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The American Journal of Managed Care April 2018
Delivering on the Value Proposition of Precision Medicine: The View From Healthcare Payers
Jane Null Kogan, PhD; Philip Empey, PharmD, PhD; Justin Kanter, MA; Donna J. Keyser, PhD, MBA; and William H. Shrank, MD, MSHS
Care Coordination for Children With Special Needs in Medicaid: Lessons From Medicare
Kate A. Stewart, PhD, MS; Katharine W.V. Bradley, PhD, MBA; Joseph S. Zickafoose, MD, MS; Rachel Hildrich, BS; Henry T. Ireys, PhD; and Randall S. Brown, PhD
Cost Sharing and Branded Antidepressant Initiation Among Patients Treated With Generics
Jason D. Buxbaum, MHSA; Michael E. Chernew, PhD; Machaon Bonafede, PhD; Anna Vlahiotis, MA; Deborah Walter, MPA; Lisa Mucha, PhD; and A. Mark Fendrick, MD
The Well-Being of Long-Term Cancer Survivors
Jeffrey Sullivan, MS; Julia Thornton Snider, PhD; Emma van Eijndhoven, MS, MA; Tony Okoro, PharmD, MPH; Katharine Batt, MD, MSc; and Thomas DeLeire, PhD
A Payer–Provider Partnership for Integrated Care of Patients Receiving Dialysis
Justin Kindy, FSA, MAAA; David Roer, MD; Robert Wanovich, PharmD; and Stephen McMurray, MD
Financial Burden of Healthcare Utilization in Consumer-Directed Health Plans
Xinke Zhang, PhD; Erin Trish, PhD; and Neeraj Sood, PhD
Progress of Diabetes Severity Associated With Severe Hypoglycemia in Taiwan
Edy Kornelius, MD; Yi-Sun Yang, MD; Shih-Chang Lo, MD; Chiung-Huei Peng, DDS, PhD; Yung-Rung Lai, PharmD; Jeng-Yuan Chiou, PhD; and Chien-Ning Huang, MD, PhD
Physician and Patient Tools to Improve Chronic Kidney Disease Care
Thomas D. Sequist, MD, MPH; Alison M. Holliday, MPH; E. John Orav, PhD; David W. Bates, MD, MSc; and Bradley M. Denker, MD
Limited Distribution Networks Stifle Competition in the Generic and Biosimilar Drug Industries
Laura Karas, MD, MPH; Kenneth M. Shermock, PharmD, PhD; Celia Proctor, PharmD, MBA; Mariana Socal, MD, PhD; and Gerard F. Anderson, PhD
Currently Reading
Provider and Patient Burdens of Obtaining Oral Anticancer Medications
Daniel M. Geynisman, MD; Caitlin R. Meeker, MPH; Jamie L. Doyle, MPH; Elizabeth A. Handorf, PhD; Marijo Bilusic, MD, PhD; Elizabeth R. Plimack, MD, MS; and Yu-Ning Wong, MD, MSCE

Provider and Patient Burdens of Obtaining Oral Anticancer Medications

Daniel M. Geynisman, MD; Caitlin R. Meeker, MPH; Jamie L. Doyle, MPH; Elizabeth A. Handorf, PhD; Marijo Bilusic, MD, PhD; Elizabeth R. Plimack, MD, MS; and Yu-Ning Wong, MD, MSCE
Oral anticancer medications are frequently used to treat patients with cancer. We found significant time and energy burdens for clinic staff and patients in obtaining these drugs.
ABSTRACT

Oral anticancer medications (OAMs) are frequently used to treat patients with cancer. Unlike intravenous chemotherapy, OAMs are covered by prescription drug plans. We examined barriers to initiation of OAMs in 116 patients with prostate or kidney cancer (149 unique prescriptions). We found that the median time from initial prescription to prior authorization was 3 days and the median time from initial prescription to patient receipt of drug was 12 days. Seventy-three percent of all prescriptions required 2 or more phone calls by clinic staff and 40% required 5 or more calls. Of 107 prescriptions with data available, 54% utilized financial assistance; these required significantly more phone calls (= .0001) and led to a longer median time to drug obtainment (P = .003) compared with those that did not require financial assistance. In those prescriptions with both initial and final co-pay information available, the initial out-of-pocket mean and median co-pays were $1226.03 and $329.73, respectively, but these dropped to $124.57 and $25.00 after utilization of co-pay assistance programs, excluding those with a $0 final co-pay. These early observations suggest that a more efficient process for initiation of OAMs is needed.

Am J Manag Care. 2018;24(4):e128-e133
Takeaway Points

Oral anticancer medications (OAMs) are frequently used to treat patients with cancer. Unlike intravenous chemotherapy, OAMs are covered by prescription drug plans. We examined barriers to initiation of OAMs. 
  • We found that the median time from initial prescription to prior authorization was 3 days and the median time from initial prescription to patient receipt of drug was 12 days. 
  • Seventy-three percent of all prescriptions required 2 or more phone calls by clinic staff and 40% required 5 or more calls to facilitate prior authorizations, financial assistance, and drug acquisition. 
  • More than half (54%) of all prescriptions with data available were too expensive for the patient to afford and required the acquisition of financial assistance. In the end, most final co-pays were less than $100, but significant work was required by clinic staff in order to obtain financial assistance and lower patient co-pays.
More than 50 oral anticancer medications (OAMs) have been approved since 1998, making treatment possible and more convenient for many patients.1,2 Unlike office-administered chemotherapy, which is covered as a medical benefit by insurance plans, OAMs are obtained through a patient’s prescription coverage. Although providers anecdotally discuss the significant burden that is placed on them to help patients receive OAMs, there are few empiric data that describe the effort and time spent to obtain these drugs. Access to these data is complicated for multiple reasons. First, there is heterogeneity among prescription plans regarding the requirements for prior authorization for OAMs and the contracted specialty pharmacies to fill them. Second, cost sharing varies substantially based on insurance; for example, many Medicare patients will face very high co-pays for their initial drug fills as they enter the coverage gap.3 Third, patient assistance programs (PAPs) may provide some relief, but accessing them can be time-consuming and complicated due to the applications involved, the availability of funds, and restrictions on eligibility.3 The reasons described above are not clear to providers at the time of prescribing and the problems they present require significant staff effort to resolve. Given the multiple parties involved for each prescription (patient, prescriber, insurer, specialty pharmacy, industry, and foundation co-pay PAPs), quantifying this effort is challenging because the data are not readily available in data sets traditionally used for health services research, such as administrative claims data.

In an initial step to characterize the barriers to timely initiation of oral therapy, we describe our efforts obtaining on-label OAMs in the Genitourinary Medical Oncology clinic at Fox Chase Cancer Center in Philadelphia, Pennsylvania. Because of the multiple hand-offs among the different parties, we sought to granularly quantify and qualitatively describe the clinic staff’s efforts to obtain OAMs. We focused on metastatic prostate and renal cell cancers, 2 diseases for which OAMs are frequently used.

METHODS

Clinical Setting 

We conducted a retrospective review of prescriptions written for on-label recommended OAMs for advanced prostate cancer (abiraterone and enzalutamide) and renal cell carcinoma (sunitinib, pazopanib, axitinib, everolimus, and sorafenib). To identify patients, we accessed nurse-maintained clinic tracking logs for OAMs between August 1, 2014, and August 31, 2015. During the study period, 4 attending physicians, 2 advanced practice clinicians, and 3 registered nurses were involved in the care of these patients.

Data Source 

The tracking sheets, which are maintained for all patients prescribed OAMs, are used by the clinic staff to organize data regarding patients’ OAM prescriptions. Notes about phone calls, pharmacy and co-pay information, patient-specific notes, and other data are kept in these logs. In addition, we searched the electronic health records for incoming and outgoing telephone calls. 

Data Elements and Measures 

We collected information on demographics, insurance coverage, use of co-pay PAPs, and specialty pharmacy assignment. In addition, we measured the number of phone calls involving clinic staff required to obtain a drug and noted the reasons for phone calls. We also recorded the date the prescription was initiated, the date prior authorization was received (if applicable), and the date the drug was received or initiated by the patient. When available, any co-pay information was recorded. Time in days and number of calls were summarized by whether the patient received co-pay assistance. Differences were compared using Wilcoxon rank sum tests. This study was approved by Fox Chase Cancer Center’s Institutional Review Board.



 
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