At practices with their own pharmacies, many patients are now given the option of picking up prescriptions directly from the clinic, known as medically integrated dispensing. Proponents of this method believe that it provides for better patient outcomes, allows for better tracking of patient adherence, and is substantially more cost effective.
Guri K. Doshi, MD
Although oral chemotherapy has dramatically changed the face of cancer treatment, how the drugs are dispensed can be nearly as important as the drugs themselves.
“It’s one thing to prescribe an oral medicine for a patient,” said Guri K. Doshi, MD, a urinary and prostate cancer specialist with Texas Oncology, the state’s largest cancer care provider. “It’s another to get it into their hands.”
The decision on how a drug gets dispensed is dictated solely by the patient’s insurance plan. At present, most plans require oral oncolytics to be distributed via mail order through specialty pharmacies.
These state-licensed facilities provide specialty medications to patients with serious health conditions through large healthcare networks. Because of their high patient volume, they’re able to negotiate bulk discounts from drug manufacturers and pass the savings on to insurers.
However, a growing number of plans have begun offering a second alternative: at practices with their own pharmacies, patients are now given the option of picking up prescriptions directly from the clinic. Proponents of this method, known as Medically Integrated Dispensing, or MID, believe it provides better patient outcomes and is substantially more cost-effective.
“It really helps improve patient care based on the shorter time it takes to have the patient obtain medication,” Doshi said.
The briefer time frame becomes apparent as soon as the physician writes the prescription. First fill prescriptions are sent electronically to the pharmacy, which must then wait for insurance authorization before it can fill it.
“The difference is that with MID there is an immediate verification so it’s received and worked on immediately,” Doshi explained. “While with specialty pharmacies there can be a delay in getting the drugs to the patient. It can take up to a couple of weeks. It’s a huge problem and most significant when we’re just getting the patient started on their cancer treatment. A delay of 2 weeks or more can really make a significant impact on a patient’s health.”
The difference between the 2 systems becomes even more apparent after the first fill is completed.
With MID, the doctor continues to manage the prescription directly through an in-house pharmacist. The patient simply picks it up from the pharmacist once it’s filled.
With specialty pharmacies, however, the responsibility of managing subsequent fills falls solely on the patient. It’s their job to contact the pharmacy and schedule delivery times.
“After the first fill, the onus is on the patient,” Doshi explained. “They have to be the one to continue to communicate with the pharmacy. Even if the doctor does it for them, it’s still external to the doctor-patient relationship, a third party.”
Jan Merriman, RPh, BCOP, director of clinical and pharmacy services for Minnesota Oncology and a longtime advocate of MID, understands the need for integrated access. She and her team work closely with approximately 100 physicians, nurse practitioners and physician assistants across 12 sites.
“The specialty pharmacy doesn’t have access to the patient’s medical list and they can’t see patient’s labs,” Merriman explained. “It’s like trying to coordinate another outside entity that isn’t under our control and one that’s difficult to communicate with. It’s not like they’re really a partner in the patient’s care.”
That’s because once the prescription leaves the clinic, providers are in the dark regarding its status.
“When we send scripts off to CVS and the larger corporations, we never know when they're mailed, when they're received, etc., unless we call,” said Kirollos S. Hanna, PharmD, BCPS, BCOP, a hematology/oncology clinical pharmacist at the Mayo Clinic. “And unfortunately, we do not have the time to do so for each patient. Unless the patient is an excellent historian (and most are not), this issue is a big problem when assessing adherence.”
Communication issues further complicate the process. Because of their massive patient volumes, specialty pharmacies rely on phone trees and call centers to manage their caseloads, a practice that can be frustrating for both patients and their healthcare providers.
Ashley Placher-Biernat, a certified pharmacy technician with Joliet Oncology-Hematology Associates in Joliet, Illinois, oversees the retail side of the clinic’s oral oncology program. She coordinates prescriptions on a daily basis, both in-house and through specialty pharmacies.
“Every single time with these mail-order pharmacies it’s the same thing,” Placher-Biernat said. “They don’t follow up. All they do is take the order. Some don’t follow up on refills. Some don’t tell us a prior authorization is needed. Some don’t schedule deliveries. It’s all up to the patient.”
She recently spent a week trying to get a specialty pharmacy to fill a prescription for a hospitalized patient.
“I got prior authorization from the insurance company, got all of the information from the patient and sent the prescription to the specialty pharmacy,” Placher-Biernat said. “The next day I called them and they told me they never got the prescription. So I gave it to them again. The next day I called again and they said their pharmacist was questioning the dose. I clarified the dose and set it up for shipping to the hospital room. The next day I called again and they said they had no record that anyone talked to the patient about delivering the medication to the hospital.
“Now it’s Friday. I could have filled this and had it done already… I ended up having a 3-way with the patient and the specialty pharmacy. The patient finally got their medicine on Tuesday because the specialty pharmacy won’t send medicine on Friday because they won’t deliver on Saturday. From start to finish it ended up being 7 days. And the mail-order people weren’t even taking notes.”
Yet simply getting the drug into the patient’s hands is only the start of the process. Adherencemaking sure the patient takes the drug correctly—is an essential second step.
Mail-order pharmacies primarily measure adherence based on refills, noted Nancy Egerton, area manager of pharmacy services for New York Oncology Hematology, a 7-site practice in the Albany area. But refills alone aren’t really an accurate measure, she said.
“Just because the patient is re-ordering pills, it doesn’t necessarily mean they are taking them,” Egerton explained. “A lot of times you find patients have pills stashed at home they never took. The only way you can check for true adherence is for the patient to come in with the bottle and have the pharmacist count the pills. At our clinics we have the ability to do that. Some patients bring in their meds with them, some don’t, but at least we’re conversing with them face-to-face.”
Because their pharmacists meet patients personally on a regular basis, MID practices are able to achieve significantly better patient adherence.
At Texas Oncology, for instance, the group’s lowest adherence rate for oral chemotherapy is 93%, according to Jim Schwartz, RPh, executive director of pharmacy operations. “The best adherence that specialty pharmacies have been able to report is about 85%,” he said.
In addition to adherence issues, regimen changesa relatively common occurrence in cancer care—present a particular challenge to oral chemotherapy.
With traditional intravenous treatment, adjustments can be made on the fly prior to treatment, so drugs are rarely wasted. With orals, on the other hand, any change in regimen can result in a previously filled prescription going unusedan expensive proposition for both the patient and their insurance company.
Yet for specialty pharmacies, it’s a situation that often is exacerbated by the same economies of scale they use to cut costs.
At Texas Oncology, Schwartz has witnessed this phenomenon firsthand.
“Some specialty pharmacies provide up to 90-day builds for the economic benefits,” Schwartz explained. “This can be problematic if the doctor changes dosages. MID pharmacies typically limit oral chemotherapy prescriptions to no more than 30-day builds. Short prescription dosages allow for changes without wasting money. That is, the patient isn’t stuck with a lot of pills of the wrong dosage.”
Because oral chemotherapy prescriptions often run hundreds or even thousands of dollars per month, the financial impact of any regimen changeunscheduled discontinuations, held treatments, or dose adjustments—can be significant.
A 2017 study by St. Luke’s Mountain States Tumor Institute in Boise, Idaho, concluded that MID avoided far more costs and generated less waste compared to specialty pharmacies.
The study monitored 2262 prescriptions filled over a 6-month period. Monetary waste was defined as filled prescriptions not used by the patient, while cost avoidance was characterized as timely interventions that prevented unnecessary prescriptions from being filled.
Prescriptions filled through the in-office dispensing method averaged $144,201 in monthly cost avoidance, versus $4305 in waste. Prescriptions filled through specialty pharmacies averaged $5124 in monthly cost avoidance, versus $9982 in waste.
Almost half of the MID prescription interventions were related to unscheduled discontinuations and withholding or returning of a prescription fill. This type of cost avoidance is unique to MID since patients generally see their doctors prior to starting their next drug cycle.
Prescription fills by specialty pharmacies usually are triggered automatically on specific calendar dates. Since processing of new prescriptions can take up 2 weeks, the chance of a successful intervention is limited.
Yet, while limiting unnecessary expenses is appealing to insurance payers, the MID benefit most noted by patients is the help they receive obtaining financial assistance.
Gina Boilard is a prior authorization supervisor for New York Oncology Hematology. She provides financial counseling to patients receiving chemotherapy on a daily basis. Her approach is typical for practices that have adopted the MID method.
“I get patients in tears, but I try to tell them they are in good hands,” Boilard said. “As long as their income guidelines are met, I can help them.”
Boilard first searches for co-pay assistance in the form of grants based on the patient’s cancer diagnosis. “All I need is the patient’s financial information, she said. “I can get approval online in 10 minutes.”
If the grant is not approved or if funds are unavailable, Boilard will try to obtain free drugs through the manufacturer’s patient assistance program.
“I’m used to dealing with companies and the long phone calls,” she said. “I’ve been doing this long enough that I know when I can help people. In 2016, I brought in more than a million dollars in grants for our patients.”
The patients she’s worked with are ecstatic about the help they’ve received.
Jean Morris was diagnosed with metastatic breast cancer in April 2018. After undergoing radiation therapy, she was prescribed palbociclib (Ibrance), an oral drug that costs about $15,000 per month.
Boilard initially was able to get her a $5000 grant. Once that was depleted, she enrolled Morris in a free drug program through the manufacturer.
“When I heard the cost, I knew I couldn’t afford it,” said Morris, who’s on Medicare. “Making me aware that I qualified for assistance was a matter of life and death, because if I hadn’t qualified I wouldn’t be taking it. It just blows me away because I didn’t even initiate (the process). Gina did everything for me.”
Albert Hulick III was diagnosed with chronic myeloid leukemia several years ago. For nearly 3 years he’s be on imatinib (Gleevec), which runs around $10,800 per month. And even though his insurance plan required him to obtain the drug through a specialty pharmacy, he ended up contacting Boilard for help.
“They weren’t user friendly. I couldn’t navigate their phone menu, and it was difficult to get the prescription filled,” Hulick said. “I got in touch with Gina, and they were able to get the script expedited.”
Boilard also helped Hulick get approved for a patient assistance program through the manufacturer.
“One of the things that makes Gina so valuable is that she knows how to navigate the process,” Hulick said.
Yet despite the proven advantages of MID, the majority of insurance carriers still favor specialty pharmacies.
“They have the attitude of ‘it’s not broke so why do we want to fix it?’” said Michael Reff, a registered pharmacist dedicated to changing the status quo. “They don’t understand the inconvenience to the patient. They don’t understand the expense.”
Reff is the founder and executive director of the National Community Oncology Dispensing Association (NCODA), a grassroots not-for-profit started in 2015 to strengthen community oncology practices with dispensing services.
“We work with practices to try and collaborate with their payers beyond the first fill,” Reff said. “We educate them, and explain that if they do it this way they’re going to have better outcomes and happier patients, and take costs out of the system.”
NCODA has launched several initiatives targeting both patients with cancer and the member clinics that serve them. These include:
“Ideally the practice should be allowed to manage the patient [with cancer] in totality, unencumbered by interference from specialty pharmacies, insurance regulations and the complicated system of authorizations and financial support,” Reff said. “We should be focused on serving the patient, not on unraveling red tape.”
The National Community Oncology Dispensing Association (NCODA)is the first grassroots, not-for-profit organization founded to strengthen oncology organizations with medically integrated dispensing (MID) services. NCODA’s “Going Beyond the First Fill” strategy utilizes quality standards and continuity of care benchmarks through its patient-centered initiatives and partnerships. For more information, go towww.ncoda.org.
Bill Wimbiscus, a contributor for NCODA, is a Chicago-area journalist with more than 35 years’ experience. He has written and edited for numerous newspapers and magazines.
Howard A, Kerr J, McLain M, et al. Financial impact from in-office dispensing of oral chemotherapy [Published online September 24, 2018].J Oncol Pharm Pract.doi: 10.1177/1078155218799853.