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Addressing Oncology Specialty Drug Management
San Diego—An important sector of specialty pharmacy is oncology. Oncology drugs rank second to cardiovascular drugs in terms of overall drug spend. Given the prevalence of varying types of cancers and the emotional and financial burdens many patients face, special attention is required when managing these agents from a managed care perspective. Oncology specialty drug management was the focus of 2 sessions at the AMCP Specialty Pharmacy Conference.
“We are really facing a challenging time,” said Rowena N. Schwartz, PharmD, BCOP, vice president, clinical content and pharmacy operations, McKesson Specialty Health, who addressed attendees during the first session. “We have more and more patients receiving cancer care” due to the aging population and more newly insured patients under the Patient Protection and Affordable Care Act.
Many of the challenges are directly related to the advances and evolution of cancer care in the United States. “Cancer is becoming more of a chronic disease with all of the different options of care,” she said. “With that transformation [in care] comes an increase in cost.”
Cancer Care in the United States
Dr. Schwartz provided an overview of cancer care in the United States highlighting the American Society of Clinical Oncology (ASCO) recent report titled The State of Cancer Care in America: 2015 [J Oncol Pract. 2015;11(2):79-113]. According to the ASCO report, there is a wider array of treatment options now available for many cancers. In 2014, the FDA approved 10 new treatments, and also approved 4 new medical devices and tests that may improve patient outcomes through early detection of cancer. In addition, more than 700 cancer therapies are in development. The report also points to growing challenges to high-quality care delivery including growing cancer care demand, disparities in access to cancer care persist, and the potential for the oncology workforce to be outpaced by growing demand.
Cancer care is a balance of cost and outcomes. Value in cancer can be de- fined as cost divided by benefit, said Dr. Schwartz, citing a study by Danielson and colleagues [J Natl Compr Canc Netw. 2010;8(suppl 7):S28-S37]. In a separate study, researchers looked at data on the incidence and survival from the Surveil- lance, Epidemiology, and End Results database and linked to Medicare records to estimate the cost at initial, continu- ing, and final phases of cancer care for common cancer. Models were used to project total cost of care through 2020. The researchers found that changes in US population were projected to result in a cost increase of 27% by 2010 [J Natl Cancer Inst. 2011;103(2):117-118]. “We have far exceeded this cost at this point,” she said.
In 2010, ASCO published a guidance statement on the cost of cancer care to provide a concise overview of the economic issues facing stakeholders in the cancer community and outlined steps to address immediate needs. [J Clin Oncol. 2009;10(27):3868-3874]. Stakeholders need to find ways to reduce the cost of care without bankrupting the healthcare system. Dr. Schwartz referenced an article by Smith and colleagues published in New England Journal of Medicine [2011;364(21):2060-2065] that offered 5 changes in medical oncologists’ behavior and 5 changes in their attitudes and practice that may help bend the cancer-cost curve downward (Table).
She noted that treatment pathways are beneficial but that cancer treatment guidelines do not provide a clear picture of what course of treatment to follow. “There is no single formula for pathways but cost plays a factor,” said Dr. Schwartz. “Pathways are only as good as the practitioners understanding and implementing them.”
“I worry about the future of cancer, especially due to market trends,” said Burt Zweigenhaft, BS, vice chairman, Onco360. Data from the American Cancer Society found that the lifetime probability of developing cancer in men andwomenwas 1 in 2 and 1 in 3, respectively.
The market is hitting a critical inflec- tion point, which he labeled “financial toxicity.” The cost of the oncology treatment spend is projected to grow to $130 billion by 2020. Almost 40% of drugs in development are oncology medications; and 90% of oncology drugs approved in the past 5 years cost $20,000 for a 3-month cycle.
He said the oncology marketplace needs flexible service options to address different stakeholder needs (eg, man- aged markets, employers, oncologists, patients, etc). Drug benefit management is a universal problem for all oncology stakeholders due to the complexity of drug dispensing and navigation of mul- tiple benefits and silos.
Pharmacists can be key players in helping reign in cancer costs. “Pharmacists have to get more involved in driving cost down in the system as well as health plans,” he said, noting that board certified oncology pharmacists are important to have because they can help fill the gap with the projected oncologist shortage.
Payer Perspective
During the second session, Debbie Stern, RPh, senior vice president, strategy and business development, medical oncology and specialty drugs, CareCore National/MedSolutions, and Mike Ellis, BSPharm, corporate vice president, spe- cialty pharmacy and infusion, Walgreens, outlined the challenges with oncology care management, payer management strategies, and the role of specialty phar- macy to improve clinical support and patient care.
There are 2 views of current cancer care, according to Ms. Stern. The 2013 Institute of Medicine report said that the cancer delivery system is in crisis and is often not patient-centered, evidence-based, and coordinated. ASCO’s 2014 report on the state of cancer care identified physician shortages, threats to community practices, and soaring costs. “Cancer care is very fragmented,” she said, for example, pa- tients go from 1 doctor to another and care is not evidence-based.
Payers identified a variety of complex specialty drug management challenges, according to the EMD Serono Specialty DigestTM, 11th Edition highlighted by Ms. Stern. Of the survey respondents, 79% cited managing oncology and 66% cited determining value of therapy as the top 2 challenges. The report also found that the top specialty drug management goals focus on quality and cost management.
She also reviewed ways to manage drug spend for acquisition cost and clinical and utilization management. Mechanisms to manage drug cost include modify provider reimbursement, redirect site of service, and use partial fill programs. Strategies to manage clinical and utilization manage- ment involve prior authorization, clinical pathways, and adherence programs.
Role of Specialty Pharmacy
Specialty pharmacy lives at the intersection of key stakeholders in oncology care, according to Mr. Ellis. “We’re sitting in the middle of a very dynamic oncology marketplace,” he said.
Specialty pharmacy programs should be designed with patient experience in mind. Specialty pharmacy data and analytics can be leveraged to better un- derstand effectiveness of programs and avoid wasted therapy. He said payers are choosing to expand their offering toward high touch, convenient access to expert specialty pharmacy care.
Mr. Ellis also discussed the evolution of the specialty care model, describing the ideal special pharmacy model as an integrated, flexible, and efficient model serving specialty patients on their terms. He also identified the goals of Triple Aim, the Institute for Healthcare Improvement initiative that focuses on improving the patient experience of care, improving the health of popula- tions, and reducing the per capita cost of healthcare. The goals include:
• Improved clinical outcomes through adherence, clinical management, and patient education and support
• Decreased overall healthcare costs through care management
• Increased patient satisfaction through engagement and tailored support
He reminded attendees, “Beyond the pill, beyond the pathway—is a patient.”—Eileen Koutnik-Fotopoulos
