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Collaborative Initiatives Aim to Improve Care for Patients with Multiple Myeloma
San Diego—Changes in the evolving healthcare environment are focusing on greater cooperation between providers and payers to improve quality of care while reducing cost. During a satellite symposium at the AMCP Specialty Pharmacy Conference, a panel of experts discussed managed care strategies for collaborating to improve care for patients with multiple myeloma (MM). The symposium was supported by educational grants from Celgene Corporation and Takeda Oncology.
David H. Vesole, MD, co-chief and director of research of multiple myeloma, John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, opened the session by highlighting several updates to the treatment of, and emerging therapies for MM from current practice guidelines. Appropriate therapies have led to a nearly doubling of the survival rate in patients older than 65, he said, citing data showing a 5-year survival of 31% in 2001 to 2005 compared to 56% in 2006 to 2010 in these patients [Leukemia. 2014;28(5):1112-1128].
Since 2010, a number of additional agents have been approved by the FDA expanding the options for MM treatment. Among the issues emerging from the use of these new therapies, is the choice of treatment and length of treatment for newly diagnosed patients with MM who are ineligible for stem cell transplantation. Dr. Vesole cited data from the first trial to compare lenalidomide/dexamethasone as either continuous therapy or given in 18 cycles along with a comparison with the drug regimen melphalan, prednisone, and thalidomide. The improved progression-free survival with continuous treatment shown in this trial established continuous treatment as the standard, he said.
Dr. Vesole also mentioned a recent trial showing impressive efficacy and acceptable toxicity with the drug combination pomalidomide/bortezomib/dexamethasone given at the maximum tolerated dose, as well as data from a large international trial (PANORAMA-1) that provided the evidence on which the FDA approved panobinostate for treatment of relapsed refractory MM was based.
Given all the new treatment options and emerging therapies, developing collaborative pathways to reduce treatment variability and improve outcomes in MM was also addressed.
Clinical Pathway Initiatives
“Clinical pathways-based initiatives condense an expansive menu of treatment options from consensus guidelines into a concise decision-support tool,” said David Frame, PharmD, assistant professor of pharmacy, clinical hematology/oncology and bone marrow transplant specialist, University of Michigan Health System, Ann Arbor, MI.
Saying that clinicians and administrators largely support guideline-based decision- support tools, he stressed that pathway programs are gaining popularity for a number of solid tumors and select hematologic malignancies, including MM. Dr. Frame cited several examples of current programs, emphasizing that pathway programs should focus on both payers and providers. “Providers are more likely to use pathway models that can be integrated into their electronic medical record system and that address relevant cancers,” he said.
A benefit for both payers and providers, he said, is the use of platforms with web-portal access or other integrated options that offer decision-support and real-time claims adjudication.
Dr. Frame said that whether providers will use pathways depend on a number of still-to-be-answered questions. These include whether (1) pathways address cancers that are relevant to oncologists’ practices; (2) providers can participate in developing specific pathways; (3) providers can access pathways in real-time for decision support; (4) specific pathways align with guidelines that providers currently use; (5) clinical tools such as imaging studies and biomarker assays are included in the pathway; (6) participation is mandatory; (7) a reporting feature is included to help providers track progress and compare performance; (8) the cost of specific therapeutic options in the pathway; and (9) what happens if a provider opts for a therapy not in the pathway for a particular patient.
James Kenney, Jr., RPh, MBA, manager, specialty and pharmacy contracts, Har- vard Pilgrim Health Care, Wellesley, MA, concluded the session discussing how to attain provider buy-in for management interventions and specialty pharmacy services.
Saying that oncology networks are often involved in decision-making regarding clinical pathways and similar initiatives, Mr. Kenney emphasized the need to make sure that clinical pathways for oncologists are reasonable to the oncologists and oncology community.
Along with clinical pathways, other current issues in provider relations, include fee schedules and reimbursement (eg, less favorable reimbursement arrangements for injectable cancer therapies have affected profit margins); sites of care (eg, administration of treatment in a facility vs provider’s office is becoming more prevalent); route of drug administration (eg, opportunity for revenue from infusion eliminated by oral therapies); and politics and other network issues (eg, need to keep oncologists satisfied by how oncology networks are managed to ensure attractiveness of health plan to potential members).
“Comprehensive care strategies that incorporate case and medication therapy management initiatives offer an opportunity to improve care and mitigate risk,” he said.—Mary Beth Nierengarten
