Pharmacy benefit management (PBM) is a reality in the healthcare business and has become a significant component of hospice care over the last 15 to 20 years. All prescriptions for patients with a hospice diagnosis must be paid for by the hospice, highlighting the value of a PBM’s bargaining and purchasing power.
PBMs provide hospice agencies with the pharmaceutical expertise they require, along with their purchasing power. For instance, hospice requirements necessitate that a pharmacist monitors each patient’s medication regimen; this is not always possible with a patient’s regular pharmacy and could be more difficult without the interface options a PBM offers (see Your EMR-PBM Interface below). Additionally, hospice agencies can evaluate and report prescription data by patient, diagnosis, or day using a PBM.
Services like 24/7 support (crucial for hospice practitioners), hospice emergency/comfort kits, nurse-specific online portals, and continuing nursing education (CNE) credits are also provided by hospice PBMs (Continuing Education Units).
Choosing a PBM for Hospice:
Of course, the cost is essential in selecting a PBM. But many of the largest hospice PBM players will be reasonably similar financially. Consider the PBM’s per-diem vs. per-drug rate alternatives.
Another critical thing to consider when hiring a PBM for hospices is ensuring that your EMR system connects with the chosen PBM. Ascertain that the PBM and your EMR vendor are willing and capable of merging their systems for the benefit of your agency. A continuous data flow from your EMR system to your PBM minimizes double inputting of patient data and adds to the reduction of drug mistakes. Additionally, it can save nurses several hours.
Certain hospices partner directly with a pharmacy that delivers the comprehensive services generally associated with a PBM, such as medication reviews, medication management, and utilization reports, in addition to clinical counseling for symptom and pain management. Those services, in addition to drug administration, are often required on a 24-hour basis by the hospice care provider. It can be time-consuming and expensive for hospice providers to decide between a community pharmacy and a pharmaceutical benefits manager (PBM).
Recent purchases in the billions of dollars show that drug use for hospice and palliative care patients is a successful business.
When billing a PBM, there are generally two types: per-diem and fee-for-service. If that’s the case, how can we pick between the two? The majority of hospices select the least expensive solution. Therefore, what is the least costly PBM pricing option?
I guarantee you that this is not one of those pieces you read and then find yourself still without an answer to your question. By the time you finish this little read, you’ll know the answer. First, I’ll review the pros and cons of both hospice PBM cost options.
Per Diem Rates:
You’re allotted a fixed sum for your efforts. You can predict your monthly drug expenses with this.
Your drug options are highly restricted. If you are trying to cut prescription costs. A medical director who does not strictly stick to a formulary can be your biggest adversary.
You are consistent in how you treat your nurses and other employees. The fundamental objective of Per-Diem Pricing models is to keep inside the formulary. This makes things easier for your staff.
No matter what, you have to pay up. The agreed-upon Per-Diem must be paid even if several patients in service are only taking inexpensive medications. In other words, you occasionally save money and sometimes lose money.
Costs for treatments not included in the plan’s standard “formulary” will accumulate. Patients on even a tiny number of non-formulary prescriptions will result in your having to pay both the per-diem and the total cost of those medications.
You get a skewed idea of how much you spend per patient per day (PPD). There is no guarantee that your PPD will be exactly $9 daily, even if the PDP is $9. Don’t forget to factor in the price of any medications or treatments that weren’t included in your insurance’s predetermined list when figuring out your PPD.
Payment for Each Service Rendered:
What you use is what you pay for. Whether the formulary covers the medication, the cost will be the same. Likewise, there will be no pharmacy charges if hospice patient does not need any medications during their stay.
As a result, you can select from a broader range of pharmaceutical treatment options. Your hospice does not incur any additional costs for the meds they prescribe. Such flexibility has the potential to enhance medical treatment.
You now know more about the whereabouts of your hard-earned cash. If you receive hospice care, you will get a monthly statement itemizing the total cost of all medications.
You have no idea how much money your drugstore costs. You won’t know when you get the bill until the end of the month because it depends on the patient’s prescriptions and the pharmacy they use.
People are taking far too many medicines at once. It’s only natural to worry less about decreasing a patient’s prescription regimen when there’s no financial penalty for using drugs that aren’t on the formulary. This is especially true when your medical director writes the prescriptions.
How much your prescription drugs will set you back is up to your Medical Director. The majority of medical directors will not take a drug’s price into account when writing a prescription. In a system where patients have “freedom of prescription,” it’s only natural to ask for the most expensive drug because it’s the “most effective.”