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In-Office Dispensing of Oral Oncolytics: A Continuity of Care and Cost Mitigation Model for Cancer Patients
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In-Office Dispensing of Oral Oncolytics: A Continuity of Care and Cost Mitigation Model for Cancer Patients

Nancy J. Egerton, PharmD, BCOP
This case study from the National Community Oncology Dispensing Association (NCODA) focuses on a new dispensary in a moderately sized oncology community practice that prescribes to NCODA’s Quality Standards and outlines the processes developed to assist Medicare patients in accessing their oral cancer medications.
IOD allows the practitioner to optimize all aspects of cancer drug therapy management. Time to therapy is significantly decreased with IOD services, with patients being able to acquire their cancer medication the same day or within 2 to 3 days of prescription orders. Patient factors and clinical scenarios are known to on-site staff, which allows for a “nimble” approach to medication management. Significant cost savings are achieved by the elimination of unnecessary refills and close overall management of the patient’s medication tolerance and side effects. One quality standard that NCODA practices adhere to is to schedule medication toxicity checks with a physician or advanced care practitioner within 2 weeks of the first fill of an oral cancer medication, to allow for early side-effect management and related dose adjustments. Refills for cancer medications are not processed without direct communication between the oncologist and the IOD pharmacist.

Patient convenience is also a critical element of the IOD model, allowing patients to obtain all their cancer medications—whether intravenous or oral—at a single location, thus allowing the overall care of the patient to be less fragmented. In addition to the onsite clinical staff support, practices have dedicated administrative support teams to complete immediate insurance benefit investigations, determine prescription coverage, and to provide comprehensive financial assistance services when needed.

Patient assistance staff members who are housed in the IOD department at the practice, are uniquely positioned to advocate for patients and their families. They help patients by navigating the complex network of assistance programs, and help them complete the forms and applications required to apply for assistance. For Medicare patients, financial support can be obtained through patient foundations, such as the Patient Access Network Foundation (PAN), the Chronic Disease Fund, and the Leukemia & Lymphoma Society. Patient foundations provide critical funding resources, which allow patients to access these vital cancer drugs. The patient assistance staff streamlines the application process to the various foundations using specific forms and online tools. Typically, notification of a foundation award is achieved rather quickly, but tracking of the foundation awards is also critical to ensure patients have continuous access to financial support as their cancer treatments progress. Timely re-applications are also important to prevent unintended treatment interruptions.

IOD Practice

A moderately sized community oncology practice began IOD services in January 2015 after it had become apparent to physician practice leadership that oral cancer drugs were increasingly becoming a more critical part of cancer treatment regimens. It was also felt that IOD and management of oral therapies would lead to less fragmented care plans, offer patients a convenient service, and improve patient outcomes.

Renovations to an area of the clinic were done in order to provide a full service dispensary, including a patient counseling area. All of the necessary computer hardware and dispensing software was acquired and linked into the practice management system and electronic medical record. Staff were hired that were to be specifically dedicated to the IOD department, and included a full-time pharmacist, technician, and administrative assistant, as well as 2 individuals trained and dedicated to obtaining prior authorizations (PAs) and patient financial assistance for oral cancer drugs.

At the practice, the patient financial assistance staff has been a key component in the success of the IOD program, providing timely and efficient assistance to patients at any point in the prescription process. When a prescription is received at the dispensary for an oral cancer drug, a PA request is completed on the same day. Unless there are extenuating circumstances, the PA is usually obtained that same day from the insurance company. The staff then identifies any patient out-of-pocket expenses, deductibles, or co-pays. All patients eligible for assistance are enrolled in the appropriate program based on whether they have a commercial or a Medicare prescription plan; uninsured patients also have assistance options explored for them. 

The “life of an IOD prescription” is as follows: a) a treatment decision is determined by the oncologist; b) a prescription for an oral cancer medication is generated by the practice physician or advanced care practitioner in the electronic health record; c) the prescription is e-prescribed directly to the IOD pharmacy system; d) the patient’s insurance information/prescription benefit is available in the practice pharmacy system, coverage is determined immediately, and PA status is identified; e) through the IOD pharmacy system, the prescription is adjudicated and patient OOP expenses/co-pays are identified; f) the practice staff helps to enroll any eligible patient in patient assistance programs that are available for commercially insured patients (pharmaceutical companies’ co-pay cards and drug-specific programs are utilized to mitigate patient OOP expenses) and for Medicare patients (foundation funding and resources are obtained).

The practice has worked very closely with PAN to obtain assistance for Medicare patients. The process with PAN has been streamlined and is very efficient from the practice perspective: 1) patient assistance staff goes to PAN website and clicks “apply now”; 2) disease is selected; 3) insurance type is selected (Medicare); 4) drug is selected; 5) staff selects option “applying for someone else”; 6) staff identifies “self” as person completing information on behalf of patient; 7) staff enters patient information, income level, number of household members, and insurance information after obtaining this from the patient; 8) staff enters prescriber information; 9) staff contacts the patient via phone and asks for permission to accept terms of PAN agreement; 10) staff clicks “accept”; 11) within a few seconds, there is notification of patient award including available balance, enrollment date, and end date; 12) patient-specific PAN ID# card is generated, which includes Rx Group#/Bin#, which is sent to the IOD pharmacist to use as a co-pay card while processing the prescription.     

The provision of comprehensive financial assistance services are a quality standard for NCODA IOD practices. From January to November 2015, the practice's IOD patient financial assistance staff has obtained over $400,000 in awards granted to Medicare patients through various foundations (Table 3). For patients who are Medicare beneficiaries, without the dedicated practice staff researching and obtaining assistance from foundations such as PAN, many would not have access to the oral drug therapies so critical to their care.

Conclusions

Cancer therapies have become more complex and more expensive, requiring the oncologist and their staff to take on a larger role to ensure patient access to treatments. IOD services, both clinical and administrative, offer an additional level of support at the oncology practice for improved continuity of care and better overall management of a patient’s cancer therapy. As additional oral cancer drugs are brought to market and approved by the FDA, there will be an increased number of opportunities to prove that IOD services allow for better patient outcomes. Studies done at NCODA member practices will demonstrate improved patient convenience and satisfaction, better medication adherence patterns and toxicity management, as well as significant cost savings to patients and the healthcare system.

Author Affiliation: National Community Oncology Dispensing Association, East Syracuse, NY; New York Oncology Hematology, Albany, NY.

Source of Funding: None.

Author Disclosures: Dr Egerton’s employer is the location of an in-office dispensary.

Authorship Information: Concept and design; acquisition of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content.

Address correspondence to: Nancy J. Egerton, PharmD, BCOP, Vice President, National Community Oncology Dispensing Association, and Manager of Pharmacy Services, New York Oncology Hematology, Albany, NY. E-mail: nancy.egerton@usoncology.com.
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7. Zafar SY, Peppercorn JM, Schrag D, et al. The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient’s experience. Oncologist. 2013;18(4):381-390. doi:10.1634/theoncologist.2012-0279.

8. Aschkenasy J. Putting a cap on physician dispensing. Risk & Insurance website. http://www.riskandinsurance.com/putting-a-cap-on-physician-dispensing/. Published September 1, 2013. Accessed February 2016.

9. NCODA - quality standards. National Community Oncology Association website. http://www.ncoda.org/ncoda_patients_first_quality_standards.html. Accessed December 2015 
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