Advances and Best Practices in the Utilization of Novel Agents in Metastatic Breast Cancer - Episode 5

Practical Challenges in Switching to CDK4/6 Inhibitors

Joyce O’Shaughnessy, MD: I’m just thinking of challenges that we have. One is when we want to make a change to a CDK4/6 inhibitor, I tell my nurse what we need to do. Of course it’s entered, we get the preauthorization, and everything is good. And then we expect it to get mailed to the patient from the specialty pharmacy. Some of our patients are reluctant to bother the doctor’s office. The drug doesn’t come. Then they come back to the clinic 4 weeks later, or 2 weeks later to get their checkup. They come back because they had an appointment. However, they never started their medication.

Michael Reff, RPh, MBA: Exactly.

Joyce O’Shaughnessy, MD: That is very difficult. It happens with some of our patients who have too many doctors’ appointments; or are elderly, don’t have the help at home, and didn’t have that second set of ears; or are just reluctant to call the doctor’s office. They haven’t been able to get it right there in the practice, which obviously mitigates the issue, right?

Michael Reff, RPh, MBA: Yes, of course. If you have systems in place to manage that, it should mitigate that. But what you described is prevalent across the country. Most practices can only keep a certain percentage—maybe 50%, 40%, 60%—of their prescriptions that are prescribed internally within their practice. The majority, so to speak, need to go out to a specialty pharmacy. The practice can lose a line of site on that prescription, and that can diminish the continuity of care. So an emphasis of NCODA [National Community Oncology Dispensing Association] is to try to fix that. It’s certainly one of the QOPI [Quality Oncology Practice Initiative] quality standards from ASCO [American Society of Clinical Oncology]. If you’re a QOPI-certified practice, being able to have that line of site on a prescription that leaves the practice, that goes to the specialty pharmacy…. There’s a requirement.

Joyce O’Shaughnessy, MD: It’s hard to do.

Michael Reff, RPh, MBA: It’s very hard to do. It takes effort. There are some best practices that we’ve shared across our network to help practices get better at it, because it’s the best thing to do for patients. That situation does occur, where they show up and haven’t received their drug. Our practices can do it better.

Joyce O’Shaughnessy, MD: If it doesn’t go outside the clinic, it’s one less thing you’ve got to track. It’s just much easier to keep it in-house, from the practicality of getting it in the first place, right?

Michael Reff, RPh, MBA: Exactly.

Joyce O’Shaughnessy, MD: The next issue is the $15,000 box that sits in your closet because it’s the wrong dose. So you see the patient back and they’ve got grade 3 or 4 neutropenia. You have to make a dose reduction on palbociclib or ribociclib, but the specialty pharmacy has already sent the patient their next month’s supply and we can’t send it back. And so, then we have to make a dose adjustment and have to resubmit the prescription. That takes a little while. It doesn’t take long, but it does take a few days to get to the patient. That’s another possible delay. Anything can happen, right? And so, then there is a lot of waste. But also, the patient has paid another co-pay for that as well. That’s frustrating. That’s really super wasteful. A lot of doctors don’t like that at all. That’s one of the advantages of ribociclib. Each pill is 200 mg. So you can go down from 600 mg to 400 mg without wasting. That’s very important. But again, how does this work with the medically integrated team? How do you guys help with that?

Michael Reff, RPh, MBA: As I mentioned before, we developed quality standards. There are 4 domains. One is foundational. The foundational quality standard considers cost avoidance and waste. One thing that a medically integrated pharmacy team needs to do or work towards is minimizing the costs associated with errant fills. They can occur in 2 different ways. If you’re able to fill that prescription at your practice, you should look within the EMR [electronic medical record], see how the patient is doing, and not automatically refill a prescription with the same strength and at the same quantity unless you get a verbal OK from the prescriber. Also, you need to confirm with the patient that they can afford it and that the prescriber still wants to prescribe that option. If there are any differences, you can make adjustments to minimize any of that waste. It’s a timing issue and it takes effort.

Joyce O’Shaughnessy, MD: It takes resources.

Michael Reff, RPh, MBA: It takes resources. And so, when you have that medically integrated team and you have commitment from senior leaders within your practice to devote time, energy, and effort to that, it can be done very well. We track that. NCODA, as an organization, tracks the cost avoidance that practices have taken out of the system by eliminating errant fills. As you described, based on timing, a patient is to receive the therapy today. It was on refill and had already been sent 5 days ago. Hopefully it arrives to the patient in time. This doesn’t always happen. But, in that 5-day span, a dose adjustment may have been needed, or a change of therapy or a delay in therapy or a holiday may be required. If we have control of that prescription at our practice, that errant fill never happens.

And so, we track that on our website. We’ve saved millions of dollars for healthcare providers and employers by being proactive and by being medically integrated.

The other situation is when it goes out to specialty pharmacy. We are trying to build in an infrastructure to try to prevent that errant fill. That’s more difficult based on time fences and milestones. The specialty pharmacy needs to mail out a prescription a week or so in front of that. And so, we try to mitigate that. But inherently, because it’s not in-house, it’s more challenging to prevent that waste. And so, we have metrics around that. We have best practices that we help to share on how to do that well.

Joyce O’Shaughnessy, MD: It’s really incredible because the pharmacist or nurse navigator can look at the EMR, or even at phone calls that have been documented about toxicity. They can see if there has been a hold. That’s important because a lot of them are not filled. They can see if the patient sees the physician to see if there is a dose adjustment, or can give the doctor a heads-up. “Hey, take a look at this. You might need a dose adjustment here. We’d love to help.”