Maureen Hennessey, PhD, CPCC

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	The call for antimicrobial stewardship is growing in the healthcare landscape. 

 of pan–drug-resistant infections have occurred and, without action, society risks returning to the pre-antibiotic era. An underlying cause of resistant bacteria is the overuse of antibiotics. The Centers for Disease Control and Prevention (CDC) 

 that 30% of antibiotic prescriptions are unnecessary. The federal government’s National Action Plan for Combating Antibiotic-Resistant Bacteria was released to provide guidance on reducing antibiotic use in unnecessary situations and help stem resistance development. The report’s goals include slowing the emergence and spread of resistant infections, strengthening resistance-prevention efforts, and accelerating the development of new 

	Health plans and PBMs face complications in how to contribute to antimicrobial stewardship. Patients receiving antimicrobials often receive a short course of treatment, require a specific product based on the infectious organism and site, and may be transitioning home to finish therapy from a healthcare facility where therapy was started. These factors make traditional management techniques difficult. In addition, antimicrobials tend to be generic and inexpensive, which reduces a payer’s focus and resources in managing antimicrobials. 

	Challenges aside, payers nonetheless have capabilities to assist in antimicrobial stewardship. The following four steps, when enacted by payers, may help facilitate appropriate antimicrobial use and reduce the 

rise of resistant bacteria and other microbes, such as drug-resistant fungi

. Health plans may wish to include any or all of these steps in their quality improvement programs and work plans.

	In November 2016, augmenting previously issued guidance for antibiotic stewardship in hospitals and nursing homes, the CDC released the 

Core Elements of Outpatient Antibiotic Stewardship

. The outpatient core elements include commitment, taking action for policy and practice, tracking and reporting, and education and expertise. The guidance provides recommendations on optimizing antimicrobial use, setting policies for effective antimicrobial prescribing, tracking success, and providing education to clinicians and staff. A payer can engage by rewarding network health systems that have a documented antimicrobial stewardship program and demonstrating improvement in outcomes. Payers can monitor participating systems’ bacteria resistance rates and overall antimicrobial usage as performance end points. Rewards could include improved reimbursement rates or preferred network status.   

	The National Committee for Quality Assurance (NCQA) includes quality measures related to appropriate antimicrobial use within its Healthcare Effectiveness Data and Information Set (HEDIS

	·      Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis

	·      Appropriate Testing for Children With Pharyngitis

	·      Appropriate Treatment for Children With Upper Respiratory Infection

	Performance on each measure generally improves with appropriate antibiotic use. Evaluating performance on the Plan All-Cause Readmissions quality measure may be beneficial as well, considering that infection is a frequent cause of rehospitalization. Payers should assess their quality scores on these measures and identify practices, hospitals, or prescribers that may be contributing to suboptimal performance. The payer could notify providers of poor performance, reinforce the importance of antimicrobial stewardship, and provide guidance on how to improve. Repeat poor performers could be subject to penalties, including reduced reimbursement, exclusion from preferred high performance networks, or network decredentialing. Payers may encourage adoption or advancement of antimicrobial stewardship initiatives further with incentives to health systems and hospitals.

	NCQA included in HEDIS 2017 a new measure, the Standardized Healthcare-Associated Infection Ratio. This measure is used to evaluate a potential infection risk for members admitted to hospitals within the plan’s networks.   The four healthcare-associated infections addressed by the measure are (ratios publicly reported by CMS):

	·      Central line-associated bloodstream infections (CLABSI)

	·      Catheter-associated urinary tract infections (CAUTI)

	The measure stratifies facilities’ standardized infection ratios (SIRs) by risks of exposure (high, moderate, low or unavailable) and estimates a member’s potential infection risk based on the percentage of discharges that fall within each risk classification. The measure also reports a plan-weighted SIR that facilitates comparisons among plans for infection exposure risk.

	Payers can monitor performance on the new measure as data become available and  identify facilities contributing to sub-optimal performance. Payers may request action plans for performance improvement from these facilities, many of which are subject, as of January 1, 2017, to The Joint Commission’s new 

. Facility hospitals performing well on the measure or demonstrating improvement could be rewarded as noted previously. Performance data on healthcare-acquired infections among Medicare-certified hospitals is presently available through Hospital Compare (according to CMS) and through other quality metric and performance aggregator tools such as Qnav. Plans may wish to review the performance of high-volume hospitals within their network and proactively develop strategic collaborations on infection reduction and antimicrobial stewardship initiatives.  Collaborations could potentially include health systems and other stakeholders, such as employer coalitions, patient safety advocacy groups, and pharmaceutical companies.

	Payers often utilize prior authorization programs when the goal is controlling inappropriate use. However, prior authorization for antibiotics can be problematic.  Antimicrobials tend to be inexpensive, making administration of the program costly. Additionally, prior authorization programs or other point-of-sale barriers require patients to wait for approval and can potentially cause a delay in therapy. A 

 of recently hospitalized Medicare patients found that linezolid claim reversals led to more rehospitalizations (23% reversal group vs 9% filled group; 

 found that recently hospitalized Medicare patients who did not fill a linezolid prescription had higher medical costs than patients who did (

 that focused on a linezolid prior authorization program in commercial patients did not find adverse consequences, but noted that 15% of patients exposed to the prior authorization program had no record of antibiotic use in follow-up.

	As alternatives to prior authorization programs, payers can implement programs that allow patients to get on therapy quickly while also reducing the potential for inappropriate use. Quantity limits can facilitate appropriate regimens while limiting daily doses and excessive durations of therapy. Payer pathway programs could be expanded to antimicrobials, allowing patients recently discharged from the hospital or with lab results indicating appropriate therapy to be approved instantly. Payers can use retrospective drug utilization reviews to identify prescribers who write excessive amounts of antimicrobial prescriptions or prescribe for inappropriate indications. Payers should communicate the issues with these prescribers and outline ways to improve performance. Finally, payers may introduce an antimicrobial stewardship program through existing pharmacy and population health management programs. Many chronic conditions are managed with the provision of high-touch interventions (e.g., medication adherence, immunizations, depression screenings, referrals, transition of care). Appropriate patient antimicrobial utilization and management could be introduced into the care management process.

	Providers frequently cite demanding patients as a reason that antibiotics are prescribed inappropriately. Prescribers refusing a parent’s request for antibiotics for a sick child may be faced with the loss of a patient or with negative reviews on prescriber rating sites. Patients and parents may not appreciate how the inappropriate use of an antibiotic in a given situation contributes to an overall growth in bacterial resistance. 

	Payers have access to broad patient populations and the opportunity to educate. A payer could implement a public education campaign communicating to members the threat of antimicrobial resistance. Social media may also be considered for payers with the capability. Language should be simple but impactful and could inform on recent cases of “super bugs.” Instructions on nonantibiotic methods to increase a child’s comfort during a viral illness may reduce a parent’s feeling of helplessness.

	Combating rising antimicrobial resistance is a responsibility of every stakeholder in the healthcare landscape. Payers have an opportunity to impact antimicrobial use on a population level. Payer action requires monitoring of the data to identify quality measure performance and inappropriate antimicrobial use trends. Additionally, payers can assist in holding other stakeholders accountable by identifying and communicating to underperforming entities, as well as by rewarding those furthering the cause of antimicrobial stewardship. By enacting the steps detailed here, payers can practice antimicrobial stewardship, but do so in a way that limits negative impact on patients.

Jeremy Schafer, PharmD, MBA, is senior vice president, Precision for Value and Maureen Hennessey, PhD, CPCC, is senior vice president,

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