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NCODA Patient Surveys Support the Need for Medically Integrated Pharmacies
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NCODA Patient Surveys Support the Need for Medically Integrated Pharmacies

Kirollos S. Hanna, PharmD, BCPS, BCOP
Oral oncolytics, or oral chemotherapies, have significantly impacted the treatment of cancer. They enable patients to conveniently manage treatment in their homes. Despite the rapid growth, therapeutic advances, novel mechanisms of actions, and improved outcomes associated with these agents, the dispensing process remains inadequate. As a result of rising drug costs and healthcare expenditures, payers have forced a “medically disintegrated” model of dispensing, limiting patients and practices to fill prescriptions through external mail-order pharmacies.
Oral oncolytics, or oral chemotherapies, have significantly impacted the treatment of cancer. They enable patients to conveniently manage treatment in their homes. Despite the rapid growth, therapeutic advances, novel mechanisms of actions, and improved outcomes associated with these agents, the dispensing process remains inadequate. As a result of rising drug costs and healthcare expenditures, payers have forced a “medically disintegrated” model of dispensing, limiting patients and practices to fill prescriptions through external mail-order pharmacies.1,2

Significant barriers have emerged from such a model, leading to treatment initiation and refill delays; inefficient monitoring practices; delays in care from insurance changes; miscommunication between patients, pharmacies, and physicians; decreased patient satisfaction; delayed recognition and management of adverse events; increased incidence and underreporting of adverse events; inability to assess adherence and compliance; and increased waste. Although mail order pharmacies play a significant role in maintenance therapies for nononcologic indications and may help to minimize costs, the high acuity and monitoring required for patients with cancer do not align with mail order dispensing.

The National Community Oncology Dispensing Association Inc (NCODA) has continued to advocate tirelessly to payers, industry, and legislators and has partnered with professional organizations on behalf of patients and practices to stress the values of in-office dispensing of oral chemotherapy. As part of the numerous initiatives demonstrating the importance of the medically integrated pharmacy (MIP), NCODA Patient Satisfaction Surveys (PSS) have supported the need for in-office dispensing. Each PSS is a paper survey that is completed by patients with cancer who receive treatment with oral cancer medications at NCODA member practices taking part in the program.3,4 The PSS aims to evaluate the patient’s overall satisfaction with the following: the pharmacy model from which they receive therapy, convenience, time to receive their medication, interaction with staff, and if financial assistance was available.

There are approximately 360 NCODA-member practices nationwide that are advocating for the MIP model. Over the course of 3 years, NCODA has collected more than 1200 PSS from these pharmacies. The results demonstrate that patients prefer to receive their oral chemotherapies from their physician’s office. Within this model, patients were most satisfied by the interaction with staff, the convenience of receiving prescriptions, continuity of care, and the time to receive their prescriptions.

The value of in-office dispensing enables providers to continuously manage prescriptions through an in-house pharmacist or pharmacy. The multidisciplinary team approach is fueled is fueled through the use of the same electronic health record (EHR) and tools to streamline the quality assurance process, patient safety, and every aspect of the oral oncology care continuum. The NCODA PSS have provided feedback to support the need for the MIP through the voice of the patient. 

Interaction With Staff
Telemedicine plays a limited role in the cancer care continuum and limits direct communication between the oncologist and the MIP.2 NCODA PSS results demonstrate that patients prefer direct interactions with their providers and pharmacists compared with calls from a mail-order pharmacy. Patients on oral chemotherapies often have complex regimens and schedules; cancer also impacts their social, mental, and physical health. As a result, face-to-face interactions with healthcare providers are integral components of patient care. Within the MIPs, pharmacists and staff can interact with patients, assess adherence and compliance, gauge nonverbal cues, and provide improved education through feedback. There are significant barriers in communication within mail order dispensing that cripple best practices in oncology care.1,5-9 Adherence and compliance are measured by refill dates, although the patient could be taking the medication incorrectly, and are directly linked to improved outcomes; once a prescription leaves the clinic, the healthcare team is in the dark regarding its status. Additionally, mail order pharmacies utilize call centers and technicians, which provides a very impersonal experience and offers limited resources to the patient.

Our survey’s results demonstrated that patients prefer and value the interactions with their pharmacist within the MIP. Patients reported that they were able to better comprehend their treatment regimen, were more inclined to discuss complications with their pharmacists, and had fewer issues obtaining their medication in a timely manner. MIPs are able to utilize the EHR to share with patients pertinent information from their providers, discuss medication changes and interactions, assess adherence and compliance, and optimize safety practices.

Convenience of Receiving Prescriptions and Continuity of Care
Several barriers to care have resulted from mail-order pharmacy dispensing of oral oncolytics. Two major barriers include the time coordination required with mailing prescriptions and if patients experience any insurance changes.1,5-9 

Patients on oral chemotherapies require frequent lab assessments and provider visits. In order to ensure safe practices, providers often limit the number of refills on oral chemotherapies—a majority provide no refills—and limit the dispensing to 1 cycle at a time. However, mail-order pharmacies have made safety practices difficult due to the time required to process the prescription and  receive therapy via mail. Providers and clinics are often forced to send in prescriptions early to avoid treatment delays regardless of the patient being seen; if a patient is seen too early, they may not have had adequate hematologic recovery.1,5-9 In contrast, if the prescription is held until the appointment, then there is likely to be a delay from mail-order dispensing. Other patients may require dose changes and potentially need to receive different medication strengths, which can lead to increased waste and delays in initiating subsequent cycles.

Oral oncolytics require extensive benefits coordination to ensure affordability for patients. Many patients on treatment are faced with changes in health benefits due to various factors.1,2,5-9 This has resulted in increased delays in receiving prescriptions, particularly with mail-order pharmacies. The mail-order pharmacy often fails to reach out to clinics to inform them of processing errors or the need for prior authorizations or additional documentation.1 Having a MIP allows prompt recognition of insurance changes and streamlines the process in reobtaining approval.1,5-9 MIPs significantly decrease the amount of time it takes for an oral oncolytic to reach the patient.

A significant portion of patients reported that they prefer to receive their prescriptions from a MIP and have had little to no issues with continuity of care. The MIP allows for patients to be seen by a provider immediately prior to their treatment cycles without resulting in delays. MIPs allow patients to receive their oral chemotherapies “within the hour.”1,5-9 Any treatment changes are efficiently coordinated through MIPs rather than trying to manage the prescription the patient may have received a week early from the mail-order pharmacy. Coupled with staff interactions, MIPs are able to coordinate a safe dispensing process that allows for adherence assessments, minimizes the waste of oral oncolytics, optimizes treatment changes, coordinates financial procurement, and provides education in a timely manner.

Future Direction
Despite the numerous advantages and patient satisfaction with MIPs, most payers still favor mailorder pharmacies. There is a clear practice gap on the payer side in understanding the negative implications of mail-order dispensing on patient outcomes, time to receive therapy, waste, increased healthcare expenditures, and clinical assessments.

The NCODA PSS demonstrate that patients prefer to receive prescriptions through a MIP due to positive interactions with staff, the convenience of receiving prescriptions, continuity of care, and the time to receive their prescriptions. A planned analysis of all collected surveys is underway, and results will be made available later in 2019 or early 2020.
AUTHOR INFORMATION:
Kirollos S. Hanna, PharmD, BCPS, BCOP, is an assistant professor of pharmacy at the Mayo Clinic College of Medicine, and a hematology/oncology clinical pharmacist at the University of Minnesota Medical Center and Mayo Clinic.
REFERENCES:
  1. Howard A, Kerr J, Mclain M, Modlin J. Financial impact from in-office dispensing of oral chemotherapy. J Oncol Pharm Pract. 2018;1078155218799853. doi: 10.1177/1078155218799853.
  2. Egerton NJ. In-office dispensing of oral oncolytics: a continuity of care and cost mitigation model for cancer patients. Am J Manag Care. 2016;22(suppl 4):S99-S103.
  3. Nubla JJ, Orzechowski RD, Budge A. Patient satisfaction surveys: a continuous NCODA initiative for improvement within the oncology dispensing practice. Am J Manag Care. 2018;24(SP12):SP490-SP492.
  4. NCODA-Patient-Satisfaction-Survey-Fillable. NCODA website. ncoda.org/other/ncoda-patient-satisfaction-survey-fillable. Accessed May 04, 2019.
  5. Krikorian S, Pories S, Tataronis G, et al. Adherence to oral chemotherapy: challenges and opportunities. J Oncol Pharm Pract. 2018;1078155218800384. doi: 10.1177/1078155218800384.
  6. Jacobs JM, Pensak NA, Sporn NJ, et al. Treatment satisfaction and adherence to oral chemotherapy in patients with cancer. J Oncol Pract. 2017;13(5):e474-e485. doi: 10.1200/JOP.2016.019729.
  7. Wong SF, Bounthavong M, Nguyen C, Bechtoldt K, Hernandez E. Implementation and preliminary outcomes of a comprehensive oral chemotherapy management clinic. Am J Health Syst Pharm. 2014;71(11):960-965. doi: 10.2146/ajhp130278.
  8. Bindler RJ. Inpatient and outpatient pharmacy monitoring of oral antineoplastic medications. Hosp Pharm. 2015;50(2):91-92. doi: 10.1310/hpj5002-91.
  9. Bertsch NS, Bindler RJ, Wilson PL, Kim AP, Ward B. Medication therapy management for patients receiving oral chemotherapy agents at a community oncology center: a pilot study. Hosp Pharm. 2016;51(9):721-729.
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