The Impact of Evolving Treatment Options in Multiple Myeloma, Part 7

Bruce A. Feinberg, DO: We’re going to change gears a little bit. I think this is a great introduction that helps level-set our audience on the complexities around this disease. And why we are at a pivotal moment where we get to a point of efficacy that has us asking the question, do we need everything? Is more continued, still going to be better?

Tom, I want to shift gears and get into the patient aspect. All a patient knows, whether they’re actually on an actuary table and have 5 years to live or 20, they just want to know that they’re going to be cured of their cancer. The second thing they want to know is who is going to pay for it. Also, dispensing the drugs since we’ve gotten oral drugs, and since we’ve got subdue drugs, it’s gotten to be complicated explaining the benefits and how we go through that with patients. I want to get into the role that pharmacy is now playing in the practice, especially if it’s a dispensing practice. Let’s start with that. Are you a dispensing practice?

Thomas Ollis, MS, RPh: We are. We have our own specialty pharmacy, yes.

Bruce A. Feinberg, DO: Talk to me about the role the pharmacists or pharmacy technician has. How engaged are they on the team within the practice? Because this becomes a big piece for the patient’s side of the story.

Thomas Ollis, MS, RPh: Yes. The pharmacist is involved as soon as that script is written. We handle the biggest piece of all this is the prior authorization. First, we have to get it through prior authorization, and then we have to get it paid for the patient through some foundation or some kind of patient assistance program. Our pharmacy is involved as soon as it’s written and the way we look at our patient population, we view all of our patients as pharmacy patients.

Meaning, even if one of the PBMs [pharmacy benefit managers] says you can’t fill this prescription, you have to send it to one of our PBM-owned pharmacies, we still take care of that patient. We still put them through our patient management program and we just keep an eye on them because in our experience, once we transfer a prescription out, then significant delays happen. Unfortunately, that happens more than we’re comfortable with. It just happens when you have to send to someplace else—the whole ball stops rolling. We try to do all of the benefit investigations up front so these patients can get their medication quicker.

Bruce A. Feinberg, DO: Do you have a pharmacist or a pharmacy technician who has got an outlook calendar with the tech work, and they’re literally calling patients every week to see what’s happening and if they’re getting their meds on time? When you’re dissociated from the process, how do you manage it?

Thomas Ollis, MS, RPh: We do exactly that. We have that once that patient is out of our system—out of our pharmacy information system—once they’re out of there, it’s hard for us to do anything except use a calendar. I have a tech that we laughed with, she has a sheet of paper, she writes down the names, and follows up that way. Logistically, it’s challenging to continue that follow-up, but I think it’s so important because there have been many times where the PBM pharmacy needed a gentle push from our pharmacists.

Bruce A. Feinberg, DO: So you actually intervene on the patient’s behalf?

Thomas Ollis, MS, RPh: We do.

Bruce A. Feinberg, DO: To get the drugs?

Thomas Ollis, MS, RPh: Because they’re still our patients. At the end of the day, they’re our patients whether we’re filling their prescriptions or not.

Bruce A. Feinberg, DO: Ryan, you’re with Emory Winship Cancer Institute. There ain’t no prior authorization for Emory. There ain’t no PBM taking my patients. Does it work that way or are you just like another schlub and you’ve got to do all this?

Ryan Haumschild, PharmD, MS, MBA: We don’t let these PBMs push us around. No, I’m kidding. We have to deal with PBMs still. The way it works with us is we have about 20 sub-specialized PGY1 [postgraduate year 1], PGY2 [postgraduate year 2], board-certified oncology pharmacists that practice in the clinic. They’re the ones that are actually sometimes initiating the prescription and working with the provider to educate the patient right there. We want to own the patient, just like you mentioned, Bruce. We don’t want them to leave our system. We have one of the largest integrated health system loans, especially pharmacies, in the southeast. Across every oncology area, including multiple myeloma, we try to capture those prescriptions. That being said, we know there’s this thing called limited distribution in multiple myeloma around the IMiDs [immunomodulatory drugs], so we capture as much as we can, but we’re not a registered dispenser inside of IMiDs. We will work to transition those patients to get prior authorization done to deal with the financial toxicity but I will tell you one thing that we’ve been doing is actually publishing research around the benefits of integrated delivery systems like Emory in our specialty pharmacy. We looked at our patients in oncology, and we looked at patients that filled an external PBM-owned specialty pharmacy in our internal, and patients that filled internally had 25% better adherence than a PBM-owned specialty pharmacy, and they got their drugs 4 days faster. We’ve been leveraging our data because it’s great to have clinical trial data, but if you don’t have the adherence that matches that in the real world, you’re not going to get those same clinical trial results so we’re really pushing that piece to gain more and more access. Then, just one more piece, Bruce, we have a case management system that every single patient’s registered in. We make sure that we do all the initial education. We monitor the prior authorization in the patient’s assistance program if there’s any financial assistance needed, then we follow up on them before every single fill, we green light to make sure that the patient doesn’t have any rate-limiting toxicities, hasn’t had any changes in insurance and is ready for that dispense. We try to wrap around that care model really to promote best practice and also show our outcomes so we can carve back those patients that the PBM specialty pharmacies are taking away.

Bruce A. Feinberg, DO: Tom, one of the most on-risk of the pharmacy management processes for patients has been REMS [Risk Evaluation and Mitigation Strategy], and in myeloma, we have drugs with REMS. Help me understand how you’re doing the REMS and are you still doing the REMS when the patients’ dispense is coming from another pharmacy?

Thomas Ollis, MS, RPh: Luckily, we do have a license to dispense the IMiDs so we go ahead and do that. We walk the patient through the whole piece. Some patients are savvier than others, and they like to use maybe a web-based tool. Our experience is that a lot of the patients like us to walk them through it. Our pharmacy technician will get the patient on the phone and they’ll do a 3-way conference with the manufacturer and walk through the survey that they need to do before each fill.

Bruce A. Feinberg, DO: Joe, at the clinician level, how much are you aware of all the stuff going on in the pharmacy? Do you know that you can dispense within the system or are they going to go out to a pharmacist? Do you have an integrated pharmacist on the team? How involved is the clinician, are they in the dark? They’re just going in, they’re seeing the patient, they’re doing their stuff, and then somebody else takes care of us.

Joseph Mikhael, MD: I’ve been around the block long enough to remember the glory days of the dark when we didn’t. I used to have a pin that said, “My pharmacist is my homie,” because I pretty much had them on speed-dial all the time. I would argue that especially in myeloma, and I know I’ve got a couple of pharmacists here, I have to be careful of what I say, but it’s true—we’re working more closely with them than ever. I think the days of disconnect between, “Here dear, take this pill because I’m your doctor, trust me,” and someone else magically behind the scenes like the Wizard of Oz fixes it all, are gone. I think we have to work in dialogue and I work in a unique practice where I’m an academician, but our clinic is nested in at Unity Hospital, so sometimes I think I get the best of both worlds and sometimes I get the worst of both worlds. Sometimes, REMS programs are really challenging. Sometimes, getting J-Codes in time, and getting this done in time are very challenging, indeed. I think it’s part of the reality of being a community oncologist, and frankly, even hematologist-oncologist in general now, is that the process is so complex with so many different variables that we need to be working together as a team to do it. I know that sounds like let’s hold hands and say, “Kumbaya,” but it’s absolutely the reality. We can’t function independently of them because the likelihood of all those things aligning in some perfect star-like fashion for the patient to get the drug at a reasonable cost in a reasonable time is impossible without all these interventions.

Bruce A. Feinberg, DO: It’s interesting, right? Just think of the cost of the system because it used to be you would just have a nurse. Then it was a nurse and you probably had an advanced practice provider. Now, it’s a nurse, an advanced practice provider, and a pharmacist, and I’m probably missing others.

Joseph Mikhael, MD: And then the MA [medical assistant], and an office manager, and I mean…

Bruce A. Feinberg, DO: Yes, because that team just gets bigger and bigger and bigger to manage the complexity of what’s involved with the patient care, so it’s crazy. Again, there needs to be this understanding that this is just one little piece ofone disease.

Last comment on REMs. Anybody can weigh in. Are REMs, are they a barrier to prescribing for the clinician? Are they a barrier to patients in getting their drug or prescription? Or is it just an unnecessary or a necessary hassle that you just deal with?

Thomas Ollis, MS, RPh: Yes. I think it’s a necessary hassle you just deal with. I don’t think anyone would not use an IMiD because of the complex REMS programs. Joseph was talking before about being a team. That’s what the pharmacies are there for. That’s what the pharmacy, the pharmaceutical technicians, and the pharmacists are there for. We walk the patient through the REMs process and we assist the prescribers and the pharmacists as well. The offices as well. It’s a team and definitely not a deciding factor in a patient’s regimen.

Joseph Mikhael, MD: I would agree with that, Tom. The only thing I would potentially add is that now that the REMS programs are expanding in a different capacity, so we have a drug now with belantamab mafodotin [Blenrep] and that it’s more than the traditional REMS program. This is not your daddy’s REMS program. Where now in addition they have to see an eye specialist prior to each single visit. I think in some cases that has actually influenced their regimen. I think it has actually been more of the potential toxicity than the actual visit that may prevent someone from going on to the drug or for clinician to select that drug. I want to be careful that I don’t put the blame on the REMS when the blame is on the potential toxicity from the drug, but it does make it more tricky, but I agree with Tom, this is just an unnecessary challenge that we have to go through because safety is paramount. I mean at the end of the day we want to do what’s right but we need to do what is safe for the patient.

Bruce A. Feinberg, DO: Ryan, you are so patient, you get the last word.

Ryan Haumschild, PharmD, MS, MBA: I think the last thing is REMS is changing. We were so used to IMiDs just being managed by the clinic but now as you see more REMS becoming available it has to be done on both the health care facility side as well as the clinic. You’re not just going to be successful in one or the other. The way we describe it to patients is, there is REMS there and Joe mentioned for keratopathy, the REMS ensures we are doing the right quality checks with those eye care professionals. As much as it’s an inconvenience, it’s really a safety check for the patient to let them know for some of these rare occurrences, we are going to make sure we have a hard stop and do that check. We are going to do the hard stop with the IMiDs. I don’t see REMS going away. I see us getting better and better at being able to work within that context to make sure we are delivering safe care.

Transcript Edited for Clarity