Alternate Sites of Care explores the commercial insurance market coverage policy shift to alternate sites of care (ASOCs), the underlying issues and resulting implications for key stakeholders around the use of biologic and specialty infusion drugs.
ASOCs refers to healthcare that is delivered in settings different from and generally less expensive than a hospital room, outpatient center or physician’s office, such as an in-home setting, hospital outpatient department clinics, retail or convenience care clinics, urgent care clinics, various independent or corporate free-standing medical clinics and now, care delivered via telehealth.
In addition to physician shortages, there is now another important factor driving the increase in ASOC options: financial risk from insurance decisions resulting in medical policy changes. This report examines that risk in the context of marketplace change like ASOCs.
In addition, transferring risk to other stakeholders (physicians, patients) challenges the marketplace to develop different, efficient, high-quality, and low-cost alternatives to delivering healthcare in the traditional hospital setting.
Currently, the principal reimbursement scheme for specialty oncology and anti-inflammatory products is known as “buy and bill,” a term that refers to the process of physician management of certain medicines—primarily specialty medicines that require injection or infusion.
The buy-and-bill model can be challenging for physicians and providers because of a number of developments within the healthcare marketplace. For these reasons and others, payers are increasingly interested in exploring alternatives to the buy-and-bill mechanism to lower their costs for specialty products.
Alternate Sites of Care Table of Contents:
Introduction – pg. 4
About ASOCs – pg. 5
- ASOCs Related to Reimbursement – pg. 6
Factors Underlying the Shift to ASOCs – pg. 7
- Risk Trends and the Commercial Insurance Sector – pg. 7
- Employee Benefits and Risk from an Insurance Perspective – pg. 7
- Stakeholders, Risk, and Care Cost Impact – pg. 8
Seeking Value: Health Plan Evolution – pg. 9
- Reimbursement (Pharmacy vs. Medical Benefits) – pg. 11
- Market Convergence, Medical Groups, Hospitals, Health Systems – pg. 12
Current Market Landscape – pg. 12
- Specialty Reimbursement Policy Fuels Alternative Sites – pg. 12
- Optimizing Care Sites by Managing Specialty Drugs
and Medical Benefit – pg. 13
Specific Stakeholder (Patient, Provider, Payer) Impacts Related to
- Coverage Policies Through 2018 – pg. 14
Perspective of Patients, Payers, and Providers in
- Expanding ASOC Environment – pg. 18
Summary – pg. 20
- References – pg. 20
- Glossary – pg. 21