Dr Barbara McAneny on Issues With Step Therapy and Home Infusion in Oncology

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Barbara McAneny, MD, founding partner of New Mexico Oncology Hematology Consultants, discusses the challenges in care delivery with step therapy in Medicare Advantage and much-debated home infusion in oncology.


Barbara McAneny, MD, CEO, New Mexico Oncology Hematology Consultants, Ltd., discusses the challenges in care delivery with step therapy in Medicare Advantage and much-debated home infusion in oncology. These and other issues will be spotlighted in a discussion titled "Assessing the Patient Impact of Insurer Mandates: White/Brown Bagging, Step Therapy, Home Infusion, & Other Strategies" that McAneny will take part in during today's Community Oncology Alliance (COA) Payer Exchange Summit sessions.


When CMS permitted step therapy in Medicare Advantage, oncologists predicted that patients would encounter situations in which they would not be able to get access to the best therapy for their particular cancer. What do you see in both the data and in clinical practice?

Okay, well, this is why I call it Medicare Disadvantage, because it has all of the hassles of commercial insurance with the payment of Medicare. So what we have been concerned about—and we've only seen a couple of instances in the practice, but this has been in the literature. For example, on an oral medication, if a patient with chronic myelogenous leukemia is stable on one medication, there are a series of those that are available. And so it's very logical for the insurance company, who are interested in the money to say, "Oh, stop what you're doing and go to the cheapest one." Well, the patient may have failed that one. And so if they block their prescription, we're doing an unintended gap in therapy, and we don't know what the effect of that will be because it takes a while to argue. It's bad for the patient and it's bad for the doctor, because one of the things that contributes to physician burnout is having to argue for every single thing your patient needs, and trying to explain to the retired pediatrician who's never seen a cancer patient in their life, why these drugs are not interchangeable, and you can't just use them as whatever the insurance company thinks they could make the most money on.

The second area that we have seen this is in the anti-nausea medicines. We all know as oncologists that there's a phenomenon called anticipatory nausea. So if the patient throws up with their first cycle, they're likely to throw up with every cycle of chemotherapy. Well, in this fail-first scenario, if they decide to make them use the less expensive, older anti-emetic that didn't work very well, then that patient is likely to throw up and then they failed, and then they can have the good stuff. But by that time, they're going to have anticipatory nausea, and it's going to make the whole course terrible. So they also, you know, they're looking really at the support drugs where they're, they're hoping that oncologists will not push back. My hope is that oncologists will push back. You know, if you're getting people sniffle medicine for their their vasomotor rhinitis they get in cold days, then, you know, perhaps doing the less expensive one will not hurt anybody. But in cancer, it will hurt patients, and it will burn out physicians.

The issue of home infusion in oncology was already a topic of debate before the pandemic. What are your thoughts on its use?

Well, I will tell you that if the insurance companies come to my practice and tell us that we are to do the E&M [evaluation and management] code and write the prescription, and they will have some random nurse I don't know go and administer the drug in a patient's home, I will tell them they need to find a new oncology practice to work with. So that pretty much sums it up. Then I'll get a secondary career doing medical malpractice, plaintive work for the patients who are harmed by this policy. I think is dangerous for patients. When they have a reaction to a medication, which is unpredictable, and is not always—there are no safe medicines. Then all you have there is one nurse who may or may not be an oncology nurse, who may or may not know anything about the drugs she's giving. And she's there by herself.

Secondly, I can't believe they used COVID [coronavirus disease 2019] as an excuse for this for convenience of patients. So imagine the scenario where I am sending a nurse—many nurses are young women—I'm sending them out with a bag of drugs to go to some random neighborhood that may or may not be a safe neighborhood to walk down the street with a bag of drugs in, and go into a patient's house where members of the household may or may not have COVID. And where the houses are almost certainly not as spotlessly clean as we keep our infusion centers. And then you ask her to deliver this not in a comfortable recliner chair with all the equipment she needs, but in someone's bedroom, or maybe their bathroom. This is not an optimal way to give chemotherapy.

They have forced oncology practices, and it's a good thing actually, to make sure that we have very high standards for cleanliness, for the safety of people administering the drug, as well as the safety of the patient receiving the drug. And we're going to throw all of that out of the window so the insurance companies can can make more money basically, that they can control the supply chain from the manufacturer to the end user, and they can pull money out of the process every step of the way.

So it's it's a very bad issue for patient safety, and I personally am not willing to do the E&M code and accept the liability when I have no control over the administration. So I'm hoping other physicians will join me in that kind of a consideration. Think about whether or not they can support their own infusion center with its USP <800> infusion center, with its oncology-certified nurses that are highly paid, trained, professional personnel, and whether or not they can afford them to ship all of these drugs out to other people to administer and still pay the malpractice claims when they arise when something goes wrong.