October 2012 Edition Vol.11, Issue 10

Can Practices Successfully Dispense Oral Anti-Cancer Agents In-House?

Can Practices Successfully Dispense Oral Anti-Cancer Agents In-House? (continued)

The IV vs Oral Model

The historic model of IV chemotherapy delivery in the office, McAneny points out, resulted from Medicare paying a markup on the drug margin and letting the practices figure out how to administer and manage therapy. Although practices, including hers, still depend on the IV drug margin, the increasing prominence of oral therapies instead of IV infusions has contributed to the instability of community oncology practices. As more oncologists have chosen to work in hospital-based centers to take advantage of the higher payments received by hospitals for their services, McAneny believes that payers will eventually come to realize that it makes more sense to pay community practices enough to manage cancer in the lower cost community setting.

Bruce J. Gould, MD, Medical Director of Northwest Georgia Oncology Centers, imagines that oncologists who have specialty pharmacies will derive more revenue from oral oncolytics; however, drug margins for both oral and IV drugs are disappearing. He is working with some national organizations to find ways of compensating oncologists for taking care of patients that is not dependent on drug margins.

Copays, Parity, and Reimbursement Affect Oral Oncolytics

High copays for oral oncolytics is one of the reasons patients don’t fill prescriptions and community pharmacies don’t stock them.1 Unlike parenteral drugs which usually involve a fixed copay for the drug and its administration, copay for oral agents may involve a percentage of the drug’s costs with no out-of-pocket limit. As of June, 20 states have enacted oral oncology parity laws giving patients equal access to oral as well as parenteral agents.9 Although these laws may be opposed by insurance companies, they don’t necessarily increase costs substantially.2

Jeff Patton, MD, is CEO of Tennessee Oncology and a founder of RainTree Oncology Services, a group purchasing organization that is providing standardized practices for all of their clients to help overcome some of the barriers to in-house dispensing of oral oncolytics. Patton says that Tennessee Oncology “definitely has patients where we choose an IV product over an oral product because financially that’s the best decision for the patient, which is really a shame.” Copay foundations and other programs that help patients with costs exist, but community practices may need to invest time to find these programs for patients.

Pre-authorization requirements by insurance companies can also take up a practice’s time. The problem can be particularly acute for individual physicians who write only a few prescriptions a year for particular agents. Having a specialist in a community practice that helps patients with financial assistance and pre-authorization full-time is likely to be more efficient and productive.

According to Ray Bailey, RPh, Pharmacy Director, Florida Cancer Specialists, the largest private group practice other than US Oncology, they have centralized nurses to do prior authorization for patients, and they take responsibility for patients getting their medication in a timely manner even if the patient goes to a specialty pharmacy. In addition to prior authorization, the practice offers a financial aid support group, copay assistance, and a foundation to fill the Medicare “donut hole.” Mr. Bailey says that his group is developing their own system to improve adherence. When medications are dispensed, it will be recorded in the patient’s electronic medical record, so prescribers will be able to see it. They are also looking at other adherence aids, such as alarmed pill containers, and having pharmacists call to remind patients about refills, and to ask them if they have any issues. The practice also has chemotherapy training classes for all patients. These issues are documented in a defined adherence care plan for each drug and data are updated in both the EMR and the pharmacy system.

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