My step-father, who has been deathly sick for the past 6 1/2 months due to an aortic valve replacement surgery that did not go well, is being discharged from the skilled nursing facility where he has resided at for the past month and a half. Before this, he was in the ICU for over 3 months, were he required a tracheostomy, gastric tube, urinary catheter, and oxygen. To be honest, there were several times when we didn’t know if he would make it through the night. But, he slowly started to make progress, and now he is ready to be discharged to go home. I am not only his step-son, but I am also his pharmacist, his pharmacy, and his POA for both health and financial matters. Because I have been a pharmacist for almost 30 years now, I know the challenges that occur during transitions of care, especially as they relate to medications.
In my step-father’s example, he is being discharged on a Sunday. I had been working with his social worker, nursing supervisor, and prescriber to make sure that I have an updated medication list. I reviewed this list, noted the discrepancies, and sent a follow up note to all three providers. They indicated that they will only fill the medications that he has been taking while in the facility and, if there are any discrepancies, I should follow up with his PCP and specialists that he sees (which include a pulmonologist, neurologist, and cardiologist). So I did this, and received new prescriptions for the medications that they want him to take following his discharge. Obviously, this was a multi-step process that occurred over several days. Now that I have his prescriptions, things should go smoothly, right? Wrong! When we went to fill the prescriptions, they, of course, got rejected as “refilled too soon” because the long term care pharmacy that fills for the facility (not our pharmacy) has already filled and billed medications. I confirmed with the facility that they will not be sending him home with any mediations, so, next step was to call the Pharmacy Benefit Manager (PBM) to get an override. This is where the frustrations and problems escalated.
I explained to the PBM representative that my step-father is being discharged on Sunday and that I am not only his step-son, but his pharmacist and pharmacy. I want to be proactive and have all his medications filled so when I pick him up on Sunday, he has all his medications there. Sounds easy, right? Wrong again? The representative said that we cannot be proactive and that he cannot get an override until he is discharged. I said that our pharmacy is closed and that I will be busy getting my step-father home, but she said there is nothing she can do. I asked for the representatives supervisor, and this person reiterated said the same information. The supervisor stated that they are “only the processor” for the plan, and that I would have to contact the plan to get an override before his discharge date. The supervisor was unable to give me a phone number to contact the plan, and said to look on the back of his card. I don’t have that information readily accessible. The supervisors solution was to have me come into my pharmacy early on Sunday, fill the prescriptions, call the PBM to get overrides (one by one for 8 to 10 medications), fill the medications, then go see my step-father. I asked her why we cannot be proactive, since we are only talking about 2 to 3 days and the supervisor said the plan will not allow them. So, now instead of focusing on helping my mother (who is also ailing) and my step-father (who’s health is very fragile), I have to figure out how to fill his medications on the day of discharge–are you kidding me!
That is why I titled this blog “Why Transitions of Care and PBMs Don’t Mix”. Supposedly payers are concerned about the quality of health care and that readmissions for the same diagnosis are frowned upon. So, when you have a pharmacist proactively working closely with prescribers to get an accurate mediation list and making sure the medications are ready when the patient is being discharged, this should be a good thing, right? Wrong, yet again. Plan and PBMs are so worried about the kind and timing of the override that they have totally forgotten about the patient.
It is time to change the system. Pharmacists are frustrated with the limitations that insurance plans and PBMs have place on patient care. Doesn’t it make sense to ensure the patient, who has been hospitalized, should get their medications seamlessly to prevent a bad outcome? And doesn’t it make sense that it should happen prior to the discharge? I was unable to get the appropriate override, but it did move me to action, as I am writing a letter to my step-father’s insurance plan and the plan’s PBM to express my concern that their limitations will end up hurting patients. Perhaps, they need to be educated about the challenges of transitions of care from a patient and caregiver perspective because, from my perspective, they know very little.
