers achieve certain goals, such as those associated with quality improvement, appropriate utilization, and cost containment. To date, health plans have not had much of a role in managing the use of antibiotics, but clearly we have reached the point where overuse has created a significant threat to patient safety. Therefore, it makes perfect sense that health plans would track antibiotic prescribing and provide financial incentives to ensure appropriate use.

Scott Flanders, MD

Payers can do more to foster appropriate use, says Scott Flanders, MD, of the University of Michigan. “How many plans require hospitals to establish infection-prevention strategies?”

Everyone involved in delivering and paying for care needs to be aware of the rates of infection for all organisms associated with antibiotic overuse. Hospitals need to track the incidence of infections potentially caused by antibiotics, such as Clostridium difficile — an organism that causes severe diarrhea and, in some cases, death. Having these data will allow plans to develop creative ways to provide financial incentives to reduce antibiotic overuse.

Many — but not all — hospitals have formal antibiotic stewardship programs. Every hospital should be asked to demonstrate that a stewardship team exists and that the team is reporting on resistance among organisms, tracking antibiotic use, and showing that the team is taking the appropriate steps to facilitate appropriate antibiotic use.

In the Morbidity and Mortality Weekly Report of March 7, researchers from the Centers for Disease Control and Prevention showed that hospitals often prescribe antibiotics incorrectly by failing to do the proper evaluation or follow-up. As my colleague, Sanjay Saint, MD, and I wrote in JAMA Internal Medicine on March 4, it is disheartening that after years of effort to educate physicians and hospital staff about the importance of appropriate use of antimicrobials, little progress has been made.

After reviewing data from its Emerging Infections Programs, CDC found opportunities to improve 37% of prescriptions for antibiotics by more timely use of diagnostic tests and better documentation of symptoms. These observations are similar to those of earlier studies showing that about 30% to 50% of antibiotic prescribing might be incorrect.

Fostering appropriate use of antibiotics is one step health plans can take, but there’s much more that can be done, starting with eliminating health care-associated infections in the first place. How many health plans require hospitals to establish infection-prevention strategies? We know that hand-hygiene programs are effective in stopping the spread of infections. But do health plans track how well hospitals enforce hand-hygiene rules?

We also know that the appropriate use of certain devices, such as catheters, can limit infections. Hospitals follow established procedures for minimizing infections from central-line associated bloodstream infections (CLABSI), for example, and the Centers for Medicare & Medicaid Services (CMS) tracks these numbers.

Here in Michigan, many hospitals have succeeded in reducing CLABSIs to near zero, in part by following checklists and implementing other best practices. It’s time for commercial health plans and CMS to do more to ensure that hospitals follow proven performance methods such as those adopted in Michigan and elsewhere.

Many hospitals are establishing efforts to reduce catheter-associated urinary tract infections (CAUTIs). By revising these efforts, hospitals could track the rate of physicians giving antibiotics to patients who are believed to have CAUTIs. Access to those data would allow health plans and hospital administrators to see prescription rates and prescribing patterns and identify physicians who need education on the use of antibiotics.

Physicians already recognize that a patient with a possible bacterial infection may or may not benefit from an antibiotic. As we noted in JAMA IM, physicians need to weigh the advantage of prescribing a potentially beneficial antibiotic against the potential harm to society.

At the point of care, this issue is not always easy to resolve. Doctors need antibiotics and they know that withholding them can cause great harm to patients. That’s why we need strategies not just to reduce the use of antibiotics but to ensure that we use the ones we have appropriately.

Scott A. Flanders, MD, is a professor of medicine at the University of Michigan and director of the hospital medicine program in the university’s Department of Medicine.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

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The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.