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Evolving Population Health Strategies for an Expanding Treatment Spectrum A Q&A With Sheila M. Arquette, RPh

Arquette: We must be better at balancing the application of population health type management strategies to a large group of patients with similar treatment plans with the needs of a few patients and the personalized, precision medicines available to best treat their disease or condition. Going forward, we must ask ourselves: How [will] we ensure that the right patient truly gets the right drug at the right time? I believe we no longer will be routinely stepping patients through prerequisite therapies with the hope that they may respond when we know they will not. Up until this point, the variability in predicting patient response and contractual arrangements supported this one-size-fits-all approach. When I look back and think about the immunology class, patients across the country were subjected to double and triple step therapy with preferred agents unless a true contraindication existed because we didn’t know then what we are discovering today. Now we are better able to understand why a trial of a particular agent does not make sense clinically or economically based on the patient’s genetic profile. Today, when we look at some of the oncology agents and at some of the rare types of cancers, we don’t have to subject patients to the gamut of available drugs hoping for a positive response. Because of personalized treatments, we know what the patient is going to respond to and can limit the patient’s exposure to toxic medications that will not produce the desired response.

We need to appreciate that the population health based approach is no longer going to be sufficient to manage all patients and diseases. Plans will begin to move away from requiring a trial of drug [X] for all patients as we are able to better identify up front those who will not respond. Managed care pharmacists will have the opportunity to partner with prescribers to select the most appropriate drug for the specific patient and demonstrate their value as a member of the healthcare delivery team. We need to focus on achieving the outcome that we expect based on the available literature and to be better at having critical conversations with patients when the drug isn’t working, and we have to discontinue or switch to a different agent. The entire thought process regarding contracting and rebate strategy is going to change and will be influenced not only by how CMS and HHS [the Department of Health & Human Services] decide to move forward but as the shift from volume to value continues. The innovation and developments we are now seeing lend themselves to more outcomes-based contracting because we will no longer be treating the same volume of patients with the same medications. I believe it is going to be 2 different schools of thought and approaches at least in the short term as we work to keep pace and adjust to the changes happening across our industry. We must be ready, nimble, and flexible enough to react so that patients do not get caught in the middle.

AJMC®: Can you discuss managed care strategies from the perspective of staging?

Arquette: Some payers and health plans are looking at staging. When, in the treatment course, have we gone past the point of clinical appropriateness and utility for this drug based on disease progression and clinical presentation? These are really difficult questions and discussions [based on] ethics and morals. At what point do you tell a patient there really is no hope? You hear all the time [about] patients [being] told they have 3 months to live, yet they are alive 5 years later. The conversation between physician and patient must be [difficult] when the decision is made that continued treatment is not expected to provide any additional value. Staging is being incorporated where there is evidence and outcomes data to support the inclusion of stage in treatment decisions. Widespread use of staging when developing prostate cancer treatment plans in addition to the patient’s functional score, presence of disease progression, tumor type, propensity of the cancer to advance and spread, and the presence of metastases is commonplace. So I think we’re now thinking differently about what’s truly best for patients and considering them as individuals. It’s important to note that many people fail to realize that just because many oncology drugs are orally administered, [chemotherapy is still toxic]. With limiting patient exposure to potentially toxic medications in mind, you don’t want to take a shotgun approach to treating the patient if there is a more personalized, precision treatment regimen to consider. There are over 700 oral cancer drugs in the pipeline that are being developed and will go through the FDA approval process. Staging will definitely continue to be evaluated and utilized to ensure the right patient receives the right drug at the right time.

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