Specialty Pharmacy and Medication Therapy Management in Oncology

John L. Fox, MD, MHA: The irony is that, [based on] the information that is available [regarding] whether or not patients fill their medications, we don’t know that they’ve taking it. I presume [that] if they’re refilling it, they’re taking it. You can look at the medical possession ratio, but who’s looking at that? I have the data. We actually published the data on all patient medications—oral medications that are filled and subcutaneously-administered medication. You can look at refills of Humira or anything else, but physicians don’t use it. Do they know it’s available? We need to do a better job of making sure that physicians have access to that data. One of the benefits of physician-dispensed orals is at least that data is in your hands.

Bruce J. Gould, MD: Exactly. I think that’s one of several benefits, but you’re right. Of course, we get some hint based on what side effects or what lab abnormalities we’re seeing in the patient’s record and so forth. But again, we don’t live with the patient so we don’t know if they’re actually taking the drugs or not. I would think that if they’re getting the medicines refilled, that in most cases, they are taking the drug.

Bruce A. Feinberg, DO: Does Priority Health have its own specialty pharmacy?

John L. Fox, MD, MHA: No, we do not.

Bruce A. Feinberg, DO: You don’t. Do you contract out to a specialty pharmacy?

John L. Fox, MD, MHA: We have a single preferred specialty pharmacy, yes.

Bruce A. Feinberg, DO: Do you believe that the specialty pharmacies do a better job of medication therapy management, in general, than physician practices do?

John L. Fox, MD, MHA: I don’t have any evidence to support one way or the other. What do I think? I don’t know, because we’re not tracking the relative performance of one versus another.

Bruce A. Feinberg, DO: Do you think, as an industry, the industry believes that the specialty pharmacies do a better job? Do you think that they believe physicians can manage this?

John L. Fox, MD, MHA: I think specialty pharmacies are more focused on medication therapy management [and] compliance than physician practices, certainly. Although, in a dispensing pharmacy at a practice, there is a pharmacist there who can be tasked with that job. I think the challenge is who’s got time to do that and who’s being [offered] the incentives? If there’s an incentive [for] the specialty pharmacy to manage compliance, they’ll do it.

Bruce J. Gould, MD: I would argue that. Specialty pharmacists also have the time, energy, and wherewithal to get in front of the payers and argue their case better than private practice physicians do—those that have in-practice retail pharmacies.

John L. Fox, MD, MHA: What do you want to get in our faces for?

Bruce J. Gould, MD: To beat you over the head and say, “Send all your scripts to us.” This is what the specialty pharmacies do.

John L. Fox, MD, MHA: Yeah.

Bruce A. Feinberg, DO: But you believe that practices can do as well or better?

Bruce J. Gould, MD: Yes, I do.

John L. Fox, MD, MHA: Today, Medicare pays for medication therapy management. A lot of health plans, including ours, are paying for medication therapy management—not only for Medicare because we’re required to, but also for commercial and Medicaid beneficiaries. So, there’s no reason [not to do it]. In fact, many of our practices who are dispensing pharmacies do get paid for medication therapy management. So, they’re someone who can not only do the medication reconciliation and do the compliance, but can also get paid for it.

Bruce J. Gould, MD: Right.

Bruce A. Feinberg, DO: So that sounds like it’s not universal in terms of what payers have adopted.

John L. Fox, MD, MHA: For a commercial patient, right.

Bruce A. Feinberg, DO: For a commercial patient being treated in a dispensing practice.

John L. Fox, MD, MHA: Right.

Bruce A. Feinberg, DO: But that could be something that, if it was more universal, could further support what you believe is the better avenue—the physicians directly work with the patient.

Bruce J. Gould, MD: And support those practices that don’t have in-house dispensing pharmacies, as well.

Bruce A. Feinberg, DO: Now, one of the things that’s happening, especially in the oral space because we’ve got precision [medicine or] targeted therapies that often focus on very ultra-orphan populations, is that the manufacturers are moving to very limited distribution models. Sometimes, it could be a sole-source distribution model [with an] exclusive arrangement. So, does a payer have any or do you have an issue with that? Is there any impact to a payer in that design?

John L. Fox, MD, MHA: In our setup, patients who are getting a drug through the specialty pharmacy go through that single specialty pharmacy. That specialty pharmacy will get it from the distributor, whoever that is, even if it’s a single specialty pharmacy.

Bruce A. Feinberg, DO: So, if you have a contracted, preferred specialty pharmacy, but they’re not the specialty pharmacy or the choice for that manufacturer, they will still get it and make that distribution?

John L. Fox, MD, MHA: Correct.

Bruce A. Feinberg, DO: Alright. I didn’t realize they could.

John L. Fox, MD, MHA: Yeah. That limits the frustrations that physicians have in contacting 15 different specialty pharmacies, at least for our plan.

Bruce A. Feinberg, DO: But that doesn’t happen for you. If there is a restricted model [or something,] that would restrict your practice from being able to dispense?

Bruce J. Gould, MD: Yes, assuming that we’re not within a distribution channel, correct.

Bruce A. Feinberg, DO: Do you have a sense right now of the product mix and—you mentioned 70 orals—how many of them (hopefully, it’s a small number), [how many] you can’t dispense through the practice?

Bruce J. Gould, MD: I can give you a percentage of the oral oncolytics that we can or can’t fill. We can fill 60% of the scripts that we write. Forty percent are mandated through the payer to go to their specialty pharmacy.

Bruce A. Feinberg, DO: Mandated through the payer, but not because it is a manufacturer relationship that has a single-source distribution or limited distribution network.

Bruce J. Gould, MD: That’s right.