FYI Dificid is a hosptial drug/formulary acceptance
DRGs. Insurance companies don't pay for single items in care of hospitalized pt. They usually will pay a flat fee for a diagnosis plus modifiers. But it does depend on what type of insurance one has. The hospital may eat some the cost occasionally but if they can move someone out quickly it will be positive for them. With the advent of ACOs it will critical to reduce readmissions since healthcare systems will be paid for care of a patient for an event of illness including all costs associated with complications and re-admissions. It will be critical to get diagnosis and treatment right the first time. ACOs are looking to pay based on outcomes not just episodes of care. So a medication that improves outcome in anyway will be hard to pass by. ACOs are being rolled out starting in 2014. fwiw.
Commercial insurers will pay an additional fee for high cost drugs, depending on the ability of the hospital to negotiate that reimbursement in their managed care contracts. Although many BCBS contracts may reimburse on a fixed DRG case rate basis, there may also be a stop loss reimbursement provision for catastrophic cases where charges or days reach a negotiated threshold. Many times, these types of stays will hit that threshold and qualify for stop loss payment. This payment will typically cover a percentage of charges, which would include payment for a high cost drug.
my understanding of ACO.. the incentive is that if a hosptial does what it is supposed to do and outcomes are their Medicare won't take about 3%.. its not as if a hospital will receive additional funds.. now hospital not getting 3% of medicare money is a HUGE deal to the bottomline, but again a lot of work for no real gain.
this was also just released.. related but unrelated to our discussion
This is by far the MAIN selling point that CBST will have selling Dificid.. but depending when these roll out hosptials will take their time making it happen.. I have seen it time and time again.. a lot of emphasis will be placed on the reps to make it happen and obviously the are talented group selling Cubicin..
Just adding my two cents because I think people are expecting too much too soon..