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PBMs: Their Role, the Problems, and How Practices Can Work With Them
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PBMs: Their Role, the Problems, and How Practices Can Work With Them

Ray Bailey, RPh, and Ricky Newton, CPA
The relationship between pharmacy benefit managers (PBMs) and community oncologists has not been an easy one. With the increasing prevalence of oral oncolytics, PBMs and community oncologists have seen a concurrent increase in their mutual interaction. Each can rail against the other, claiming better, faster, and more cost-effective care, or community oncologists can find a way to co-exist with and manage PBMs in a manner that would benefit patients and their practice.

The Role of PBMs in Cancer Care

In many areas of medicine, the role of PBMs is established. PBMs can be a beneficial part of the patient care team, especially for chronic conditions such as hyperlipidemia, hyperglycemia, and hypertension. However, the role of PBMs in cancer care is less clear. For acute, severe, and often life-threatening conditions like cancer, the community oncologist is better able to provide the intense, rapid-response, personalized, and familiar care that is necessary.

Adverse reactions and dosing refinements are common in oncology care and require prompt attention by someone familiar with patient history. PBMs do not have access to patient medical records and are, therefore, hampered in their ability to understand and resolve problems. In contrast, community oncology pharma- cists and pharmacy technicians, working under the supervision

of their community oncologists, have access to patient medical records and are familiar with the 50-plus oral anticancer agents, the most frequent and expected reactions, and the most prompt and effective response.

Community oncology-based pharmacists, pharmacy technicians, and oncologists know their patients and the drugs in ways PBMs do not. PBMs are very much on board with dispensing many drugs, but they may have less experience with the more varied and critical care cancer drugs. PBMs are well-suited to manage the orals process, to adjudicate claims, and to manage the process of obtaining drugs, but they are not experts in determining drug access options.

The Role of the Community Oncology Pharmacist and Pharmacy Technicians

During traditional chemotherapy, patients are very closely monitored by clinic staff —from the lab technicians, pharmacists, pharmacy technicians, nurses, nurse practitioners, and chemotherapy nurses to the physicians. This changes with oral drugs, placing a much greater responsibility on the pharmacist and pharmacy technicians.

In most practices, it is the responsibility of the dispensing pharmacist, lab technician, and oncologist to manage the patients receiving oral chemotherapy. These chemotherapy agents often carry the same risks and reactions as an intravenous chemotherapy agent. In the absence of a linear connection between dispensing and patient management, there is a disconnect that affects treatment, compliance, outcomes, and the cost of care for patients.

It is not only the standard of care, but also required by law in most states, that the dispensing pharmacist, pharmacy technicians, and oncologists are responsible for patient education and management. For oral cancer drugs, this includes dosing plan explanation (eg, should the drug be taken with or without food, drug storage and handling, possible adverse reactions, how to mitigate those reactions, monitoring compliance, and when to provide medical intervention). Based on their knowledge of the agents, community oncology pharmacists and pharmacy technicians are prepared make recommendations to the oncologist for OTC medications or supportive care medications that can ameliorate common reactions, such as diarrhea or skin toxicities, rather than discontinuing treatment. They are familiar with options such as dosing changes and/or drug holidays, and they recognize signs of toxicity and know when lab testing, in-office hydration, or other supportive care may be warranted. Recognition of these signs can avoid disruptive occurrences, such as trips to the emergency department.

Community oncology-based pharmacists, pharmacy technicians, and oncologists have access to patient records and can more closely monitor patients which empowers them to provide the most coordinated care. These tools are not available to anyone outside the practice, including PBMs.

The Most Common Problems

Delays

Patients receiving their oral drugs from a community oncology practice have access to those drugs within 24 hours of prescribing, and they begin treatment immediately. Patients receiving their oral cancer drugs through a PBM, on the other hand, often have a much longer wait, sometimes 14 days or more. Common causes of delays include:

  • More complicated or cumbersome internal PBM protocols that require more time to process a prescription
  • Multiple back-and-forth conversations between the PBM and the practice
  • Time needed to confirm and re-confirm patient information, including addresses and insurance coverage, as well as additional information requests
  • Transferring prescriptions for processing between facilities for actual dispensing
  • Mail delivery time
  • Insurance verification and approval
  • Providing patient financial assistance


Poaching

Some PBMs force patients currently receiving their oral drugs from the community oncologist to switch to pharmacies that the PBM owns. However, PBMs are often disconnected from the patients and may invoke internal systems that make presumptions about the preferred method of care and attempt to dispense drugs without evaluating what might be the best care, from the patient’s perspective.

For drug prior authorization, PBMs document all of the information necessary for subsequent prescriptions, including the physician and patient names, payer information, drug name, dosage, and authorization. Some PBMs will automatically create a prescription and fax it to the physician. Without scrutiny from the oncologist or staff, patients may be directed away from the practice’s pharmacy.

Trolling and Steering

Physician dispensing has become increasingly popular in the United States and has expanded to include a variety of medications in both the retail and specialty spaces. This growth in popularity has largely bene ted overall patient care. William Shell, MD, in The History of Physician Dispensing, reports that patient compliance with drug therapy is 60% to 70% higher from a dispensing physician than a pharmacy.1

Patients cannot be compelled to fill their prescription from a specific dispenser; however, many report receiving correspondence from their PBM that implies they must use a pharmacy owned by the PBM. These letters often explain that the insurance company has its own pharmacy, from which the patient may already be receiving other prescribed drugs, and offer for the patient to also get their oral cancer drug from this same source. Many patients find this confusing and do not understand the repercussions that jeopardize the monitoring, care control, and care management that they receive at their community oncology pharmacy, and they mistakenly, or unintentionally, switch their drug dispenser.

A community oncology pharmacist will recognize drugs that may be di cult to tolerate or patients whose conditions may require multiple dosing refinements. In these cases, in anticipation of modifications, practices will often dispense a 15-day supply rather than a 30- or 90-day supply. PBMs can lack the expertise for such forethought or do not have the experience with care management to know when a smaller supply might be the wiser, more economical choice. In-house pharmacies are often able to lower medication waste in cases when a patient’s drug dose is expected to be reduced or when drug tolerance is a consideration.

Caring for Patients, Coping With PBMs

Although PBM problems are not guaranteed, patient care is enhanced when a practice is aware of what may happen and is prepared to handle problems as soon as they arise. Practices that have coping systems in place and have developed ways of dealing with the PBM problems can enhance patient care and avoid treatment delays.

Pick Up the Phone

PBMs may delay shipping a drug because they require address confirmation; they often send a letter requesting address confirmation to the very address they wish to con rm. Other times patients wait, often too patiently, for overdue drugs. Paper work problems, red tape, and conflicting or missing information are often easily resolved with a short conversation. Relatively simple problems that can cause unnecessary delays can usually be resolved just by picking up the phone.

Community Oncology Pharmacy Association Support

The Community Oncology Pharmacy Association (COPA), within the Community Oncology Alliance (COA), was formed in response to the increasing number of community cancer clinics dispensing oral cancer drugs and ancillary therapies. COPA is a nonprofit entity that has established standards; provides information, education, and resources; enhances information exchange; and advocates for the patient-centric model of integrated, high-quality cancer care. Due to the increasing costs of cancer drugs, there are commercial interests, such as PBMs and specialty pharmacies, attempting to separate oral cancer therapy from the point-of-care and oncologist control, thus interfering with the physician-patient relationship. As a nonprofit focused on enhancing patient care, COPA is in the unique position of serving as a noncommercial organization dedicated to addressing a variety of pharmacy-related issues, all in the sole interest of patient care.

COPA provides tools that can assist practices in resolving issues with PBMs and benefit patients, including:

  • Letter templates when challenging, usually in cases of steering, PBM violation of the Health Insurance Portability and Accountability Act and other laws
  • Access to State Boards of Pharmacy consumer complaint forms to report incidents of interference in the physician-patient relationship over drug dispensing
  • Access to HHS’ Office for Civil Rights (OCR) forms to file a Health Information Privacy Complaint


Internal Practice Systems

Many larger practices are developing internal protocols to deal with some of the most common problems. Rapid referral systems establish procedures for follow-up—daily, when necessary—if a delay of the onset of treatment due to drug delays could be detrimental to the patient’s prognosis. Follow-up systems enable practices to track prescriptions as they move through a PBM system, avoiding potential delays and preventing intentional or unintentional poaching, trolling, or steering.

Incident Report Collection

 
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