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 … Continue reading Why Transitions of Care and PBMs Don’t Mix
Recently, I spent over one hour to resolve an issue that should not have taken nearly as long as it did, nor should have been a problem from the start. It had to do with a patient who needed blood glucose strips filled. This patient uses an insulin pump, so she must check her blood sugars … Continue reading Who’s Paying Pharmacy to Resolve Insurance and PBM Issues?
The PBM Industry The Pharmacy Benefit Manager (PBM) industry has gone from being a claims processor (simplifying paying claims for the insurance payor) to a manager of the entire pharmacy benefit for hundreds of millions of patients. Is not uncommon for a PBM to tout the savings they garner the system thru their management of … Continue reading Why PBMs May Become an Extinct Species
I don’t know about you, but the amount of actual postal mail I receive today is significantly diminished from a decade ago. But unlike land lines (phones that were attached to your house, for those that grew up in the cellular phone era), the mailbox isn’t going anywhere soon. Electronic mail may be good for … Continue reading Snail Mail
Today we have a few more details of the contract discussed in yesterday’s blog. If you have not read the blog post yesterday here, please take a moment to do so now. Before we discuss how to proceed, let’s make a few more observations: As mentioned above, PBM seems to be all-in on this plan. It is … Continue reading What to do When Faced with a Bad Contract
Pharmacy is a difficult business for a lot of reasons. The PBM industry, years ago, turned the profession upside down by transitioning from selling a service to pharmacy (processing claims) to selling access to their pharmacy networks, and later also selling patients of those networks as a commodity. This pivot made pharmacies essentially dependent on … Continue reading Bait-and-Switch?!?
As I previously explained, a couple of significant changes happened at the start of the new year. DIR fees became effective at the point of sale, and many contracts have reverted to MAC language. The positive aspect of these changes is that we know immediately what we are making on any given prescription. But there … Continue reading 2024, a First Look at GM
Many pharmacies and pharmacists have been dreading 2024 due to the arriving DIR Cliff (tsunami, hangover etc). The new year brings a two very dramatic changes to the pharmacy landscape: DIR changes DIR fees are essentially discounts built into the pharmacy contract with the PBM. The discounts were supposed to be based on pharmacy performance; … Continue reading 2024 — Industry Changes
Last time we discussed the added complexity of health insurance: the administrative layers involved. At the end, we made the observation that any company purchasing health insurance from an insurance company is essentially pre-paying for health care: your health care premiums will always reflect your usage. Therefore, every company with a health benefit is, in … Continue reading Parting out Health Insurance?
I promised we would delve further into health insurance, and like onions, there are lots of layers. A basic form of insurance, like Whole Life or Term Life insurance, involves a contract between the insured and the insurance company. There also exists a relationship between the insurance company and the insurance agent and possibly a … Continue reading Layers
