Strategies to Mitigate Access Barriers for Patients With Cancer: Ryan Haumschild, PharmD, MS, MBA

Novel therapies have revolutionized the cancer care paradigm, but access and affordability are persistent issues when it comes to the latest, most cutting-edge treatment options.

In this interview with The American Journal of Managed Care^® (AJMC^®), Ryan Haumschild, PharmD, MS, MBA, vice president of pharmacy at Emory Healthcare and Winship Cancer Institute, discusses the barriers patients face in accessing novel therapies and the ways in which providers can mitigate financial toxicity.

This transcript has been edited for length and clarity.

From your perspective, what are the most significant barriers patients face when trying to access cancer therapies, especially immunotherapies and targeted agents?

Haumschild: Patients are running into barriers when they're trying to access cancer therapies, particularly when we think about some of the targeted agents and immunotherapies, and some of these barriers are multifactorial. One of the first things I think about is financial toxicity. How are patients going to access these therapies? Do they have appropriate insurance coverage? Are they going to have to pay out of pocket? And does that create any delays in care? I also think our payers are trying to do a great job in building criteria of use for these therapies, but sometimes, if there's missing documentation or there might be a longer, extended review, that can create delays for patients as well. Some of these patients, even just seeing their provider or getting treated, might suffer from transportation vulnerability. There might be other considerations around social determinants of health that are also a barrier to the adoption of treatment, which I think, in reality, impacts their ability to follow up with appointments and could lead to a higher abandonment rate.

With some of these treatments, there are also some side effects that are associated. If someone isn't engaging with that patient early and making sure that they're mitigating side effects that are coming, I think that also runs into a barrier of use, because the patient may go ahead and say, “Hey, I don't like this symptom. I don't know if I'm associated with it. I want to stop taking this therapy.” Again, I think the barriers to the adoption of immunotherapies and targeted agents exist, and it's really our job as provider groups and for payer groups—the whole ecosystem—to help mitigate those for patients.

When prior authorizations or formulary restrictions create delays, what strategies have you found most effective for expediting approval or identifying alternative coverage pathways?

Haumschild: Inevitably, prior authorization, utilization management, and clinical policy can sometimes create delays for patients. It can be frustrating, and in the same regard, how do we work within those contexts to make sure that we get that patient more of that urgent or that expedited approval when they need it? I think, number one, it's understanding where the payers are coming from when they're making these policies. I truly believe that payers are not trying to make it overly burdensome or difficult, but at the same time, they're trying to create appropriateness of use. It’s understanding how that policy came about and what's missing, and do we need to connect with that payer to say, “Hey, we read your policy, and we identified the most appropriate patient. We're recognizing that the submission of this documentation doesn't really translate to the real world.” A great example is that some of the clinical trials require a liver biopsy, while others just require a FibroScan. A FibroScan can be done a lot faster in the clinic to get that patient started on therapy, but a liver biopsy is going to take longer.

I think when we think of major depressive disorder, the Montgomery-Asberg Depression Rating Scale is used in the clinical trial. But if a payer requires that for the real world, it's going to take so long, because it takes about 40 minutes to administer that test. I think the same is in oncology. We want to make sure that the burden of proof can be documented, and it's part of the natural diagnostic criteria for a patient. And 2, when we submit that authorization, that there's a timely approval, and if we're meeting the needs of that medical policy and prior authorization, the payer can adopt new therapies in terms of EPAs; they can do automatic lookbacks to see if they've already approved a therapy that was a step therapy prior, or as we submit information, they can have more of an expedited approval in their regard. Then, if we run into barriers, we know there's an urgent pre-certification, and we know that we can call directly to that payer to find out what the issue is. I think we're really good at medical exemptions as well. And lastly, following up on any peer-to-peer appeals that are needed to make sure that doesn't get in the way of the patient starting therapy.

Looking ahead, what policy or system-level changes—such as value-based contracts or biosimilar adoption—do you think could meaningfully improve affordability and equitable access to cancer drugs?

Haumschild: Cancer is a high-cost disease state. It keeps getting more costly because there's greater and greater innovation, but there are also combination therapies. I think biosimilars, lower-cost therapies, and even centering around value are the future of care. As providers, so many times we depend on net cost recovery, and sometimes it was that with the higher cost therapy plus a higher ASP [average sale price], you got a higher reimbursement. I don't think that's the long-term option. I do think we can center around outcomes and the value of care, just like we saw being focused on an Enhancing Oncology Model. And a lot of other payers are saying, “How do we think about this patient and getting a great response, but not just using high-cost therapies just to drive margin alone?”

A great example is that there are bevacizumab biosimilars, rituximab biosimilars, and trastuzumab. With these agents, how do we make sure that we're looking to treat the patient, and if we can do it with a lower-cost therapy that reduces the total cost of care, that that's something we can engage in? How do payers also create total cost of care incentives so that as providers, as we're treating patients, if we align with value, there's value back to the organization? It's benefiting both parties, because I think when we can do that, that's when the patient wins, and that's when we make the treatment paradigm much more sustainable, and ultimately, we're able to deliver care in a timely manner and a cost-effective way that really emphasizes and supports outcomes.