This article was developed from the Evolving Role of the Oncology
Pharmacy: Multidisciplinary Perspectives Pre-Conference at the ACCC 35th National
Oncology Conference, October 17, 2018, in Phoenix, AZ.
Along with all of the clinical and practical benefits that come with
oral oncolytics, these therapies can also present new obstacles to
treatment. In addition to higher out-of-pocket expectations for some, patient monitoring of side effects and compliance with therapeutic regimen may become more complex to manage when patients take oral therapies rather than receive infusions. Oncology pharmacists have proven that they can help address these issues by taking on expanded roles to support the cancer care team, enhance patient options and access to effective treatments, improve patient outcomes, and maximize reimbursement.
These issues were addressed at the Association of Community
Cancer Centers (ACCC) pre-conference workshop at its 35th
National Oncology Conference in October 2018. There, Nikki
Barkett, RN, BSN, OCN, an oral antineoplastics nurse navigator
at the University of Arizona Cancer Center, and Eric Dallara, RPh,
head pharmacist at New England Cancer Specialists, described
how dedicated oral antineoplastics teams composed of oncology
pharmacists, financial advocates, and nurses are streamlining the
processes required for a medication to move from prescribing to
dispensing and follow-up care.
Increasingly complex treatment regimens; a growing number of
combination therapies; multiplying indications and approvals; and
continually changing regulatory, authorization, and reimbursement
requirements can make treatment with oral oncolytics challenging
for both patients and providers. At the same time, the cost of treatment continues to rise, increasing patient cost sharing.
The oncology pharmacist can play a pivotal role by providing education about oral agents to patients and staff, monitoring costs to the patient, collaborating with specialty pharmacies, and coordinating efforts with a nurse or nurse navigator and financial advocate to ensure patients have dedicated support. As payment models and quality programs proliferate and greater emphasis is placed on proving value as measured by programs such as the Oncology Care Model (OCM) and the ASCO’s Quality Oncology Practice Initiative (QOPI), the oncology pharmacist is assuming responsibility for streamlining access, improving reporting, and enhancing the patient experience.
At the pre-conference, Barkett described an OCM-compliant
model at the NCI-designated University of Arizona Cancer Center
that was created to improve patient outcomes and lower costs by
aiming to reduce the severity of side effects and the frequency
of emergency room visits and hospitalizations. Under this model,
the cancer center employs an oral antineoplastics team-based
approach in which an oncology pharmacist, financial advocate,
and nurse navigator work together to support oral oncolytic access and compliance for patients treated by the center’s 28 providers. The Oral Antineoplastics Program meets daily to review individual patient prescriptions and flag items that need to be addressed.
The financial advocate handles all authorizations for oral antineoplastics and free drug applications. This team member works with patients and providers to obtain insurance information and liaise with the dispensing pharmacy. The oral nurse navigator then determines if there are any barriers to drug administration and medication adherence, such as inability to access the drug or difficulty swallowing pills or opening medicine bottles. If necessary, the oral nurse navigator also helps patients apply for financial assistance. Once a therapy is dispensed, the oral nurse navigator calls patients weekly to assess adherence and identify any adverse events. The oral antineoplastics pharmacist manages refills and monitors test results, and liaises with provider teams to adjust dosages or delay therapies based on possible adverse events. Together, the team aims to enhance treatment and maximize reimbursement.
Challenge: Complex oncology therapies make proving value difficult. Oncology pharmacies have an expanding responsibility to ensure patient adherence to oral medications for optimal patient outcomes. Although documentation of assessment of oral compliance is central to achieving QOPI certification and meeting OCM value-based metrics, measuring patient compliance is challenging. Oral oncology medications are not necessarily taken daily, and the regimens vary. Dosages can be withheld for various reasons and this does not equal noncompliance. Multiple pharmacies may be involved in dispensing different medications, and medication adherence tools can vary in their reliability.
Solution: New technologies can enhance communication and treatment monitoring. A range of digital and decision-support tools is emerging to enhance compliance monitoring and reporting. For example, oncology pharmacies can now integrate reminders and tasks regarding oral regimens into electronic medical records, enabling care teams to download outcomes data for QOPI or other reporting purposes. In addition, either nurses or pharmacy staff can now initiate follow-up calls using a custom standardized communication template. And smartphone apps that integrate with EMR dashboards and pharmacy software are being developed. These apps will enable pharmacy staff to contact patients via text about side effects, financial updates, or specialty pharmacy issues.
Challenge: Specialty oral oncolytics are often only available through limited distribution networks. Many oral oncolytics must be accessed through specialty pharmacies or other limited distribution networks. For many patients, mail order specialty pharmacies are mandated by their insurer or the pharmacy benefit manager (PBM), or the pharmaceutical manufacturer. However, according to a 2016 analysis of three ACCC member programs, mail order pharmacies are more likely than brick-and-mortar ones to have delays in delivery. In-house dispensing can sometimes offer an alternative, more efficient route of dispensing oral oncolytic therapies in a value-based context.
Solution: Bring pharmacies in-house. Eric Dallara, RPh, described how New England Cancer Specialists, a large independent practice, manages all oral oncolytics via an in-house dispensing pharmacy that determines coverage, cost, and the specialty pharmacy being used. Benefits to this model include: increased access and adherence to medications, the ability to dispense most medications to patients during their office visits, and increased revenue.
However, there are several issues to take into account when considering whether to establish an in-house specialty pharmacy. For one, state laws regarding dispensing medication vary, which can influence the pros and cons of setting up a physician-dispensing or licensed retail pharmacy. Other considerations include ease of access to medications from a wholesaler, access to the pharmacy networks and being able to fill oncology medications, adequate space and staff, and financial risks and benefits.
Access to oral oncolytics can be more challenging for many patients.
Those with suboptimal insurance coverage, those who are denied
drug coverage under Medicare Part D, and those whose income is
deemed too high to make them eligible for compassionate use all
struggle to obtain the medications they need. Financial navigators
can assist in making sure that the patient has access to the medication
within a reasonable amount of time, so that their care is not
delayed due to cost-related barriers.
As Barkett and Dallara noted, the eligibility standards for compassionate
use for oral oncolytics are not the same as the standards
for intravenous therapies. Additionally, oral parity laws vary across
states and this disparity reinforces the need for federal oral parity
legislation. In the meantime, an integrated pharmacy that includes
financial advocates, nurses, and pharmacists, effective patient education,
and informed oncology pharmacists can help expand access
to therapies and reduce costs for both patients and programs.