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Routes of Administration: Adherence and Persistence


The importance of offering the best product first regardless of the medical or pharmacy benefit and how drug adherence and persistence are impacted by the different routes of administration.


Neil B. Minkoff, MD: Let me ask a question here. We’ve been starting to explore some of the different routes of administration. You could have 2 different products, very similar, one that’s being given by the health care provider and another that’s self-administered. Mike, I’ll bring you in here. How does that affect your evaluation when you’re trying to choose between 2 of these different products?

Michael Fine, MD: The most important thing is that you choose the best product for the patient regardless of what the route of administration is. It used to be that there was a lot of separation between drugs under the medical benefit, physician-administered drugs, and the pharmacy benefit. There was a lot of siloing; 2 separate committees evaluated them, but most plans, including our own [Health Net of California], have integrated that operation. Medical drugs and pharmacy drugs, particularly those that are managed, are essentially reviewed by the same committee. They have the same committee make decisions about authorization criteria. If they are going to prefer one over the other, they will make the decision with that same committee, so you won’t have independent evaluations of medical drugs and pharmacy drugs.

In a disease like multiple sclerosis [MS], which is what we’re using as our model today, what is most important is what is the drug that is most effective for the patient, regardless of the route of administration. Some of the antibody drugs that are used are effective, more effective certainly than some of the traditional products. You have to, in a disease where there can be significant harm to the patient, such as permanent damage to the nervous system, if you don’t get their multiple sclerosis under control, you have to offer the best product first regardless of whether it’s a medical benefit or a pharmacy benefit.

Neil B. Minkoff, MD: I want to open this up to the group, but Kevin, you could start. How do you think about adherence and persistence and how that is impacted by the different routes of administration? I’ve heard pros and cons for all the different routes.

Kevin U. Stephens, Sr, MD: The first tenet that we all use is what the best thing is for the patient,irrespective of the route of administration and irrespective of the drug or the pharmaceutical intervention. We use our medical science, which is so important, to look at studies and look at the efficacy based upon our literature to see, and then you have to individualize. People are all different, and they have different populations and different responses to the same drug. It’s a complicated picture that you have to take into play to determine what, when, where, how much, and how often.

Michael Fine, MD: I’d like to weigh in, Neil. In terms of adherence, that is one area, at least from my perspective, where infused products have some more accurate information. When a patient picks up a prescription, you never know whether they take it, you just know that they have possession of it. In the case of an infused product, you know whether they received it. With regard to whether there’s any significant difference between a medical drug and a pharmacy drug, most studies have shown that there probably isn’t, because patients can not show up for their infusion, but it’s clear that there probably isn’t a big difference in terms of adherence. One doesn’t have an advantage, but you have better data on infused products, better data showing whether they actually received it.

Kevin U. Stephens, Sr, MD: I’d like to weigh in on that as well because in adherence, people often do not take the full course. In fact, we know that in antibiotics and the like, when you give people a regimen that they self-administer, as you increase the number and frequency, the compliance goes down. That’s another factor as you consider that type of arrangement.

Neil B. Minkoff, MD: Let me throw the wrinkle in. This is for everybody. I’m not picking on Dr Stephens. What about the difficulty some patients have with getting to the clinic, transportation costs, child care, etc, as opposed to self-administered or home-administered products? How do you think about that as you weigh that in to preferred products?

Michael Fine, MD: I’ll answer that. More and more payers, which I’m sure is true in this group as well, are beginning to offer other options like home infusion. Many of our members now, when it’s safe, receive home infusion, and that takes away the trouble of getting to the physician’s office or the infusion center. We’ve also arranged it so they can do it fairly conveniently. If they’re working, it can be done around their work such as in the evenings or on weekends. Home infusion has, to some degree, solved a lot of these access issues, but not for all patients because not every drug is safe for home infusion. For many patients, it has resolved the problem. It’s become particularly important and more accepted now that we have COVID-19 [coronavirus disease 2019] because accessing infusions through clinics or physician offices has become more problematic.

Eric Cannon, PharmD, FAMCP: Michael, you point out an important point. The reality is that, with the environment we live in today, we need to consider who the appropriate patient is to be going into the clinic and what we can do to facilitate their infusion and put that in the safest place. We’ve addressed this a lot in the past through transportation benefits, and it’s easy for us to provide transportation to get someone into the clinic or wherever to receive an infusion. We’ve had to take a step back over the last several months and look at what the appropriate location is. Some of the motivation that may have existed to bring the patient into the clinic, and adherence was definitely one of them, and the patient’s ability to self-inject was another; we’ve looked at it from the perspective of how a self-injectable may be appropriate, but if the patient can’t self-inject, then we’ll send that out with a home health nurse. Many people have a family member, a neighbor, or somebody that can be trained on the administration of that particular product. The environment today has made us take a step back and look at how we’ve administered these drugs and what can be done to simplify it and put it in the most appropriate setting. Many times, the infusion is probably still the most appropriate. Michael brings up a great point about home infusion, how do we make sure that the existing protocols that we thought had to be administered in the office can also be administered in the home?

Kevin U. Stephens, Sr, MD: I would like to add to that. There are many instances, particularly in states like Louisiana where you have a large rural area, where the nearest facility is 2 hours away by driving. I’ve had patients whose car broke down on the way to get that therapy and so forth. Another thing, I like the option of having, not one-size-fits-all, but not even the same size for everyone at the same time. If you train the person while they’re in the office on the first 1 or 2 doses to make sure that they understand how to administer it safely, then after that, when they feel comfortable, they can administer it at home. With the home positions of people, it’s variable because some people live in insecure housing. We have to take that into consideration too because it’s not that they don’t want to, but it’s the circumstances. In other words, they can have multiple generations in 1 house and all sorts of things that can complicate the issue.

Neil B. Minkoff, MD: From an employer point of view, or if we look at it from the point of view of someone with a different relationship to the patient or the person experiencing the route of administration, is that something that your end of the equation has strong feelings about? How do you take into account how your membership is affected by intravenous versus at-home versus self-administered care, and how do you make allowances for those things?

Cheryl Larson: In a perfect world, it wouldn’t matter if medication came through the medical benefit or the pharmacy benefit, and there would be information on its efficacy and its relation to value and cost, but it’s not a perfect world. People with MS struggle. As all of you on the line know, it sometimes takes 4 or 5 or more different drugs before you find the right drug that works for you. Adherence is especially important, but those without medication recognize that they’re not going to feel as well, and their disease can progress. Adherence is a big deal to employers; the site of administration is a big deal. We’re not telling providers which drug they should choose, but we’re also looking at waste in the system in terms of site of care and in terms of keeping rebates. We’re relying on our carriers and our PBMs [pharmacy benefit managers] to recommend what we should do, and carriers to do a much better job of making sure that things are not wasteful. At the same time, the provider community is making money off a lot of these things, so it’s a delicate balance. We’re in a tough time right now with COVID-19, and adherence has never been never more important. I’m not sure how much some entities in the marketplace have focused on it, but people who have a chronic disease like MS and more serious diseases, gratefully, are usually taking their medications.

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