What is the Hospice PBM Process?

Pharmacy benefit management is a reality in health care and has become an essential component of hospice care over the past 15-20 years. Hospices must pay for all patient prescriptions related to a hospice diagnosis, highlighting the importance of negotiation and the purchasing power of a PBM.

In addition to their buying power, PBMs provide hospice agencies with the pharmaceutical expertise they need. Hospital regulations require a pharmacy to oversee the patient prescription regimen, which is normally not available through a local pharmacy provide, and must be challenged without the interface capabilities of a PBM (consult your interface EMR-PBM, then). Additionally, hospice agencies can analyze and report prescription data by patient, diagnosis, or day when using a PBM.

Hospice PBMs also provide essential support and education services, such as 24-hour support (essential for hospice physicians), hospice comfort or emergency kits, portals nurse-specific online and even nursing CEUs (continuing education units).

Choosing a PBM for Hospice

Of course, the cost is an important aspect in selecting a PBM, but many of the larger hospice PBM players will be quite similar financially. Consider the possibilities of rate per day vs. per PBM drug.

Another critical factor to consider when choosing a hospice PBM is to ensure that your EMR system communicates with the PBM you have chosen. Make sure the PBM and EMR vendor is willing and able to integrate your systems. A seamless flow of data from your EMR system to your PBM eliminates duplicate patient data entry and helps reduce medication errors. This can save nurses countless hours.

Hospice care aims to keep patients comfortable by addressing the pain and other symptoms associated with a terminal illness. Given the centrality of pharmacotherapy to this end, it is not surprising that pharmacists play an important role in inpatient care. Likewise, the Hospice Pharmacy Benefits Manager, or PBM, does the same thing.

The primary role of a PBM in the broader healthcare market is to handle claims and reimburse pharmacies for dispensing prescriptions. Additionally, they help with cost management by managing formularies and negotiating prices with pharmaceutical companies.

Due to the specialized requirements of hospices, they often rely on PBMs and other pharmaceutical providers who specialize in hospice care. Our origins go back to some of the earliest pharmacies and PBM providers specializing in hospice care. It now serves more than 450 hospices and more than 90,000 patients daily.

As a 51-year-old company, Pharmacy Benefit Managers (PBM) has gone through significant changes since its inception in Scottsdale, Arizona. PBMs are a four-letter word to many because of Scrooge's reputation, especially among pharmacists.

The first modern hospice in the United States opened in 1974, following Dame Cicely Saunders' groundbreaking presentation to American medical professionals on the success of the UK hospice movement. When hospice became a Medicare-covered benefit in the 1980s, hospice drug therapy became a covered benefit. Newly eligible hospices have partnered with PBM to adjudicate claims. Because both companies were new to healthcare, partnership opportunities were limited.

In the 2000s, a hybrid competitor emerged: the hospice-PBM pharmacy, which was in charge of ordering/dispensing prescriptions and pharmaceutical benefit claims. They attracted hospices by passing on large discounts obtained through rebates from wealthy and influential parent companies. Hospices benefited, but the savings didn't trickle down to patients, who, like others, saw their drug spending increase by 169% between 1994 and 2015. That percentage has certainly increased now. Atropine presents an increase in the price of hospice drugs. Atropine often used to dilate the pupils during vision tests, has the strange side effect of calming the throat of death. Although the components and manufacturing costs do not change, a $10 drug now costs $50.

PBM process

Hospice care has different goals than curative medical care. There are insufficient data on the effectiveness of specific drugs in terminally ill patients. The dying process poses many complications with drug metabolism. As patients' health deteriorates, they may require alternate methods of administration.

Hospice care PMBs must provide specialized hospice and palliative care clinical services and timely access to medication information and education. This includes providing evidence-based alternatives to drug delivery to address availability challenges or better meet patient needs.

Our clinical support program includes strategic utilization management and training opportunities, as well as pharmacists available around the clock to assist in the administration of drug therapy, increasing the efficiency of the interdisciplinary team. They help nurses and prescribers with a variety of issues, including:

• Complicated cases

• Dose conversion

• Drug substitutions

• Precautions

• Deprescribing