Jim Schwartz, RPh, corporate pharmacy manager, Texas Oncology, discussed pharmacy challenges regarding equitable care and distribution of specialty drugs in the community oncology setting.
At the patient level, distrust in the health care system continues to present barriers to achieving uptake of specialty medications in the community setting. Other challenges that pharmacies face include pharmacy benefit managers and financial toxicity, said Jim Schwartz, RPh, corporate pharmacy manager, Texas Oncology.
Schwartz participated in a panel discussion at the 2022 Community Oncology Conference titled “The New World of Oral Cancer Drug Dispensing: Pharmacy Challenges & Solutions.”
What health equity concerns arise from oral cancer drug dispensing patterns, and how have Texas Oncology worked to address these issues?
Health equity and disparity in the ability for patients to get cancer [treatment] is a big topic. One of the physicians here Kashyap Patel, MD, he's not from Texas Oncology, but he's a big proponent of looking at that. Texas is a big state, we have a lot of urban patients, we have a lot of rural patients. So, sometimes we may overlook rural patients, not because we don't [want to care for them], but [because] they're not very close so we can't bring them back in that quickly.
We have patients that come in from 100 or more miles to come to one of our centers. So we just have to sometimes find resources closer to their home when they're having something go wrong. The big disparity is sometimes between racial groups, old age—sometimes as patients get older they don't have transportation, they don't have somebody there to encourage them to get them to come in. We just have to actively reach out to these patients, and we do. When they're referred to us, we take them by the hand and walk them through as much as we can, whatever their disparity is.
There's the question of trust, I was just talking to somebody about this the other day. Some of the disparities among races—some people just don't trust the health care system. They go all their lives not going to doctors, they're just not sure to believe what they're being told. It's a matter of bringing them, talking to them on their level: tell us what your concerns are, here's how we're going to alleviate those.
So, it's a matter of recognizing that and we've hired a number of social workers that will sit in. They'll listen to the doctor, but they want somebody that's not necessarily a health care professional that is trained to listen to what their concerns are, what they have to say, and say: OK, here's how we can get through that. So, I think it's making use of social workers more than anything else that helps get over those barriers.
What are some future considerations for payers, providers, and others involved in oral cancer drug dispensing within the community setting?
I don't know how we can do it, but somehow we need to get the foundations beefed up. I mean, drug companies have been hesitant for a number of years to put money into those foundations. The federal Office of Inspector General thinks there's collusion between the pharmacy companies and the foundations that they're giving money specifically for their drug. They can't do that, it's not legal, and they wouldn't do it, but that suit is still ongoing. So there's a fear among the pharmacy manufacturers to put money into those foundations.
We need to get over that, because I think they'd rather do that than give away free drugs. When they put money into a foundation, it's for all the prostate cancer patients or all the breast cancer patients—it's not specifically for their drug, but we've worked on that. There's a litany of issues with the pharmacy benefit managers, PBMs—they sign contracts where they limit the patient's ability to get a drug where they want.
There's a place for mail order pharmacy, for maintenance drugs, for hypertension, things like that. Oncology drugs are just a special class of drugs. It's not just the financial toxicity—we take care of that, they don't do as good a job. But the side effects, you have to constantly monitor that and that's not something that specialty pharmacies do. They may know the drugs, but it's not the same thing as what our staff does when we start any new patient on an oral oncolytic.
We call them weekly to make sure: Are you taking your drug? What time are you taking it? We don't just say are you having side effects, that doesn't mean anything. Are you having diarrhea? Any nausea? Any tingling in your fingers? We ask them specific questions on their drugs: Oh, yeah, I'm having a little of that.
So, it's a matter of the health care provider asking specific questions and the patient will answer specific questions. Going into the future, and we've been developing this for years, the concept of medically integrated pharmacy where the doctor, nurses, APPs [advanced practice providers], pharmacies are all working together in one health care record so we can all see everything that's been done to the patient. That's something that will continue.
In terms of financial toxicity, it'd be nice if people came out with drugs that were less expensive than the previous one, but that hasn't happened. There's starting to be a move—most of our drugs are filled on either commercial co-pay or if it's Medicare patients, it's Medicare Part D more often than not.
There are some that are filled on Part B, but Part D is much harder to get coverage for, so they need to work on that to try to make it easier. I mean, they'd like to move all of the patients’ medications, including injectables, over to Part D and that's just not going to work. Having to adjudicate retail claims takes a lot longer than getting prior authorization for clinic drugs.
So, it's just going to hold up patients' therapy and the new patients are always anxious. They want to start right away and we tell them: No, we have to get coverage anyway, but let's just stop and think about it. We give them a lot of information. I feel sorry for them, we give them so much written information, but giving them a chance to read through that to understand what's going to happen. And then for us to adequately get the authorization and tell them what they're going to pay and make sure they know we're going to find resources to help them.