Overcoming the challenges to meet the special needs of long-term care patients, this pharmacy provides a careful approach that provides positive results.
The article in this issue entitled “Specialty Trend on the Rise in Senior Care: A Focus on Long-Term Care” reviews important considerations such as regulatory and personnel factors that should be taken into account when dispensing specialty medications to patients residing within senior care facilities.
This article will illustrate how Edwin’s Prescription Pharmacy is able to overcome those challenges to meet the specialty medication needs of longterm care (LTC) patients. Edwin’s provides specialty medications to the LTC residents that it services throughout the Southern California area. Edwin’s services about 7000 beds in skilled nursing facilities, assisted living facilities, intermediate care facilities, hospice, board and care, and substance abuse facilities. Mirroring the results of the annual MHA Independent Long-Term Care Studies conducted in 2011 and 2012, Edwin’s is also seeing an increase in the utilization of specialty products within its LTC practices, particularly in oral oncology, transplant, HIV, and hepatitis C.
BILLING AND REIMBURSEMENT
One of the major obstacles to overcome in the dispensing of specialty medications to patients within LTC facilities is proper billing and reimbursement. Edwin’s has a dedicated reimbursement team to ensure that the staff has expertise in the billing intricacies of both specialty medications and Medicare billing standards. In addition to a comprehensive understanding of Medicare Part A, Part B, and Part D, the reimbursement team must be proficient with supplemental coverage, commercial coverage, major medical billing, prior authorization procurement, and copayment assistance programs.
Often a patient who is admitted into an LTC facility will need a partial supply of a medication to line up medications for once-a-month filling, or a few days’ supply might have to be advanced before a prior authorization is approved so that the facility can have the medications on hand to match the written order, such that the facility can stay in compliance with medication-related regulations. A lack of understanding of complicated partial supply and other specialty billing issues, such as quantity dispensed and days supply, can result in a big financial loss for a pharmacy serving an LTC facility with a specialty product.
During Part A stays, Edwin’s fills the specialty items and bills the facility, paying particular attention to ensure communication with the facilities on the costs of specialty medications. However, in order to minimize the impact of specialty costs to the facility during Part A stays, some facilities might ask families of residents to obtain the medication from an outside retail pharmacy to bring into the facility. State regulations offer guidance on this issue, and often do not allow this practice.
This can create significant issues for the outside retail pharmacy that may not know that the patient is residing in a facility and fills these medications for the patient at the request of the patient or his or her family. Subsequent audits by Medicare Part B or Medicare Part D plans can then recoup those drug costs from the outside pharmacy during the time in which the patient was a resident in a facility, resulting in the potential for significant financial losses to the outside retail pharmacy. Maintaining communication with the facilities regarding the cost of specialty drugs and the implications of trying to obtain these drugs from an outside retail pharmacy during a Part A stay is an important function of the LTC pharmacy.
Edwin’s and other pharmacies servicing the LTC population encounter a difficult challenge when a patient has a mandatory mail order plan. These plans will typically not cover medications dispensed by a pharmacy other than the mail order pharmacy, even during an in-patient stay. This means that the LTC pharmacy chosen to service the facility is not able to provide medications to that particular patient, resulting in a confusing situation for the facilities and the potential for the patient to be underserviced for their maintenance medications as well as any specialty medications that may have been prescribed for them. Although Edwin’s is not able to service that particular patient, they do provide a high level of communication to the facility in these instances to help mitigate the risk that the patient will not receive the medications he or she needs in a timely manner.
COMMUNICATION AND EDUCATION
Communication and education play a vital role in successfully meeting the specialty medication needs of LTC patients. In addition to ample communication regarding billing and reimbursement issues of specialty medications, clinical communication is necessary to ensure that all parties involved in the LTC patient’s care are on the same page.
Consultant pharmacists who work with the facilities that Edwin’s services are educated about and familiar with specialty products. The consultant pharmacists are able to provide valuable feedback to the facility and the ordering physician pertaining to necessary lab testing, therapy adjustments that may need to be made based on lab results, and monitoring for side effects. Facility education conducted by the consulting pharmacist as well as the dispensing pharmacy relating to therapy-specific monitoring parameters helps ensure that medications—such as immunosuppressants for transplant patients— stay within the appropriate therapeutic range.
Communication between Edwin’s and the facilities they service is constant. When a new order for a specialty product is received, the pharmacy communicates back to the facility regarding the medication as soon as possible, usually within hours of the initial order. There is continuous communication between the pharmacy staff and the facility to ensure adherence to the medication regimen and that no adverse effects are being experienced.
Edwin’s closes the communication loop by continually communicating with the physicians about the status of the order and any issues that may arise. In addition, Edwin’s makes an effort to educate and inform nursing staff when there have been new therapies introduced into the market.
Edwin’s Prescription Pharmacy provides case management, facilitates support groups, and can assist senior care facilities with other important services to ensure optimal patient care. Edwin’s provides comprehensive support for facilities and for those patients who have complex specialty regimens for HIV, hepatitis C, or oral oncology therapies. SPT
About the Authors
Raquel Dina, PharmD, earned her doctor of pharmacy degree in 2000 from Western University of Health Sciences, Pomona, California. Raquel joined Edwin’s Prescription Pharmacy in 2011 and has worked as a specialty pharmacist at The Apothecary Shop, BioScrip, AIDS Healthcare Foundation, and Walgreens.
Stacey Ness, PharmD, MSCS, has worked in both national specialty pharmacy and payer organizations and has experience in clinical management, adherence and persistency programs, and chronic disease cost optimization strategies. Dr. Ness is active in the Consortium of Multiple Sclerosis Centers, Academy of Managed Care Pharmacy, National Home Infusion Association, and Hematology and Oncology Pharmacy Association, and has served on the Minnesota Medicaid Drug Formulary Committee since 2008. She is a multiple sclerosis certified specialist and currently serves as the director of specialty clinical services at Managed Health Care Associates, Inc, a health care services organization based in Florham Park, NJ.