PBMs (pharmacy benefit managers) are third-party corporations that administer and manage prescription medication coverage on behalf of major employers, health insurers, Medicare Part D plans, pharmacies, and other payers, such as pharmacies and insurance companies. PBMs were initially designed to save money and time. They hoped to make the medication claims procedure easier while keeping prescription expenditures in check.
In the pharmaceutical supply chain, PBMs serve as the go-betweens. They handle prescription-related claims and negotiate with medication makers and distributors on behalf of their clients to keep prescription costs down.
PBMs aren’t merely middlemen. However, they’re more than that. Currently, PBMs are involved in:
- the process of creating and revising formularies, or the lists of prescription medications, both generic and brand-name, that insurance companies must approve and cover
- Negotiating rebates for prescription with pharmaceutical companies
- Dealing with local pharmacies for reimbursements, discounts on medications, and delivery fees
- Determine which pharmacies are part of a prescription medication plan’s network and manage the distribution of among these pharmacies
- Keeping tabs on the use of medications
- ensuring the adherence of patients
- Claims are processed and paid.
- Mail-order and specialty pharmacy services at discounted rates
Proposed Solutions to Issues Raised
PBMs are under scrutiny in the healthcare business due to a lack of transparency in the PBM arena, and the percentage of benefits and rebates passed down to the consumer. Policymakers have examined reforms to address these concerns, and they could involve state and national regulation of PBMs and pass-through percentages. PBMs that charge more to a payer than they reimburse to a pharmacy and pocket the difference is a target of several states and the Centers for Medicare and Medicaid Services (CMS).
While these worries abound, a survey of health plans and PBMs revealed that the percentage of manufacturer rebates passed on to health plans climbed from 78% in 2012 to 91% by 2016. Additionally, CMS determined that PBMs’ capacity to negotiate more significant rebates from medication makers has helped cut costs and slow prescription spending growth over the past three years.
PBMs for hospice
As a reality in healthcare, pharmacy benefit management (PBM) has emerged in the last 15 to 20 years as a critical component of a hospice program. A PBM’s bargaining and purchasing power are all the more vital for hospices because they must pay for all of the patient associated with a hospice diagnosis.
Besides their purchasing power, PBMs give hospice agencies the pharmaceutical expertise they need. A pharmacist is required by hospice rules to manage each patient’s prescription plan, which is usually unavailable from a local pharmacy provider and can be challenging if a PBM does not give the interface capabilities it offers (see Your EMR-PBM Interface, below). In addition, hospice agencies can access medication data by patient, diagnosis, or day for reporting and analysis.
Additionally, hospice PBMs provide vital support and education services, such as 24-hour support, hospice Emergency or Comfort Kits, online portals for nurses, and even nursing CEUs (Continuing Education Units).
How to Pick a Hospice Case Manager
The cost of a PBM is, obviously, an important consideration, but many of the largest hospice PBM players are pretty comparable from a financial standpoint. Ensure that the PBM’s per-day alternatives are thoroughly analyzed.
Additionally, hospices should ensure that their EMR system can interface with the PBM they choose. Verify that your PBM and EMR provider is ready and able to link their systems for the benefit of your organization. Eliminating double entry of patient data and reducing prescription errors are two benefits of integrating your EMR and PBM systems. In addition, it can save numerous nursing hours.
Your PBM Solution for Hospices
We provide PBM solutions to handle all of your pharmacy requirements for hospices. High-touch pharmacy management solutions that offer hospice workers more time to focus on providing quality end-of-life care are what we push for.
For hospice patients, medication plays a critical role in their final days of life. Through the use of cutting-edge clinical programs and practitioner and pharmacy management skills, we help hospices cut expenses while still enabling your nurses to provide the best possible care for their patients’ needs.