High Cost Medications

Specialties LTC Directors

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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.
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?

At one time, lovenox was very expensive, although since going generic, enoxaparin costs about $400 for a 14 day supply if you're buying it at walgreens, much less if you're buying for a facility of patients. Anticoagulation therapy can be billed separately, although you can't submit a claim for enoxaparin if the indication does not fit the criteria, which is fairly narrow (as it should be). If it's prescribed inappropriately then it's not covered, which is a fixable problem. I'll try to find a link for you.

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.

I don't think any studies have been done, but Zyvox is a "reserve antibiotics", meaning it is to be rarely used. In 8 years of ICU, I've had less than 5 patients on Zyvox, that's about .002%. Part of what I do now involves reviewing SNF patients as part of a medicare readmission reduction project which has involved a few hundred patients, not a single one has been on Zyvox. Whatever the number is, it's well under 1%. You could figure it out by looking at Pfizer's yearly Zyvox revenue versus the typical cost, which shows about .0007% of the population will use zyvox. Obviously the SNF population is more likely to use zyvox than the typical person, but to reach 1% they would have to be 143 times as likely.

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"...while it has forced SNFs to be more careful in their screening processes." This is exactly the point the OP made. And since this quote is over 13 years old, it's only that more relevant today.

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"Knock, knock". "Who's there?". "SNF". "SNF WHO?". "SNF Village. We're here to 'prescreen' your last Medicare referral to us. The LAST one left after only 2 days, but cost us $23,000, and had already used up all her MED-A days. THREE WEEKS AGO!".

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At one time, lovenox was very expensive, although since going generic, enoxaparin costs about $400 for a 14 day supply if you're buying it at walgreens, much less if you're buying for a facility of patients." I'll argue for the sake of it, that Walgreens or Wal-Mart or AARP online or etc. would be a better price for sure, if the SNF wasn't obligated to be at the mercy of its contracted institutional pharmacy. This post makes it appear as though the SNF has the ability to shop around for prices, or even possibly 'buy Lovenox in bulk'? Hmm.
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Specializes in Gerontology, Med surg, Home Health.

Perhaps it's geographic, but of the last 20 referrals we got, 14 of them were on Zyvox. Or Zyvox AND IV Cefapime AND IV Diflucan. These people are very ill, and can't participate much with therapy. Or the only thing they need is IV antibiotics. I've been in the business for years and have worked in many different places. Not once were we ever told that we could bill separately for Lovenox. It's called bundled billing for a reason.

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Specializes in Gerontology, Med surg, Home Health.
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.

I do not have to take every person referred to me. If I cannot provide the care they require or their actions could put my other residents at risk, I do NOT have to accept them.

I don't know where you get your information.

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Specializes in Critical Care.
Perhaps it's geographic, but of the last 20 referrals we got, 14 of them were on Zyvox. Or Zyvox AND IV Cefapime AND IV Diflucan. These people are very ill, and can't participate much with therapy. Or the only thing they need is IV antibiotics. I've been in the business for years and have worked in many different places. Not once were we ever told that we could bill separately for Lovenox. It's called bundled billing for a reason.

If the national average for zyvox use is .002% of the population, and the Physicians in your area are prescribing it to 70% of patients in SNF's, then that's a problem between the SNF's and your inept Physicians.

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Specializes in Critical Care.
I do not have to take every person referred to me. If I cannot provide the care they require or their actions could put my other residents at risk, I do NOT have to accept them.

I don't know where you get your information.

I got my information from CMS. If a patient requires a level of care you cannot provide then you can refuse them, if you cannot provide the level of security necessary then you can refuse them. If you think you might not make money on them and you take other CMS patients, then you cannot refuse them, that is illegal, and worse, unethical.

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Specializes in Critical Care.
At one time, lovenox was very expensive, although since going generic, enoxaparin costs about $400 for a 14 day supply if you're buying it at walgreens, much less if you're buying for a facility of patients." I'll argue for the sake of it, that Walgreens or Wal-Mart or AARP online or etc. would be a better price for sure, if the SNF wasn't obligated to be at the mercy of its contracted institutional pharmacy. This post makes it appear as though the SNF has the ability to shop around for prices, or even possibly 'buy Lovenox in bulk'? Hmm.

Nobody buys lovenox in bulk, facilities buy medications in general in bulk, if any facility is paying more than what you'd pay at Walgreens, then somebody failed in their job.

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Specializes in Critical Care.
"...while it has forced SNFs to be more careful in their screening processes." This is exactly the point the OP made. And since this quote is over 13 years old, it's only that more relevant today.

I think that was the point, despite laws preventing SNF's from bilking the system, they continue to steal from the system through creative screening techniques.

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As I sit here shaking my head as in "Come AGAIN?", I just recalled a quote from W.C. Fields: "If you can't dazzle them with brilliance, baffle them with bull." :)

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Specializes in Critical Care.

Maybe you could be more specific?

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