Physician-Pharmacy Integration in Cancer Care: Pillars of Medically Integrated Pharmacy

ABSTRACT

Medically integrated pharmacies (MIPs) offer a multidisciplinary, patient-centered approach essential for complex oral anticancer therapy. Unlike traditional pharmacy dispensing, which creates a fragmented approach to patient care, MIPs integrate pharmacists directly into the care team, leveraging electronic health records for informed decision-making, thereby enhancing continuity and reducing costs. For patients, critical challenges associated with oral anticancer medications include abandonment, adherence, and access and affordability. Using an integrated and comprehensive approach, core activities of MIPs have demonstrated reductions in prescription abandonment rates and increases in adherence rates through proactive interventions and education. MIPs also enhance affordability by seamlessly coordinating financial assistance programs that can lead to cost savings for both patients and health care systems, presenting a compelling value proposition for managed care. High levels of patient and provider satisfaction further underscore the benefits of this integrated model. The evidence within this commentary demonstrates that MIPs help patients with cancer adhere to their oral anticancer medications while simultaneously minimizing financial burdens, thus providing a robust underpinning for patient-centered value-based care.

Am J Manag Care. 2025;31(12):In Press

Takeaway Points

Medically integrated pharmacies (MIPs) offer significant value for cancer care by improving patient outcomes and simultaneously reducing costs.

• The summarized data support the implementation and prioritization of physician-pharmacy integrated care models such as MIPs within health care systems that aim to improve the quality and efficiency of treatment with complex, high-cost oral anticancer medications.
• Study findings indicate that MIPs can lower medication abandonment rates and increase patient adherence, achieve significant cost avoidance through financial assistance coordination, and reduce overall medical and prescription spending.
• MIPs help streamline delivery of oral anticancer medications while enhancing communication among the health care providers caring for patients with cancer.

In the era of precision medicine, cancer care has evolved to be individualized and complex. To maximize treatment benefit and outcomes, a multidisciplinary patient-centered approach is necessary. NCODA, the Network for Collaborative Oncology Development & Advancement, has established the benchmark of cancer care excellence through its dedication to developing and maintaining quality standards for medically integrated pharmacies (MIPs).¹ The MIP model differentiates itself from the traditional pharmacy model by integrating pharmacists as active members of the care team with physicians, advanced practice providers, nurses, pharmacy technicians, and patients,leveraging electronic health records for informed decision-making. This enablesdirect communication with providers, and enhances continuity and quality of care, all while reducing costs and forging relationships for proactive interventions with patients.

Members of the NCODA Executive Council reviewed the current evidence on MIPs, discussed their institutional practices, and shared their perspectives to develop a dynamic list of core values that MIPs offer patients with cancer receiving oral anticancer medications (OAMs). The pillars of MIPs’ value center around access/affordability, abandonment, adherence, time to fill, education, patient satisfaction, and cost avoidance (Figure). This commentary focuses on the benefits of the MIP pillars of abandonment, adherence, and access/affordability.

Abandonment

Medication prescription abandonment, defined as a patient deciding not to fill or to fill and never pick up a prescription, is reported to be as high as an average of 18% nationally.² Factors driving the abandonment of OAMs include pharmacy plans, higher out-of-pocket costs and cost-sharing amounts, and concurrent prescription activity.^2-4 As OAMs become pricier and the mainstay of treatment for certain cancers, it is troubling to see that abandonment rates have reached up to 49% in patients prescribed a new OAM with an out-of-pocket cost of more than $2000.⁴

With a primary goal of getting OAMs to patients and thus ensuring adherence and preventing abandonment, MIPs have demonstrated the ability to lower OAM prescription abandonment rates to less than 1%.² This occurs through continual communication and coordinated activities by the pharmacy and clinical teams in integrated patient assistance activities. (eg, co-pay assistance programs, charitable grant funding, manufacturer-provided free drug programs).² Results of a study of Medicare beneficiaries with advanced prostate cancer, for example, showed that new prescription fills for oral targeted agents increased after the adoption of MIPs relative to those for men treated by practices without in-office dispensing.⁵

Adherence

Medication adherence is the extent to which a patient takes a medication as prescribed.The keyconcern when prescribing a new OAM is whether the patient will have the medication filled within an acceptable time. Reasons for new OAM prescription primary nonadherence (ie, not being filled within an acceptable time) include patient decision, medication not approved by insurance, intentional delays based on provider/patient request, medication changes, clinical decline, death, no longer appropriate, or unaffordable co-pay.⁶ Nonadherence to OAMs also includes overadherence (intentionally or unintentionally taking too much medication in a prescribed period, which can lead to increased toxicity) and underadherence (taking an inadequate amount of prescribed medication).⁷ Impactful factors identified as affecting adherence to OAMs include patient confidence, health literacy, perception of treatment, quality of life, social support, and complexity of chemotherapy regimen.⁸

Duration of treatment is likely to decrease with each line of therapy, so maximizing time on therapy is crucial for patients with cancer. Because a substantial proportion of patients have difficulty adhering to OAMs as prescribed, interventions aimed at improving adherence and time on treatment are critical. These interventions include reminder systems, management of adverse effects, discussions of misconceptions around disease or medication efficacy, dosing and administration instructions, strategies for accessing the medication, and referral for cognitive behavioral therapy.⁹

Numerous studies have demonstrated that interventions from members of the MIP multidisciplinary team improve adherence to oral oncolytics.^7,10-12 For example, an initial education session and follow-up as needed related to adverse effects, drug interactions, and adherence significantly increased the medication possession ratio (MPR) in a multi-institution study of patients with chronic myelogenous leukemia (CML).¹⁰ Similarly, pharmacist education on adverse events and ongoing adherence counseling resulted in increased detection of drug-related errors and adherence (MPR > 90%) in a case-control study.¹¹ In a multi-institution case-control study, an initial education session with a pharmacist and ongoing counseling resulted in a significant improvement in daily adherence to capecitabine in patients with breast or colorectal cancer.¹²

Indeed, with the ultimate goal of improving patient outcomes, MIPs have set the standard for maintaining low rates of nonadherence and improving adherence.⁶ Relative to external specialty pharmacies, adherence rates in patients who fill their OAMs using a MIP are significantly higher.^13,14 In a real-world study that aimed to characterize patient-centered MIP practice, patients with metastatic breast cancer taking a CDK4/6 inhibitor who were followed at a MIP reached a high level of adherence, with an average proportion of days covered and MPR of more than 90% throughout the study period.¹⁵

NCODA patient satisfaction surveys have documented that patients prefer to receive their prescriptions through MIPs due to positive and personalized interactions with staff, convenience of time to obtain prescriptions, and continuity of care.^16,17 Improved patient satisfaction translated into significantly better adherence to OAMs in a study of 2546 patients with CML; moreover, patients who found their doctors approachable to discuss the challenges of taking their CML medication were also more likely to have higher adherence.¹⁸ These sentiments have been quantitatively captured in patient satisfaction surveys at Texas Oncology and Florida Cancer Specialists & Research Institute that reveal a 94% to 96% rate of satisfaction with MIP.^19,20

Access/Affordability

Affordability and financial barriers to OAM access include cost, prior authorizations, and availability of financial assistance.²¹ Pharmacists and pharmacy technicians within a MIP seamlessly coordinate financial assistance for patients receiving OAMs by performing benefits investigations, assessing out-of-pocket responsibility, and enrolling patients in assistance programs to alleviate the high cost burden of OAMs and prevent therapy abandonment.²² MIPs offer patients and insurance providers a single point of contact, reducing paperwork and correspondence among multiple parties, thus ultimately expediting time to medication access.²³

Prescription claims data from an academic MIP were retrospectively analyzed, demonstrating that 32% of patients who had their OAM or supportive care medication filled within the MIP were enrolled in a financial assistance program, and cost savings ranged from $5 to $13,138 per intervention.²² Furthermore, the financial grant approval process was rapid: 1.2 days from insurance approval. A study assessing the financial impact of obtaining OAMs via a MIP vs a mail-order pharmacy demonstrated a net cost avoidance annually of $1,730,416 with MIP compared with an estimated $119,794 net annual waste with mail-order dispensing.²⁴

Medical spending is also reduced with the use of MIPs for OAMs relative to nonintegrated pharmacies. In a study of 30,928 commercially insured patients initiating an OAM between 2019 and 2022, MIP dispensing was associated with a $5672 reduction per patient in medical spending compared with nonintegrated dispensing, almost half of which was due to changes in inpatient nondrug medical spending.²⁵ In addition to reductions in medical spending, 6-month oncology prescription costs were lower with integrated MIPs. In a study of 36,816 patients between 2016 and 2020, dispensing from an integrated MIP was associated with a mean $9219 reduction per patient in prescription costs compared with a nonintegrated MIP.²⁶ These expense reductions may be associated with closer monitoring of patients’ medical records and lower number of prescription refills in MIP pharmacies. As the myriad financial benefits of MIPs continue to be realized, institutions are revisiting optimal dispensing approaches. For example, UCSF Health in northern California, which previously outsourced OAM access and financial counseling to retail pharmacies, is reverting to what worked in the past: in-house MIPs.

Summary

Testimonials from patients utilizing MIPs to obtain their OAMs attest to the meaningful interactions and relationships they have gained from members of their MIP team as well as the tremendous value of a one-stop shop for all their cancer care needs. Some patient and provider testimonials are provided in the Table.

A unique quality of MIPs is the relationship and connection that the providers and MIP team have with the patient. Also, unlike nonintegrated pharmacies that experience a lag in communication, discussions between the MIP team and the patient take place in real time. As part of the core health care team with direct patient and records contact, the MIP team knows the patient and always strives to be proactive in providing care beyond dosing to include education, preauthorization/access efforts, tracking of OAM dispensing and speed to commencement, timely outreach and proactive adverse effect management and monitoring, and minimization of the cost of care and complications. Patient care always comes first in the MIP model, and the core pillars outlined in this article highlight the value MIP brings to patients with cancer navigating their OAM treatment journey. 

Acknowledgments

The authors wish to thank Kara Sammons, MSPharmReg, for administrative support, and Claire Gilmore, PharmD, BCOP, for editorial support, which was funded by NCODA.

Author Affiliations: Texas Oncology (GKD, NDa), Houston, TX; Florida Cancer Specialists & Research Institute (LG), Gainesville, FL; Minnesota Oncology (KH), St Paul, MN; Memorial Sloan Kettering Cancer Center (SF), New York, NY; Tennessee Oncology (NDi), Nashville, TN; University of California, San Francisco (DK), San Francisco, CA; Yale New Haven Health (OA), New Haven, CT; Moffitt Cancer Center (KK), Tampa, FL; NCODA (MR), Cazenovia, NY.

Source of Funding: Editorial support was funded by NCODA.

Author Disclosures: Dr Freeswick has participated in advisory boards for The American Journal of Managed Care, Kura, and Sanofi/Genzyme and is employed by Memorial Sloan Kettering Cancer Center, which owns a nonprofit medically integrated specialty pharmacy. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (GKD, LG, KH, SF, NDi, DK, OA, NDa, MR); acquisition of data (KH, OA); analysis and interpretation of data (GKD, KH, SF, DK, NDa, MR); drafting of the manuscript (GKD, KH, NDi, DK, OA, KK, NDa); critical revision of the manuscript for important intellectual content (GKD, LG, KH, SF, NDi, OA, KK, NDa); provision of patients or study materials (KK); administrative, technical, or logistic support (KH, MR); and supervision (LG, KH).

Address Correspondence to: Gury K. Doshi, MD, Texas Oncology, 12377 Merit Dr, Ste 700, Dallas, TX 75251. Email: Gury.Doshi@usoncology.com.

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