Posted by Autumn Spence
Next week is NHPCO's Annual Management & Leadership Conference in Washington DC and the Outcome Resources team looks forward to seeing you there! If you have the chance to attend this year, stop by Booth #202 in the Exhibit Hall. We will have a special treat for the first 100 attendees that come by at the Opening Reception on April 22nd from 5:15pm - 7:00pm. Also, be sure to enter to win our contests and pick up information to share with your team. If you are not attending, request your Free Information Kit or a Free Consultation to learn more.
Outcome Resources is a Pharmacy Benefit Manager for hospices. Take a look at some of the benefits available to your hospice by partnering with OR:
- With one contract, your hospice receives one low discounted rate on ALL medications.
- Your patients have their choice of pharmacies (including mail order options) while your hospice receives one clear and concise invoice.
- Easier management of hospice patients in skilled facilities since all closed-door pharmacies are included on your invoice.
- With custom-tailored plan design and formulary control, you are in control of the medications that are dispensed and paid for by hospice.
- Your pharmacies are paid electronically every 15 days and processing claims through our program means fast and easy dispensing along with reduced chance for error.
- Unlimited Access to a team of experienced PharmDs for patient consults, drug information, and education programs.
- Online access to reports and patient medication information means you always have management tools at your fingertips.
- Dedicated lines of communication with your Account Claims Manager and Pharmacists to eliminate time-wasting transfers and phone trees.
- Partnership with a company dedicated solely to hospices - we understand your specific complex requirements.
- You can keep your hospice's medication dollars in the local economy, supporting the community that in turn supports your hospice.
Posted by Autumn Spence
Pharmacy Benefit Manager: Abbreviated PBM. A company under contract with heath care sponsors such as managed care organizations, self-insured companies, and hospice programs to administer and manage pharmacy networks and contracts, provide drug utilization review, outcomes management, and disease management. A pharmacy benefit manager will fill drug prescriptions by a network of pharmacies and/or mail order pharmacy. The aim of Outcome Resources, as a PBM exclusively for hospices, is to save money through specialized focus on palliative symptom management and patient driven outcomes for hospice organizations.
PBM is a term which refers to any prescription drug program administrator. PBMs technically are private companies that contract with health care sponsors (such as hospices) and specialize in claims processing and administrative functions. With increased attention focused on prescription drug programs, expenditures, and coverage, interest also has increased in drug program cost control measures, in particular those of Pharmacy Benefit Managers (PBMs). (The University of Wisconsin School of Pharmacy report in 2000.) PBMs have had a central functional role in prescription drug coverage plans built around claims processing and program administration activities. A number of strategies and techniques to control costs in drug programs have been used by PBMs. Some of the strategies utilized by PBMs include the combination between a discounted Average Wholesale Price (AWP) rate, generic substitutions, formularies, Drug Utilization Reviews and symptom relief management.
The standard approach for pharmacy reimbursement for dispensed prescriptions is to pay an ingredient cost for the drug dispensed plus a dispensing fee. Ingredient cost payment for drugs is typically determined by deducting a percentage from the drug's average wholesale price (AWP). Though this is changing, AWP has been a common contractual rate. Due to a PBMs volume of claims and network relationships, contracts with a PBM generally provide a deeper discount than an organization can negotiate on their own. Hospices can benefit from the ease of one contract and one rate with access to multiple pharmacies. Working with a PBM can streamline administration by providing one consolidated invoice.
The goal of generic substitution is to increase the use of generic drugs and decrease costs. At the time of dispensing the pharmacist will be notified about the generic substitutions. Only if specified by the Doctor will a brand product be filled. In addition, Outcome Resources also provides consultation services with clinical pharmacists trained in end-of-life medication management, enabling hospice staff to consult regarding drug substitution, interactions, and the best medication based on individual patient circumstances.
Online real-time adjudication is another one of the benefits to a hospice of using a PBM, since many errors are caught at the time of dispensing thereby reducing the need to resubmit claims. Outcome Resources also offers detailed oversight of a clinical pharmacist team in analyzing each hospice's drug utilization, providing monthly reports and using the information to increase the quality of patient care, decrease costs, and customize formularies and education programs for the hospice.
A formulary is another way PBMs manage drug utilization. A list of covered or reimbursable drugs is approved based on the formulary. The underlying intent of a formulary is to improve prescribing and drug use quality. Formularies can be established by PBMs, hospices, or other health care sponsors. Formularies can be labeled in various ways to reflect the drugs included and ease access to drugs not on the formulary or not covered. An open formulary includes all drugs. Any drug transmitted will be approved and dispensed. A closed formulary includes only covered drugs such as those on a specific formulary. A closed formulary varies from including only one select drug within a therapeutic category to including multiple drugs within a therapeutic category. A preferred or partially closed (restricted) formulary specifies the drugs covered, but allows exceptions to the list. Each PBM handles the development and monitoring of formularies differently. For example, Outcome Resources allows hospices to custom-tailor their formulary as part of their individualized plan design. Some other PBMs insist on a strict formulary that must be adhered to.
Palliative management has evolved with some PBMs through the Disease Management model. This generally refers to the practice of identifying patients with specific conditions and providing intensive care and monitoring of drug utilization and effects. The goal is to minimize treatment costs and maximize patient care. Pharmacists may be paid separate professional service fees for their efforts in disease management or it may be included as part of your overall service contract with a PBM. The target of disease management programs is the consumer, through the efforts of pharmacists providing educational and therapeutic interventions for patients, caregivers, and prescribers.
Cost control strategies of PBMs do work and some successes have been supported empirically. Prescription expenditures and pharmacy costs have been the most rapidly growing component of health care expenditures in recent years and health care sponsors such as hospices are demanding the services of a PBM to help control these complex costs. Hospices are finding that a partnership with a Pharmacy Benefit Manager (PBM) can result in maximizing palliative symptom management and minimizing drug therapy costs. Also the competitive industries for PBMs provide a large spectrum of programs and services offered to hospices. If your hospice is considering a partnership with a Pharmacy Benefit Manager (PBM), please contact us for information and a free consultation.
Outcome Resources is a PBM that has partnered exclusively with hospices nationwide for a decade, and we would be honored to discuss the value of a partnership with your hospice organization.
Posted by Autumn Spence
The Pharmacies
The pharmacy is one of the primary relationships when dealing with a Pharmacy Benefit Manager (PBM). Ask for pharmacy references and call them. The pharmacy will have a lot of insight to the level of service the hospice can expect from the PBM. Most likely, if a pharmacy has had problems so will the hospice.
The Mail
Work with a PBM that offers mail order, if needed, but also one that has relationships with local pharmacies. Every hospice that works with a PBM will need to utilize local pharmacies, whether as common practice or in emergency situations. You want to be sure that pharmacy is expecting you and can service you. Many pharmacies will not regularly stock all hospice medications if they are not regularly servicing them or not expecting the hospice patient.
The Specialist
Though PBM's have been around for over 25 years, most are not equipped to handle hospice business. PBM's traditionally set up strict formularies without any changes; they enter the information into the computer system and do very little after the initial enrollment. Most PBM's do not have the capabilities to manipulate the data on an individual basis that is needed for hospice. This can mean unnecessary denials from the pharmacy, multiple phone calls to get a patients medications filled and non-hospice approved medications being billed to the hospice.
The Decision
Whether choosing a PBM for the first time or considering a new provider, the choice is important. Hospices need to partner with a PBM for a variety of different reasons. Pharmacy services and costs are too much for most hospices to handle internally. New hospices, small rural hospices, and established nationwide hospices alike are seeking the expertise of a PBM. Choose a PBM that will sustain a long and valuable relationship. Find a PBM that meets your hospice clinical needs, provides you a competitive price and excellent customer service with a commitment to a lengthy partnership.
PBM for past, present and future
Choose a PBM that will meet your needs today and tomorrow. With new legislation, pharmaceutical costs on the rise and changes happening on a daily basis, be sure to choose a PBM that is able to make the changes that the future demands. Ask questions about their company, employees, pharmacy networks, continuing education and their vision for the future - you will be a part of it!
Contact Us for a Free Consultation for your Hospice
Posted by Autumn Spence
The Choice
The primary reasons hospices are choosing to partner with a PBM are rising pharmacy costs, complex patients, a growing census and strain on resources. Even hospices that own their own pharmacy are partnering with a PBM for some of their patients. It can be very costly for an organization to put off an evaluation of their pharmacy services and PBM relationship. If you are not working with a PBM, now is the time to consider. Choose a PBM that is more focused on client services and building relationships rather than one focused on sales and procurement of new business. If a PBM is running correctly, they will have slow, steady growth with a strong base and solid reputation.
Your Needs
Communicate what you are looking for in a relationship with a PBM. There are many options so you want to be sure to pick the best one for your hospice. Be clear about what your needs are and demand they are met.
The Beginning
Trust and confide in the sales representative you are working with. If you cannot, get another one. Contact the company directly and request a new representative. This person is pivotal in the decision making process and you will need to be confident in their ability to define their scope of business. Be sure they are "selling" a program that they can deliver. The biggest mistake made by sales associates is "over selling".
The Relationship
Look at the other layers of the organization you will be working with. Once the "sales" job is over, you will primarily be in contact with someone who did not "sell" you the program. Inquire about who will be handling your account once a contract is signed. Inquire about the enrollment and set-up process. Meet with the clini-cians and others you will be in a daily contact with. Communicate with other members of the organization you will be working with to make the best choice.
The Value
Get the best value for your hospice. Share your contracted rate or what you are being offered; use this as leverage to get the best value. Request a specific price comparison. Consider carefully the services you will be getting for the price offered. Cheaper is not always better.
The Patients
Patient care is the primary factor in any decision a hospice makes. Choose a PBM that will increase hospice patient care and services. Pharmacy choices are just the beginning. Good clinical assistance, palliative symptom protocols, educational services and strong relationships with local pharmacies are some of the differ-ences between a good PBM and a great PBM.
The Clinicians
Patient care is affected by the skill, experience and knowledge of the caregivers. Partner with a PBM that has experts in palliative care, symptom management, certified in geriatric care and experience with hospice patients. Also, a great PBM will have specialists in the field that can also provide formulary recommendations, consultation for patients in skilled facilities and other areas specific to hospice.
TO BE CONTINUED, SEE PART TWO OF TIPS FOR CHOOSING A PBM