Specialty Pharmacies Transforming Cancer Care

AS THE MODEL OF COLLABORATIVE HEALTHCARE

expands and grows, every person who participates in patient care will have a distinct role to play to improve patient outcomes. Specialty pharmacies are increasingly bearing the charge of dispensing, distribution reimbursement, case management, and other services that serve a patient’s specific disease needs.¹

From adherence management to communicating with physicians, coordinating financial assistance, and managing prior authorization, specialty pharmacies offer patients a variety of comprehensive services. At the Patient-Centered Oncology Care^® meeting, held November 17-18, 2016, in Baltimore, J. Ike Nicoll, President, The Morrison Group, and Joshua A. Rademacher, MBA, executive vice president, Enterprise Solutions and Business Development, at Avella Specialty Pharmacy, spoke to pairing novel cancer treatments with high-touch and high-technology support.

Introducing the 2 speakers, Joseph Alvarnas, MD, editor-in-chief of Evidence-Based Oncology™ and co-moderator of the meeting, said, “If we are talking about patient-centered care or financially sustainable care, the mindset that goes behind that has to evolve.” He pointed out that when caring for patients, the idea often gets lost or isolated, which, he said, meetings such as PCOC^® can help bring to the forefront by inviting diverse stakeholders to participate. Alvarnas pointed out that a partnership with individuals who can help navigate the issue of complex, potentially toxic drugs that are typically very expensive, and ensure that patients have adequate knowledge and capacity to receive the information in an equitable way, can also help.

Nicoll, who has worked with oncologists, as they try to navigate the healthcare system and changes within it, said that his company strives to provide physicians with the infrastructure that can help them guide the cost, as well as the quality of therapy. “We would like to create a case and show how specialty pharmacy can help oncologists and providers as they provide care outside of their walls.”

The complexity of cancer care, the daily innovations in the field of diagnostics and drug development, and the high cost, “Have resulted in a lot of visibility for cancer in the payer community,” Nicoll said. Referencing a presentation by Michael Kolodziej, MD, when he was the national medical director for oncology, at Aetna, Nicoll showed a slide that provided insight into the top cost drivers of oncology care for Aetna. The data, presented in 2014, showed that Aetna’s annual drug spend in oncology was $1.5 billion represented a 30.8% growth in spending. Inpatient spending and radiology followed at a close second, at $1.1 billion each.

Nicoll pointed out that standard cost-saving strategies used by health plans—such as lowering physician payments, increasing prior authorization requirements, creating narrow formularies and choosing generics as the preferred option, utilizing pharmacy benefit managers and specialty pharmacies, and shifting the payment burden to patients by increasing co-pays and deductibles—have had only a limited effect on bending the cost curve in oncology. “They have, however, had a significant effect on the way we coordinate and deliver care,” Nicoll added.

Coming back to where healthcare stands today, Nicoll said that we are at a point where we need to choose our path between value-based treatments and the traditional volume-based care. “We have seen a number of value-based models and a great deal being done with medical homes, bundled payments, and some early forms of ACOs [accountable care organizations],” he said, adding that we are now rethinking the paradigm of how we deliver and finance care.

Nicoll indicated that as payers shift responsibility onto patients and align it more with financial responsibility, the problems arise with inherent capabilities that exist or are required, with practices and academic medical centers taking up financial risk. This has shifted the landscape for providers in terms of what is “required” in the delivery of patient-centered care, he said, because it forces physicians to think about care delivery in the broader context of the total cost of care.

“It would require clinical organizations to develop capabilities to manage their patient not just inside, but also outside their walls, to create a patient-centered experience,” Nicoll added. Providers and their organizations would need to effectively engage, educate, and support the patient and their caregivers to:

• Define, direct, and manage care across the entire care continuum
• Identify issues in real time and effectively intervene to manage the patient
• Collect, evaluate, and report the key clinical and financial data necessary to demonstrate high-quality patient care

Specialty pharmacies, according to Nicoll, can play an important role in this integrated approach since this model builds upon many of the necessary functions that he and his team perform every day, including:

• Patient outreach/triage
• Clinical guidelines/quality
• Care management/coordination
• Technology/data analytics

Acknowledging the tremendous job that clinical teams strive to achieve with tracking and monitoring not just inpatients, but also their outpatients, Nicoll said that clinics might not always be systematic with the way things are managed. Specialty pharmacies, on the other hand, have honed these capabilities with the models they have built around these operations. While existing reimbursement models are an impediment to the collaboration between a specialty pharmacy and a clinic, value-based models could alter physician payment. “When it is the clinician’s role to manage the patient and to be compensated based on the quality, the outcome, and the total cost of care, then you’d develop the capabilities to accommodate that,” he added.

Rademacher then came up on stage to speak about the various services offered by his company. These include:

1. Initial assessment. Patient profile, adherence and persistence risk, predictive, and criteria-based cadence of Avella interventions.
2. Clinical assessment. Patient history, concomitant and co-morbid conditions, disease-specific criteria, depression screening, social support, and disease progression rates.
3. Clinical services. Nursing assessments, patient education, nursing and pharmacist criteria-based cadence of interventions, and side effects and adverse events (AEs).
4. Follow-on care support. Clinician follow-up for AEs and/or side effects management, patient self-management tools, persistence and compliance, and documentation and shared information.

Being the point of integration and clinical coordination with our oncology partners, “We make significant investments in technology, to deliver both provider-specific and patient-specific applications, such as patient portals, mobile applications, and data analytics,” Rademacher said. He went on to describe some of the tools and portals that have been developed by Avella to monitor patient compliance and send feedback to providers.

Rademacher said that patients who receive counseling have, on average, a 7.8% greater medication possession ratio than those who opt out of the counseling that is provided by Avella. A successful case study for Avella was the improved adherence observed among patients with HIV using a mobile app developed by Avella—these patients presented a 49% improvement in adherence compared with the national standard.

AdhereTech and Proteus Discover are 2 technologies that the company has developed for tracking patient adherence. AdhereTech is a wireless pill bottle that gathers patient adherence information, populates and analyzes the data, and sends custom alerts to patients—all to improve patient adherence to treatment. Proteus Discover involves encapsulating an ingestible sensor into a pill or tablet to monitor adherence and also track outcomes.

REFERENCES

Rademacher concluded that specialty pharmacy best practices, such as adherence strategies, patient engagement, and data sharing between providers and pharmacists will be critical components of value-based care delivery models. These, he believes, will force providers and pharmacies to rethink their traditional relationships and move toward true collaboration.

1. Moore CD. Cancer care: the role of specialty pharmacy. Pharmacy Times website. http://www.pharmacytimes.com/publications/issue/2015/july2015/cancer_care. Published July 21, 2015. Accessed January 12, 2017.

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