by Flora Y. Bessey, Pharm. D., CGP

As dedicated caregivers, it sometimes slips our minds that the business of long-term care is, well, a business! Ultimately, the buildings we serve have to find a way to provide quality care for our patients while controlling costs. This can be incredibly challenging, so it is helpful when we can provide solutions that can assist in this effort.

In the Medicare/Part A/Rehab setting (i.e. non-custodial), most buildings have a "fee-for-service" contract with their pharmacy provider. In other words, the buildings take the money that Medicare provides and pay for each of the medications that the patients take (in addition to everything else...nursing care, meals, etc.).  Understandably, buildings attempt to limit the pharmacy bill any way they can: use of generics whenever possible, DC-ing of unnecessary meds, etc. The alternative reimbursement structure found in the market is a negotiated per diem rate that allows nursing facilities to shift some portion of the cost risk for Medicare Part A residents to the pharmacy. Typically there are exclusions for certain expensive drugs that limit the risk the pharmacy actually bears and brings the per diem rates more closely in line with Medicaid rates. The pharmacy will renegotiate the per diem rate periodically based upon the charges that the facility incurs.

In the past, when a patient with Type 2 diabetes was insulin-dependent, there was very little that could be done to limit this expense; insulin was provided in 10-ml bottles containing 1000 units. The post-opening expiration of insulin is 28 days. Even if a Medicare resident remains in a facility for longer than 28 days (and as we all know, the goal of our facilities is increasingly to discharge residents as quickly as is safely possible), the vast majority of patients do not use 10 ml of insulin in a month.  And when the resident is discharged, or 28 days passes, the remainder of the 10-ml bottle is thrown away (along with the money!).

There is a 3-ml vial dosing option for some of our short-term residents, which can result in almost 70% savings on the cost of insulin!  Click here for more information on how to help with this challenge. 

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