Spectrum

November 2013

Shifting Dynamics in U.S. Prescribing Power: Who Are the New Decision Makers?

Report Authors
Jane DuBose, M.B.A.
  • Pages:33
  • Tables:10
  • Figures:17
  • Citations:30
  • Drugs:0
  • Interviews:3

Introduction:

The U.S. healthcare system is undergoing its biggest changes in more than 40 years as the Affordable Care Act unfolds. Millions of U.S. citizens who were previously uninsured will now have access to prescription drug benefits, a boon to the pharmaceutical industry. But prescriber dynamics are changing to accommodate the other goals of healthcare reform: cost savings, more coordinated care, and improved outcomes.

Biopharmaceutical companies must understand the new prescribing dynamics and tailor their messages to stress value, improved outcomes, and overall cost savings in episodes of care. Biopharma can be a resource to physicians and hospitals who are under increasing pressure to bend the cost curve and provide value to patients.

Questions Answered in This Report:

  *   Hospitals are buying up physician groups and aligning through ACOs, and physician groups are getting larger, all leading to more centralized control over prescribing. Prescribing choices are under more scrutiny because of their role in accountable care organizations and patient-centered medical home standards. To what extent is the physicians’ control over prescribing choice evolving? How is physician compensation used to control prescribing?

  *   Through formularies and utilization controls, managed care plans have long imposed controls over physician prescribing for commercially insured patients. Through expansion of managed care in Medicaid, more physicians and patients are subject to those controls. At the same time, three out of four seniors are now part of Part D plans with built-in formularies and networks. How will managed care’s deeper reach into Medicaid and Medicare affect prescribing? To what extent are managed care tools such as clinical pathways and electronic prescribing impacting prescribing?

  *   The ACA mandates that most people have insurance, driving those without insurance to the new health benefits exchanges and forcing managed care organizations to market directly to individuals. Even if the consumer finds affordable premiums, cost-sharing will force members to take a hard look at deductibles, copays, and formularies. How is the patient’s role in prescribing changing? What drives patients’ choices?

Scope:

Markets covered: United States.

Analysis of Accountable Care Organizations: Percentage of physicians who are full or partial owners of their practices; Quality of care metrics for Medicare Accountable Care Organizations; Drug reimbursement in an ACO; Insights from hospital and ACO management; Mechanisms to involve physicians in risk-sharing; Medical home standards.

Managed care’s growing influence in public markets: Growth of Medicare Part D, 2010-2013; U.S. Medicare Advantage growth, 2010-2013; Percent of Medicare Advantage plans by star rating; Oncologists’ participation in clinical pathways programs; Oncologists’ incentives to follow pathways; Impact of physicians’ use of EMR in diabetes.

Patient’s role in prescribing: Average copays and coinsurance for workers with 3 or 4 tiers of prescription benefits; Growth of health savings and health reimbursement account enrollment; Consumer actions after finding health/medical information online; Influence of information sources in key medical situations.


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