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When it comes to attaining 5-star ratings, there are several reasons your PBM may not be aligned with your goals like you think they are. Read below to learn how your PBM may actually be working against you.

 

  1. Cheap Medications

    Drugs for Per Diem contracts are typically chosen based on what will be most profitable for the PBM. If a medication that is in your current formulary goes up in price, there is a risk that the medication may be taken off the Per Diem formulary.

  2. Formularies are not flexible

    Per Diem formularies are rigid and controlled by the PBM, not the hospice. There is a penalty for using off-formulary medications (i.e., higher medication costs for the hospices).

  3. Does not promote medication utilization

    PBMs are not focused on reviewing or reducing the costs of medications for hospices. They are focused on what benefits them most in Per Diem contracts.

  4. Lack of transparency

    “Free” services increase per diem rates. Hospices often are unaware they pay extra for additional services (ex., pharmacist consultations & delivery fees) that are not included in the Per Diem.

  5. Lack of patient focus

    Per diem contracts are developed to benefit the PBM, not the patient or the hospice. If a patient requests a preferred medication, it is not typically not taken into account.

  6. More work for nurses

    Per diem contracts can cause more work for nurses. They are often left with the task of researching patients’ medications so they can convert them to something approved on the formulary.

  7. Lack of hospice focus

    See above in ‘More work for nurses’.

  8. Lack of time-savings

    See above in ‘More work for nurses’.

  9. Does not promote positive nurse/patient interactions

    PBMs are not as focused on providing nurses the tools for success when explaining to patients why certain medications can not be ordered. (i.e., medications not being included in the hospice formularies.)

  10. Does not allow for individualized medication management

    Per Diems are a one-size-fits-all approach to medication management. They typically do not take into account the individuality of the patient and what might be best for their situation.

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