The Role of Payers in Antibiotic Stewardship: Facilitating Transitions of Care for Patients With Active Infection

All members of the health care community must play a role in antimicrobial stewardship. The payer role is to monitor appropriate antibiotic use, encourage low-cost options, and help to facilitate the transition of care for patients with active infections leaving the hospital. However, the lack of effective management tools to meet the goal of low-cost, effective care for patients with active infection presents a challenge to patient-focused payers. Alternative management approaches, including clinical pathways, should be considered to allow payers to facilitate transitions of care while practicing antimicrobial stewardship.


Inappropriate antibiotic use represents a challenge for all members of the health care community, including payers. The Centers for Disease Control and Prevention estimates that 30% of antibiotic prescriptions are unnecessary.1 The federal government has taken notice of the growing crisis presented by the overuse of antibiotics and released the National Action Plan for Combating Antibiotic-Resistant Bacteria.2 The report sets goals that include slowing the emergence and spread of resistant infections, strengthening resistance-prevention efforts, and accelerating the development of new treatments.2 Also called for in the action plan is the strengthening of antimicrobial stewardship programs in inpatient, outpatient, and long-term care settings. The payer has a role to play in these programs by monitoring appropriate antibiotic use, encouraging low-cost options, and helping to facilitate the transition of care for patients with active infections leaving the hospital. 

The unique nature of serious infections makes management by payers difficult, however. Patients often receive a short course of treatment, may have unique product needs based on the infectious organism and site, and may be continuing treatment while transitioning from the hospital to their home. Consistent therapy is crucial to avoid treatment failure or development of resistance.

Unfortunately, traditional payer management techniques may have unintended consequences. An example of this is the management of linezolid use for the treatment of methicillin-resistant Staphylococcus aureus infection. The release of this drug heralded the arrival of a new class of effective antibiotics, and the oral and intravenous dosage forms allowed for patients to transition from hospital to home to finish therapy. Due to the cost of branded linezolid—claims can exceed $2000—and concerns about misuse, some payers have implemented prior authorization (PA) programs for this drug.3 Patients restricted by a PA can receive medication only if they pay the cash price until the PA is approved. This stoppage could mean that a patient discharged from the hospital with a still-active infection is not being treated.

A study by Pasquale and colleagues4 found that linezolid out-of-pocket costs in excess of $100 were associated with more claim reversals in recently hospitalized Medicare patients (P < .0001), and higher reversal rates were associated with more rehospitalizations (23% vs 9% for patients whose claims were filled; P < .0001). Ball and colleagues5 found that recently hospitalized Medicare patients who did not fill a linezolid prescription had higher medical costs than patients who did (P = .004). On the other hand, Starner and colleagues3 reported that a linezolid PA program in a commercial population (regardless of recent hospitalization) lowered drug costs by $0.024 per member per month without raising medical costs or the risk of hospitalization. In all three studies, claim reversal was associated with patients not obtaining any antibiotic treatment at all in follow-up, affecting a total of 27%, 35%, and 15% of patients in the Pasquale, Ball, and Starner studies, respectively.3-5 

The findings of these studies suggest that PA programs for antimicrobials may lead to negative outcomes, particularly among patients recently discharged from the hospital. Therapy abandonment was noted in all three studies and may pose a risk of worsening disease. Rehospitalization also negatively impacts health system quality ratings.

To more effectively manage patients with active infection to meet the goal of low-cost, effective patient care, payers should consider ways to facilitate transitions of care while practicing antimicrobial stewardship. For example, edits that limit quantity or duration of therapy may allow patients to start reasonable regimens more quickly. Drug utilization review could identify high prescribers of expensive antimicrobials and allow the payer to engage these providers to encourage more appropriate use of these medications. Additionally, care should be taken regarding on which tier antimicrobials are placed, as high out-of-pocket costs have been shown to increase therapy abandonment. Placing antibiotics in lower cost-share tiers to reduce out-of-pocket costs may mitigate this risk. Finally, clinical pathway programs could be leveraged for antimicrobials. Payer pathway programs could implement rules that would allow patients recently discharged from the hospital or with lab results indicating appropriate therapy to be approved instantly.

These interventions can aid payers in the shared goal of antimicrobial stewardship by helping patients achieve the best outcomes while managing appropriate use. 


1.    Fleming-Dutra KE, Hersh AL, Shapiro DJ. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-1873.

2.    Centers for Disease Control and Prevention. National action plan for combating antibiotic-resistant bacteria. website. Published March 2015. Accessed February 15, 2017.

3.    Starner CI, McClelland RS, Qiu Y, et al. A linezolid prior authorization program: clinical and economic outcomes. Am J Pharm Benefits. 2014;6(2):81-88.

4.    Pasquale MK, Louder AM, Deminiski MC, et al. Out of pocket costs and prescription reversals with oral linezolid. Am J Manag Care. 2013;19(9):734-740.

5.    Ball AT, Xu Y, Sanchez RJ, et al. Nonadherence to oral linezolid after hospitalization: aretrospective claims analysis of the incidence and consequence of claim reversals. Clin Ther. 2010;32(13):2246-2255.