Who Pays for Immuno-Oncology?

Reimbursement remains a primary concern with the new immuno-oncology agents. Who pays and how do you ensure payment was fervently discussed by oncologists at the recent ICLIO meeting hosted by the Association of Community Cancer Centers.

Immuno-oncology clinical trials have transformed the cancer treatment landscape. Nearly every week we hear improved trial outcomes across a broad range of tumor types. However, challenges remain with clinical integration of these revolutionary agents into mainstream cancer care. To discuss existing challenges and possible solutions, the Association of Community Cancer Centers hosted the first annual conference of the Institute for Clinical Immuno-Oncology (ICLIO) on October 1st, 2015, in Philadelphia. ICLIO launched as an immuno-oncology resource for community oncologists earlier this year.

One of the sessions at the meeting was a presentation by Niesha Griffith, MS, RPh, FASHP, administrator of Oncology Pharmacy and Infusion Services at the James Cancer Hospital, Ohio State University. Griffith provided insight into administrative challenges with immuno-oncology agents, existing coverage policies, and reimbursement concerns. She ended with suggestions on the best practices for successfully using these agents in practice.

The primary challenges for her as an administrator, said Griffith, were:

1. Patient and staff education. Identify a point person to be a resource for immuno-oncology and a core group to manage patient education. Proactive staff education on immuno-oncology updates.

2. Patient triage, especially with respect to unfamiliar adverse events. Staff attending patient phone calls should be aware of potential adverse effects in need of immediate attention. Develop protocols for patient triage/management.

3. Navigating financial challenges for these high dollar agents.

  • Reimbursement concerns with new-to-market agents. Assign a dedicated financial or reimbursement staff to focus on immuno-oncology agents who are familiar with manufacturer programs, co-pay foundations, and patient assistance programs.
  • Off-label use may cause reimbursement concerns. Need a policy in place to ensure best practice with off-label use, with patients being kept well informed on financial challenges with reimbursing off-label use.

Griffith pointed out that their cancer center moved reimbursement specialists to their pharmacy department to handle high dollar approvals and they also developed a work flow to ensure a smooth process for both on-label and off-label immuno-oncology agent use—a staff-intense process that would need additional hands on board. Several oncologists attending the session pointed out that this would be a difficult proposition for an already resource-stretched community oncology practice.

“Payers need to keep up with accelerating evidence-based new indications,” said Griffith. She believes that as market place competition increases, payers may include step therapy in precertification requirements to specify preferred agents.

During a subsequent panel discussion, Spencer Green, MS, MBA, business operations manager, Bozeman Deaconess Cancer Center, said, “By entering into alliances with organizations like the ACCC, community centers can gain access to experts for the necessary information on these novel treatment options. Company sales representatives are an additional resource to understand the program—it can help avoid back end issues with billing and reimbursement.” This can also prevent delays in patient access to care he added.

Steve D’Amato, BSPharm, BCOP, executive director, New England Cancer Specialists, and current president of ACCC, insisted on including payers in the conversation. “We have a good relation with our payers,” he said. “We have shared some of our data with Anthem on new therapies, cost implications, and what we are doing as beneficiaries. Both Aetna and Anthem have been quite supportive of the programs in place at our clinic with these agents.” Keeping payers informed on policies being devised at our institutions and clinics can have a huge impact on reimbursement and can also help payers understand the challenges we face with using these agents, added D’Amato.