What are the responsibilities of a hospice PBM?

Hospice is concerned with ensuring the comfort of terminally ill people through the management of their pain and other symptoms. Given the importance of pharmacotherapy in achieving this goal, it is not surprising that pharmacists play an important role in patient care. The same is true for the Pharmacy Benefit Manager (PBM) for hospices.

The primary function of a PBM in the major healthcare industry is to handle claims and reimburse pharmacies for dispensing prescriptions. Additionally, they help manage prescription costs through formulary management and price negotiations with pharmaceutical companies.

Because hospices have unique needs, they often rely on PBMs and other specialty hospice pharmaceutical suppliers. SpectrumPS Pharmacia originated from some of the first pharmacies and PBM providers to serve the hospice industry only. Currently, it supports more than 450 hospices representing more than 90,000 people per day.

What is the role of a PBM hospice?

Each PBM hospice offers a different combination of services. They are divided into the following categories:

• Access to medicines

• Usage Management

• pharmacological advice

• Normative compliance

• Process optimization

• Pharmaceutical access

Hospice patients generally receive treatment at home, but often rely on strong painkillers that cannot be found at a typical corner pharmacy. In addition, their conditions may vary from hour to hour. In an instant, different medications, dosages, or formulations may be required to provide symptom relief.

In many ways, hospice PBMs enable access to medicines. Some hospice PBMs operate or contract with several "closed-door" non-retail pharmacies across the country to dispense medications. However, maintaining adequate coverage in certain areas can be difficult. SpectrumPS offers a variety of models based on retail pharmacy usage, and often SpectrumPS' own mail-order pharmacy that can meet next-day demands.

Usage Management

Medication costs are often the largest expenses for hospice, postpartum, and facilities. Hospice PBMs can help clients develop tools and best practices to improve quality and control costs. SpectrumPS clinical pharmacists use a variety of devices, including:

• Custom forms

• Evidence-Based Treatment Procedures

• Protocols should be deprecated

• Training on clinically appropriate and cost-effective alternatives

Reporting is another critical usage management technique. SpectrumPS' proprietary business intelligence platform provides real-time visualization and trending data. Users can explore multiple levels (eg, site and team) to uncover opportunities to improve care and control expenses. Real-time warnings can identify future spending spikes.

Pharmacological advice

The goals and pharmacology of hospice are distinct from curative medical care. Data on the effectiveness of some treatments for terminally ill patients are often insufficient. The death phase presents complex difficulties with drug metabolism. As their disease worsens, patients may also need other routes of administration.

In addition to providing easy access to pharmacological information and education, hospice PMBs should offer specialized clinical services relevant to hospice and palliative care. This includes providing evidence-based options for medication management in response to availability issues or to better meet patient needs.

SpectrumPS' clinical support program includes strategic utilization management, educational opportunities, and pharmacists available 24 hours a day, seven days a week to prescribe prescription treatments, strengthening the interprofessional team. They help nurses and prescribers with many issues such as:

• Complex cases

• Dose conversion

• Substitute drugs

• Precautions

• Deprescribing

• Regulatory conformity

Hospices are heavily regulated, especially in the administration of medication. Medicare's terms of participation, for example, require admission and ongoing drug utilization reviews. These include all prescription and over-the-counter medications, herbal supplements, and alternative treatments that may interfere with drug therapy. This is an opportunity for clinical pharmacists at SpectrumPS to carefully review the list of prescriptions and identify therapies where the risks may outweigh the benefits. They may be beneficial in screening over-the-counter medications and dietary supplements for potential adverse effects or interactions.

Concerns about opioids have led to increased regulation of banned drugs in recent years. SpectrumPS helps hospices improve compliance with existing and future state and federal requirements by implementing appropriate policies, procedures, and workflows. SpectrumPS can also look at overall usage for potential areas of concern.

Workflow Improvement

Hospice nurses cultivate intimate bonds with patients and their caregivers to build trust and promote the highest level of care. Complicated or outdated medication management workflows can distract them from this crucial work. Nurses can spend countless hours buying prescriptions, locating faxes, and re-entering data into various databases. This negatively affects not only patient treatment but also staff morale and retention.

PBMs are third-party companies that administer and administer prescription drug benefits on behalf of large employers and organizations, health insurers, Medicare Part D drug plans, pharmacies, and other payers. PBMs were created with convenience and cost-effectiveness in mind. Their goal was to help streamline the drug claims process and contain and reduce prescription drug spending.

PBMs are considered pharmaceutical intermediates. On behalf of their clients, they negotiate with drug manufacturers and distributors to reduce costs when handling prescription-related claims. According to the Commonwealth Fund, PBMs help insurers and pharmacies predict total drug prices. In an August 2018 Stat News article, John Arnold points out that PBMs represent the consumers of many large insurance companies, operating as huge buying networks with significant buying power in the pharmaceutical industry. Ideally, PBMs use this purchasing power to reduce the total cost of pharmaceuticals and pass the savings on to consumers.

However, PBMs are not mere intermediaries. PBMs are currently involved in:

• You create and review formularies, ie the list of generic and brand name prescription drugs that will be covered by insurance plans.

• negotiate discounts with pharmaceutical manufacturers

• Local pharmacies handled reimbursements, drug discounts, and delivery charges.

• They determined which pharmacies were included in a drug plan network and managed distribution within the networks.

• Perform drug utilization evaluations

• Patient compliance monitoring

• Processing and payment of complaints

• Offer affordable mail-order and specialty pharmacy services