Outcomes of a Specialty Pharmacy Program for Oral Oncology Medications
Published Online: August 02, 2012
Suzanne J. Tschida, PharmD, BCPS; Saad Aslam, PhD; Lincy S. Lal, PhD, PharmD; Tanvir T. Khan, MSc; William H. Shrank, MD, MSHS; Gandhi R. Bhattarai, PhD; Jon C. Montague-Clouse, BS, MS; Brett D. Sahli, PharmD; and Lee N. Newcomer, MD, MHA
Oncology management has changed dramatically over the last decade with the approval and rapid adoption of newly targeted oral oncology medications.1 These medications have moved much cancer therapy away from the inpatient setting or outpatient infusion therapy care setting and into the home, offering patients greater convenience and flexibility of timing and location of treatment.2 Oral oncology therapy represents one of the fastest growing expenditures for payers, costing up to $8000 per month per prescription.3
The movement to oral oncology medications has altered the balance of risks and adverse effects in the treatment of cancer care. These treatments are associated with a different constellation of adverse effects and drug interactions. Moreover, delivery of these medications at home has raised the possibility of nonadherence to therapy.4,5 Many studies have indicated that nonadherence is associated with treatment failures and downstream healthcare costs in oncology patients.6-10 There are also studies that indicate that high patient copayment burden is one of the main reasons for poor medication adherence, with a higher rate of discontinuation and non-adherence as the cost-sharing amount increases.11-13 Our research will focus on another aspect of benefit design, where designated specialty pharmacies are selected to deliver pharmaceutical care and distribution services to patients taking oral oncology medications.
Specialty pharmacies, in addition to providing basic dispensing and counseling services, use trained nurses and pharmacists to educate patients and more actively manage their care.14,15 Specialty pharmacies aim to reduce variability in care delivery, improve appropriate medication use and the quality of care, and reduce costs of cancer care.16,17 However, little is known about the effect of specialty pharmacy services in the marketplace.18 Accordingly, we compared the effectiveness of a specialty pharmacy program implemented by a large commercial national health plan through specialty pharmacies to improve cancer care compared with services through retail pharmacies in the same insured population.
UnitedHealthcare Pharmacy implemented a s pecialty pharmacy program for specifi c oral oncology medications for its commercial patients in August 2007. The program required the contracted specialty pharmacy to provide clinical expertise and patient education in oncology medications and comorbid conditions, a monthly proactive adherence program including refi ll reminders, adherence screenings, and interventions with the patient and physician if nonadherence was detected. Additionally, an oncology clinical management program of telephonic clinical counseling sessions was required to provide extensive patient education, assessment of disease-specifi c parameters, depression screening, pharmaceutical care interventions, and provider outreach and referral to health resources.
The specialty pharmacy program had requirements for contracted medication reimbursement rates, staff expertise, operational services, and clinical programs that were met by the contracted specialty pharmacies. The interventional adherence program included reminder calls to the patient to coordinate medication refills, with assessment during the call for medication nonadherence in the past 30 days of therapy. If nonadherence was suspected, clinical counseling with specialty-trained pharmacists was provided to address any adherence-related issues through patient education and support strategies, identifi cation of financial assistance opportunities, and/or engagement with the physician.
Consultations were conducted biweekly to monthly for the first 3 months and then approximately every 3 months thereafter while the patient was in the program. Patients were also advised to contact their specialty pharmacist with questions as needed, and this support was available 24 hours a day/7 days a week. When appropriate, the pharmacist engaged in communication with the healthcare provider about their intervention recommendations or immunosuppressive therapy clinical concerns
that were identified in the consultations.
The insurance coverage was offered through employers and consisted of both self-insured and fully insured employers. For those employer groups who enrolled in the specialty pharmacy program, 2 specialty pharmacy vendors meeting the above program requirements were designated as the sole providers of prescriptions for the specific oral oncology medications. Competitive negotiated drug rates incorporated the cost of the additional services and no additional costs were passed on to employers or patients. Figure 1 summarizes the specialty program flow of interactions between the patients and the specialty pharmacies.
Data and Sample Selection
The data source was an administrative claims database that included data for approximately 14 million enrollees from United Healthcare with both medical and pharmacy benefits. The claims were de-identifi ed and compliant with the provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
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