High Cost Medications

Specialties LTC Directors

Published

Do you all have a cap on spending for medications? We screen everyone coming in and usually say no to anyone on high cost Lovenox or high cost Zyvox....a 14 day course is about $4000. What SNF can afford that cost for one resident for 2 weeks of meds?

Specializes in Critical Care.

Legally it's been my understanding that you can't screen based on their medications, if a SNF wants the medicare patients that will make them big bucks, they have to take the ones that might lose money as well, you can't pick and chose. (And yes, SNF's make a lot of money on medicare patients as a whole).

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Specializes in Gerontology, Med surg, Home Health.
Legally it's been my understanding that you can't screen based on their medications, if a SNF wants the medicare patients that will make them big bucks, they have to take the ones that might lose money as well, you can't pick and chose. (And yes, SNF's make a lot of money on medicare patients as a whole).

We DON'T make a lot of money on every medicare patient. In fact if someone is one meds that cost $3600 in the first two weeks, we'll be lucky to break even.

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Specializes in LTC, Hospice, Case Management.
(And yes, SNF's make a lot of money on medicare patients as a whole).

Typical Medicare reimbursement for a medicare resident (we'll assume they are there for 2 weeks of rehab). Daily rate of about $450/day x 14 days = $6,300 - revenue

Costs:

Zyvox 600mg bid x 2 weeks - cost $3,450.15

Lovenox x 2 weeks = $700

Bulk of all other meds = $200

Therapy costs = $2000

..... Uh Oh, I've already used all the revenue and I haven't paid for a single nurse, a single aide, a bite of food, a bit of utility costs, a clean environment, etc.

We must screen high cost medications or we will not survive.

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What the DC planner failed to mention (and your admission coordinator missed because she was out marketing) is that the patient is 325 pounds, with a blown back surgical incision (hence the orders for the air bed and the wound vac), and her COPD (hence the O2 (and she refuses that via concentrator) and BI-PAP). And on day two her Foley is plugged, and she 'insists' that it can only changed in the ER (by 'real' nurses), so she calls 911 for herself, and the ambulance comes to get her, and she comes back in 3 hours. Then? On day 3 she has decided to transfer to a SNF across the street (because the room has a better view)- leaving YOU to 'pick up the pieces'? I bet you miss her already.

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Dumb joke: "Knock, knock". "Who's there?". "It's corporate on the phone. They wanna know who gave the OK to admit that last patient".

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Specializes in ICU, CM, Geriatrics, Management.
... It's corporate on the phone. They wanna know who gave the OK to admit that last patient".

Oh, oh! :nailbiting:

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Specializes in Critical Care.
Typical Medicare reimbursement for a medicare resident (we'll assume they are there for 2 weeks of rehab). Daily rate of about $450/day x 14 days = $6,300 - revenue

Costs:

Zyvox 600mg bid x 2 weeks - cost $3,450.15

Lovenox x 2 weeks = $700

Bulk of all other meds = $200

Therapy costs = $2000

..... Uh Oh, I've already used all the revenue and I haven't paid for a single nurse, a single aide, a bite of food, a bit of utility costs, a clean environment, etc.

We must screen high cost medications or we will not survive.

The percentage of SNF on zyvox is well under 1%. Those few that are might me money losers. Lovenox is actually one of the few things that doesn't fall under the compounded billing rule and can be billed separately.

The money that medicare pays is not intended to provide a profit on each individual patient, it's intended to provide a profit overall, which it does.

You can't have it both ways; you can't get paid in a generalized reimbursement format, where you get far more for some patients that they cost, and then also weed out the ones that are supposed to balance those other patients out. If you want the patients who bring in more money, you have to accept the ones that bring in a little less.

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Spot on, yes. Still, due diligence is required constantly to keep the doors open. And a profit is not a given with Medicare, not hardly. It takes a village, all working their orifices off. I've been in several places that only took about half of the patients referred to them. There are as many reasons to say 'no room at the inn' as they are to say 'welcome home'. The village makes a collective decision, more often than not- keeping in mind that you can't just get the peaches, because the DC planner will send those elsewhere if you refuse too many bad apples. Like it or not, there's a lot of behind the scenes investigations before some patients make it through the door of a nursing home. There's a lot at risk if one of those peaches... isn't.

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Specializes in Critical Care.

I don't doubt that SNF's lie and say they don't have an available bed for a patient, even though they do, they just don't think they'll profit as much off this patient as they would like, but it's still illegal to do so. If you want medicare patients, you have to take them all, that's the law.

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Like I said, I've seen half of referrals end up on the cutting room floor, MED-A or whatever pay source, or not. And even if the census was circling the drain. I've never heard about a law that reads every SNF has to take any MED-A patient, regardless of condition, needs, costs, ability to provide for those needs, even the ability of the patient to adversely affect other patients- and that's suprising, since hospital DC planners would then simply be able to call and say "We're sending you this patient, and that's the law". A hyperlink would be good, thanks. I'm awfullly curious.

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Also, if you would, send a source that Lovenox is an outlier cost- since every single person that has that order causes debate in a SNF (to admit or not)- I've never heard that, ever. If it were an outlier, who would even care about Lovenox, and why would it repeatedly be mentioned in here? Also, if you have a source of the 'less than 1% that use Zyvox'? I can't find any reference to that, even though it sounds about right- it's certainly not common in a SNF. Thanks.

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Specializes in Critical Care.
Like I said, I've seen half of referrals end up on the cutting room floor, MED-A or whatever pay source, or not. And even if the census was circling the drain. I've never heard about a law that reads every SNF has to take any MED-A patient, regardless of condition, needs, costs, ability to provide for those needs, even the ability of the patient to adversely affect other patients- and that's suprising, since hospital DC planners would then simply be able to call and say "We're sending you this patient, and that's the law". A hyperlink would be good, thanks. I'm awfullly curious.

"The federal government's two-year-old cost-saving reimbursement plan for Medicare patients admitted to skilled nursing facilities has caused irritation for some hospitals, while it has forced SNFs to be more careful in their screening processes. Federal officials say it is illegal for Medicare-certified SNFs to discriminate against Medicare patients, but it's not illegal to say 'we don't have space for the patient'."

Report confirms nursing homes cherry-pick pa... [Hosp Case Manag. 2000] - PubMed - NCBI

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