Bruce A. Feinberg, DO: One of the areas that’s been really interesting around orals has been this question of adherence—compliance, persistence. The numbers are kind of striking. In the order of breast cancer for aromatase inhibitors, it could be [that] as low as 40% or 50% of patients are actually completing scheduled therapy for a minimum of 5 years. The good news is [that] 2 years may confer a lot of the benefit, but, nonetheless, the studies [look at] 5 years or more and you’ve got 40% or 50% [adherence to treatment]. How do we fix the problem? How do we do medication therapy management? How do we improve adherence around orals?
I think that for a long time, doctors often stood their ground on orals. Granted, there weren’t the number [available then as there are available now]. In the early days of capecitabine, for instance, [providers thought] that “I know what my patient is taking if the needle is in the arm and I see the infusion, but I don’t know that when I give them pills to go home.”
So I’m concerned about it, one, because you could have to pay for a drug that’s not being used. In your case, you expect a certain end result or a certain outcome, but the drug is not being used. It brings up [the topic of] office dispensing versus specialty pharmacy-based medication therapy management [programs], which are often highlighted as a benefit. Although, if you look at who’s doing that medication therapy management, it may not even be a pharmacy tech. It may be a call center with unskilled labor. So it questions that big picture of adherence, or compliance, or persistence.
On the payer side, is it a big issue or is it made a big issue by the pharmaceutical companies and specialty pharmacies because it’s about dollars? Is it about more of a drug being distributed, or is it a big issue because of the implications for the patient? How does the payer see it?
John L. Fox, MD, MHA: I think there are some conditions where we know that if you have poor compliance, your risk of healthcare consequences increases. For example, in CML (chronic myeloid leukemia), if you fall below a medication possession ratio of 80%, you are at increased risk of accelerated blast phase. So, we monitor that because we know that there are adverse consequences.
Bruce A. Feinberg, DO: How do you monitor that?
John L. Fox, MD, MHA: We monitor that through the specialty pharmacy. There’s outreach. You have to outreach to the physician and patient if they fall below that [level], but I would say that’s the exception. That’s not the rule. For as much as people don’t like health plans knowing their business, this is an area where we haven’t been any more aggressive about promoting compliance than in say, for example, hypertension or hyperlipidemia management.
The fundamental issue is that we know that patients aren’t compliant, but do we know why? What resources do we have to assess why? Is it toxicity or side effects? Is it affordability, or are there other issues? They don’t feel any better on the drug, so I think it’s more than just identifying that they’re noncompliant. It’s trying to understand why and address those problems, [but] there’s really no one who is tasked today, overall, with doing that.
Bruce J. Gould, MD: I would say that obviously, adherence and persistence are very important to the physicians. Our job is to help patients get better. I think we have almost as much invested in the patients’ health as they do. The practices really work hard to educate the patients in terms of what the drug does, how it is going to impact their disease, and what the expected side effects are. Some patients quit taking medicines because they don’t have any side effects and they think the drug is not working, and then other patients have terrible side effects, so of course they’re going to quit taking the drug.
John L. Fox, MD, MHA: Yeah.
Bruce A. Feinberg, DO: In either case, are they telling you [that they stopped taking the drug]?
Bruce J. Gould, MD: Our job is to ask the right questions and find out.
Bruce A. Feinberg, DO: Wait a minute. I want to interrupt you because I want to know how you are doing that. Is that only when they come in the office, or do you have a formal [procedure]? “After we give the script, I have a nurse call that patient in 5 to 7 days to do that follow-up.” How structured is that process?
Bruce J. Gould, MD: In our practice, it’s very structured. We have the patients come back in 5 to 7 days to see a provider (whether it’s a mid-level practitioner or a physician), just to see if they were able to get the drug, are taking it properly, and if they are having any side effects. Obviously, I think if someone is going to have a lot of side effects, you want to intervene early and make the proper dose adjustments so that the patient doesn’t get discouraged or get into too much trouble with side effects and not want anything to do with the drug. So I think earlier intervention is helpful for helping and reassuring the patient that you’re going to monitor things and you’re going to work [with] him or her to make sure that they get the proper care.