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Pharmacy Team Engagement in Navigating the Revenue Cycle for High-Cost Medications in Patients With Cancer
Brandon R. Shank, PharmD, MPH, BCOP; Phuoc Anh (Anne) Nguyen, PharmD, MS, BCPS; and Emily C. Pherson, PharmD, BCPS
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Pharmacy Team Engagement in Navigating the Revenue Cycle for High-Cost Medications in Patients With Cancer

Brandon R. Shank, PharmD, MPH, BCOP; Phuoc Anh (Anne) Nguyen, PharmD, MS, BCPS; and Emily C. Pherson, PharmD, BCPS
With the clinical and financial implications of high-cost medications, and their impact on health system revenue, it is of utmost importance for all key stakeholders to be engaged in the complex revenue cycle.
HEALTHCARE TEAMS FUNCTIONING IN today’s evolving healthcare landscape shoulder the responsibility of delivering high-quality care while reducing costs throughout the entire revenue cycle. This cycle encompasses several key steps to appropriately bill patients and third party providers and capture revenue. The major components of the revenue cycle include patient access, clinical documentation, coding, billing processes, denial management, and reimbursement.1 To optimize the revenue cycle, key stakeholders, including clinicians, financial staff, and institutional leadership, need to be engaged in the process to maximize reimbursement for the health system and minimize patient costs and burden. Pharmacists and pharmacy staff play a pivotal role in cost containment through optimization of medication regimens and engagement in the revenue cycle, particularly for high-cost medications (Figure 1).1,2 The high-cost medications referred to in this article are those commonly used in the treatment of patients with cancer, such as oral antineoplastics, immunosuppressants, antifungals, and select anticoagulants.

To facilitate the billing process, the medications must be appropriately coded. Every hospital has a charge description master, which includes the general ledger number, product description, billing units, Healthcare Common Procedure Coding Systems (HCPCS) codes, revenue codes, and pricing information.3 With constant updates to CMS’ billing requirements and rapid changes in the drug market of new brand and generic medications, there is a high possibility that HCPCS codes can easily become out- dated or incorrectly associated with a medication. For example, blinatumomab (Blincyto), approved in 2014 for the treatment of Philadelphia chromosome–negative relapsed or refractory B-cell precursor acute lymphoblastic leukemia, had different HCPCS codes for 2015 (J7799) and 2016 (J9039).4 It is essential for hospital and pharmacy leadership to understand the financial implications of such changes. These leaders should include individuals well-versed in charge coding and actively engaged in the ever-changing drug market and insurance industry.

Growing Drug Costs

In addition to the complexities associated with billing, the problem of sky-rocketing drug prices has garnered much attention in recent years and made budget management more complex. In its annual report on national trends in prescription projections and spending, the American Society of Health-System Pharmacists (ASHP) showed a 6% increase in US prescription sales between 2015 and 2016, totaling $448.2 billion in 2016.5 Overall, adalimumab was associated with the highest overall spend in 2016 with $13.6 billion in expenditures; in clinics and nonfederal facilities, in iximab had the highest expenditure with $5.3 billion in spending.5

Nonfederal facilities are de ned as licensed hospitals that are not owned by the government, including inpatient treatment and rehabilitation facilities. Nonfederal facilities also include general and specialty acute care institutions. Federal facilities refer to US ships or hospitals that belong to the Public Health Service, the Veterans Health Administration, and other federal branches. Higher drug prices and more prescribing were primarily responsible for the growth in expenditure in nonfederal hospitals and clinics.5 Drug expenditures in 2017 are projected to increase 6% to 8% overall and by 3% to 5% in hospitals.5 Therefore, health-system pharmacy leaders and clinicians should be actively engaged in the revenue cycle process and develop strategies that emphasize cost containment and ensure optimal medication reimbursement.2,6,7 

Top 5 Opportunities for Pharmacy Team Engagement in Containing Drug Costs and Maximizing Reimbursement in Patients Undergoing Cancer Treatment

Pharmacists caring for patients undergoing cancer treatment are in a unique position to help other providers and patients navigate the convoluted reimbursement structure. Strategies include finding suitable therapeutic alternatives to meet the needs of formulary restrictions or obtaining approval for off-label use of agents. Starting upon admission and continuing post discharge, transitions-of-care pharmacy team members provide continuity of care and enhance medication adherence. Transitions-of-care pharmacy team efforts, starting upon admission and continuing through discharge, can ensure coverage and enhance medication adherence.

Many antineoplastic and supportive care medications are expensive and/or challenging to obtain. Timely acquisition is essential in order to initiate cancer treatment expeditiously. This article reviews key strategies that pharmacy team members can utilize to optimize medication-related revenue cycle compliance, including prior authorizations (PAs), hospital formulary management, patient assistance programs, accessibility of medications, and risk evaluation and mitigation strategies (REMS) programs.

1. Managing inpatients who are taking medications outside of the hospital formulary as outpatients.

Hospital formularies ensure safe, efficacious, and cost-effective medication use in the inpatient setting, especially for high-cost medications.6 Medications included on a hospital formulary vary based on an institution’s patient population and contracting options, among other factors. Strategies to appropriately manage admitted patients who continue to take medications as outpatients that are not included on the inpatient hospital formulary include therapeutic interchanges, nonformulary review processes, and using the patients’ own medication(s) during their hospital stay.

A therapeutic interchange is a tool that provides a roadmap to transition patients from an outpatient medication that is not on the hospital formulary to a medication that is included, and this often presents healthcare providers with a medication that has an equivalent dosage as the formulary medication.8 For example, if a patient was taking candesartan 8 mg by mouth once daily as an outpatient and losartan was the hospital formulary angiotensin receptor blocker, a therapeutic interchange would direct prescribers to order losartan 50 mg orally once daily. These interchanges are most effective when the electronic health record (EHR) automatically directs prescribers to this alternate choice when the nonformulary drug is ordered. This strategy alerts prescribers that they are attempting to order a non-formulary medication and presents them instantly with alternatives. Some institutions utilize automatic therapeutic interchanges whereby the pharmacist, upon order verification, would automatically make the switch to the appropriate formulary medication. Developing therapeutic interchanges requires appropriate research and evidence supporting the specific interchange so that the healthcare team has information readily available.

For a medication that is not a part of an institution-approved therapeutic interchange, most institutions have a process in place whereby pharmacists are responsible for reviewing non- formulary medications and providing formulary alternatives, when appropriate.9 Depending on the specific institutional practice, this may be built into the role of the pharmacist who is verifying orders or a pharmacist with specialized training in the particular therapeutic area may be consulted for reviewing and approving nonformulary medication use, if needed. By having a review process in place, prescribers can become accustomed to discussions with the pharmacist when ordering nonformulary medications to assist with providing formulary alternatives.

When it may not be appropriate to transition a patient to a hospital formulary medication, the hospital may elect to order the medication and dispense it from their inventory. In certain circumstances, if a patient brought the medication with them to the hospital, that may be used during the hospital stay. This may occur if waiting for the hospital to acquire the nonformulary medication poses a safety risk to the patient or if the medication requires a patient-specific distribution channel, such as a REMs program or clinical trial. Ensuring safe use of a medication brought in by a patient requires appropriate practices for ordering and verifying these medications. Many EHRs have an option to allow the prescriber to indicate that a patient’s own medication may be used. This acts as a trigger for the verifying pharmacist to check the product by confirming identity and appropriate dating. When applicable, appropriate barcoding of the patient’s own medication also needs to be accounted for using institution-specific practices.

An example of this in oncology practice is the tyrosine kinase inhibitor, dasatinib. If a hospital did not have this medication on formulary, it would not be clinically appropriate to substitute another agent during the hospital stay. If the patient brought his or her own supply to the hospital, it would be important to not interrupt therapy, to continue the medication using the patient’s supply. Many hospital formularies do not include all oral antineoplastic agents; this becomes an important education point when prescribing oral chemotherapy in the outpatient setting by informing patients that they should be prepared to bring their own supply in the event of hospitalization.

Using a combination of the above strategies will prepare institutions to appropriately manage patients that are taking medications outside of the hospital formulary as they transition to being inpatient.



 
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