EP314: Why Do SNF (Skilled Nursing Facility) Patients Need Two Pharmacies and a PBM? Following the Kinda Long Long-term Care Pharmaceutical Supply Chain, With Sheldon Weiss, MD

This episode is for anyone as curious as I have been about pharmaceutical supply chain goings-on in long-term care facilities like skilled nursing facilities, otherwise known as SNFs. There are a lot of players in the mix: You have your PBMs. You have your wholesale pharmacies. You have your LTC (meaning long-term care) pharmacies. You have the facilities themselves. You also have Medicare Part A and Medicare Part D and, in some cases, Medicare Advantage.

Let me just lay some groundwork here before we dive headfirst into the confoundingly messy middle. If we’re talking about patients who have been in a SNF for services not covered by Part A—maybe because the patient needs help with basic activities of living—then their drugs are covered by Part D (Med D) or maybe their Medicare Advantage plan. The point I’m making is that it’s not a global payment at that point in the SNF. The patient’s Part D drug coverage is gonna be the same as if that patient were outpatient. They may have deductibles and coinsurance just like an outpatient.

In this health care podcast, I speak with Sheldon Weiss, MD, who I pretty much interrogate about the who, what, and when of the various parties involved in getting a drug into a long-term care facility. Dr. Weiss is a great guy to ask because he is a practicing physician and operating efficiencies consultant and a previous COO of an LTC pharmacy.

Now, let me editorialize a moment: At its core, the model of having a consultant pharmacist working with a medical director and a director of nursing at a long-term facility is a really interesting one. I just saw another article (this one in Health Affairs) the other day that came out proving yet again that provider teams outperform solo providers in managing chronic diseases. In theory, having a team including a pharmacist should definitely level up care. But there are confounders when it comes to the care of older Americans in facilities. One of them is that physicians—and I say this as an unfair broad stroke—sometimes don’t listen to the advice of consultant pharmacists because they’re just a pharmacist and not an MD. I’ve heard this go down myself and not just with pharmacists.

In fact, in my recent interview with Dr. Douglas Eby from the Nuka System of Care, he said the same thing about doctors and behavioral health specialists. At the beginning, the docs are, like, “Oh, we don’t need behavioral health specialists. That’s what we do very well, thank you very much.” It didn’t take them long to revise that opinion, but it’s really common pooh-poohing that I hear repeatedly. And so, for possibly this reason and others, we have a situation where one of the main reasons why patients wind up in the ER from SNFs is that they have adverse drug events.

Now, this being said, patient care in SNFs is a hard row to hoe because patients and SNFs are often highly complex and under the care of, in some cases, 10 or more specialists, all prescribing drugs without any knowledge of what other specialists are prescribing. Will the medical director of a facility want to take on the responsibility of contradicting a cardiologist or a pulmonologist or an oncologist and unprescribe some med? It takes a certain amount of fortitude and willingness to take on that risk. Keep in mind one point to ponder, however: Most people “aging in place” at home right now are not going to have anybody at all looking over their shoulder and even partially coordinating care reconciling meds.

You can learn more by connecting with Dr. Weiss on LinkedIn.

Sheldon Weiss, MD, practiced OB/GYN for over 30 years and has a master’s degree in hea