Achieving Quality and Containing Cost Through Oncology Pharmacy Management

In 2011, one large pharmacy benefit manager spent more than $25 per member per year (PMPY) on oncology specialty pharmacy, an increase of $4 PMPY from 2010 (Table). Spending is forecasted to exceed $40 PMPY by 2014 (Figure 1). Emerging oral cancer drugs are shifting costs from medical benefits to pharmacy benefits. With increasing numbers of expensive specialty pharmacy oncology drugs on the market—and hundreds more in the pipeline—it is clear that improvements in oncology pharmacy management are needed.

At the 2012 Academy of Managed Care Pharmacy Annual Meeting, a panel made up of a patient advocate, a cancer survivorship specialist, health plan representatives, an oncologist, and a health services researcher discussed the desired outcomes of oral oncology drug management, practical next steps, and gaps in and barriers to implementation.

Over the last 10 to 20 years, the introduction of new therapeutic agents has markedly improved overall survival for many types of cancer. In most cases, however, supporting data have not kept up with these advances, leaving knowledge gaps that make coverage and treatment decisions difficult. For many patients, cancer has become a chronic condition requiring long-term therapy. These evolving trends are bringing long-term cost implications. Payers and health plans find themselves attempting to manage practice patterns, provider and patient behavior, treatment options, and quality—a huge administrative cost burden. For many patients,cancer has become a chronic condition requiring long-term therapy. These evolving trends are bringing long-term cost implications. Payers and health plans find themselves attempting to manage practice patterns, provider and patient behavior, treatment options, and quality—a huge administrative cost burden.

Identifying Indicators of Outcomes

John Cruickshank, DO, MBA, chief medical officer, Lovelace Health Plan, provided an overview of outcome indicators and treatment pathways during the program. “Payers are beginning to expect that improved outcomes by an agent or regimen be demonstrated prior to full reimbursement,” he explained. “Historically, the overall survival end point has been the gold standard for oncology drug approval by the FDA, but that is changing rapidly.” Recently, approvals have been granted based on surrogate end points, such as objective response rate, progressionfree survival, disease-free survival, and time to progression. A major problem with surrogate end points is that they often do not translate into long-term survival benefit. The use of different end points across trials makes comparative analyses difficult.

Implementing Treatment Pathways

The panelists and attendees agreed that standardized treatment pathways that take into account comparative effectiveness and cost data are the ideal foundation for coverage decisions. The consensus among the panel was that preferred pathways will help relax prior authorization requirements and other barriers to approval, thereby lowering cost for managed care organizations while easing access for both patients and providers. Health plans would like to be able to use treatment guidelines or pathway programs for a balance of clinical, qualitative, and economic features to yield the most cost-effective treatment results. Numerous treatment options, a poor evidence base upon which to make decisions, and wide variability in treatment plans present barriers to making this a reality, however.

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Existing guidelines do not offer a single drug recommendation in most cases, do not include cost information, and are not always in agreement with one another or with compendia. To achieve desired outcomes, the numbering the program. “Payers are beginning to expect that improved outcomes by an agent or regimen be demonstrated prior to full reimbursement,” he explained. “Historically, the overall survival end point has been the gold standard for oncology drug approval by the FDA, but that is changing rapidly.” Recently, approvals have been granted based on surrogate end points, such as objective response rate, progressionfree survival, disease-free survival, and time to progression. A major problem with surrogate end points is that they often do not translate into long-term survival benefit. The use of different end points across trials makes comparative analyses difficult. of pathways in use must be reduced to a manageable number. Until these challenges are overcome, panelists and attendees both agreed that National Comprehensive Cancer Network (NCCN) guidelines are an excellent resource and that their consistent use as a basis for decision making will reduce barriers to access for appropriate therapies. The panelists summarized other specific suggestions that came out of session workshops ().

Applying Oncology Formulary and Benefit Design Innovations

The panel discussed innovations in formulary and benefit design models through which to better manage oral oncology drugs. With the introduction of more effective and expensive oncology drugs, vigorous debates have ensued about the overall value of treatments, said Jeffrey Dunn, PharmD, MBA, formulary and contract manger,

Figure 2

Select Health Inc (). Payers are actively applying payment reforms and quality measurement to cancer services.

Health information technology (HIT) is a powerful tool that should be better exploited by pharmacy management. Effective application of HIT can enable rapid identification and incorporation of emerging data and provide a common data platform that supports decision making and patient monitoring.

HIT might also be used to address fragmentation of care between specialty pharmacy and the oncology care team. Fragmentation poses a significant management barrier. For example, logistic procedures may differ from drug to drug or between classes of drugs on both the payer and provider sides of healthcare. This issue is particularly relevant to oncology because the medication regimens of cancer patients frequently evolve.

Dunn emphasized that improved communication and collaboration between plans and oncologists will be vital to success and that achieving desired outcomes will be impossible without them. Successful management of cancer care requires a strategy that supports rather than hinders successful payer/physician collaboration.

The panel supported patients and patient support groups as important stakeholders whose perspectives should be considered during overall benefit design— especially with respect to issues such as copay versus coinsurance, emotional distress, supportive care, advance planning, and the impacts on decision making of dynamics between plans, employer, oncologist, and family/caregivers.

In summary, the panel agreed that a tiered oncology benefit model will undoubtedly be a part of designs going forward. Overcoming barriers will be helped by integration of specialty pharmacy and investing in technology that improves access to data and collaboration. Other valuable approaches discussed included utilization of case management programs and certain aspects of patient-centered medical homes, value-based models, and adaptation of education and diseasemanagement strategies that have been proved effective in other disease states. Furthermore, ownership of outcomes should be shared among key stakeholders, including patients, payers, and healthcare providers.

Funding Source:None.

Author Disclosure:The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information:Concept and design; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.

Achieving Quality and Containing Cost Through Oncology Pharmacy Management