The challenges for specialty pharmacists that offer comprehensive services in oncology are great. Here's how our columnist sees the problems and opportunities for community specialty pharmacists.
Cancer is the overgrowth of abnormal cells. It is a term we give to a large group of diseases that vary in type and location. As a community specialty pharmacy, we see firsthand the overwhelming complex feelings and lifestyle changes that follow a cancer diagnosis. This disease creates a great number of physical, emotional, and financial challenges for the patient, their family, and their friends.
Specialty pharmacies that offer comprehensive services to oncology patients also face many challenges. Besides the minimum array of clinical services offered—side effect management, compliance and adherence, and coordinating management with physicians—a specialty pharmacy must offer prior authorization, billing and reimbursement, and patient assistance programs. This arena has significant reimbursement challenges. Before a specialty pharmacy can help an oncology patient be compliant, it must make sure a patient can afford the medication. The pharmacy must navigate the coverage restrictions for the medication(s) prescribed. For example, a drug may only be covered if multiple agents are prescribed at the same time, a specific diagnosis is indicated, and in the case a drug is covered by Medicare Part B or Part D, an assessment must be made. More importantly, what manufacturer assistance programs are available?
An almost daily occurrence in our specialty pharmacy is the false sense of accomplishment when a prior authorization for an oncology medication is received. We consider assisting and obtaining the prior authorization step 1—and the easiest in our oncology offerings. When the prescription is processed and the patient has Medicaid Part D, we find out that the copay is thousands of dollars. Now the real challenge begins.
Initially, all the manufacturer copay assistance programs cannot be used to reduce the copay because these programs are not valid if a patient has a federal or state funded insurance (eg, Medicare, Tricare, or Medicaid). Now the patient must rely on foundation or manufacturer assistance programs, but these have income restrictions. If the patient does qualify for the manufacturer assistance, then the prescription is usually sent directly to the patient.
Although we still try to provide clinical management and adherence programs for these patients, it becomes extremely difficult because of the lack of communication between the assistance program and our pharmacy. The complexities of the medications and the underlying disease cause frequent dose adjustments and breaks in home therapy due to hospital admissions and stays. Sadly, the patients sometimes experience gaps in receiving their treatment because of the restrictions in the manufacturer dispensing program. For me, this is perhaps the most frustrating aspect of being a specialty pharmacist.
How can we go through health care reform and not address the copay for cancer patients with Medicare? Why isn’t there a better system in place to provide the best level of care and outcomes for our patients without placing all the hurdles of coverage restrictions, limited distributed programs, and mandated mail order fulfillment?
There are more than 1.5 million new cases of cancer diagnosed each year in the United States alone. These patients and their loved ones will inevitably experience the complex effects of this disease—and the sense of urgency to get the medication is always in the forefront of their minds. Community specialty pharmacies have a great opportunity and responsibility to provide all the necessary services needed for the patient to obtain the best possible outcome.
The fact that we can provide the immediate availability of these medications is an invaluable asset. However, we need to ensure that the manufacturer, payer, and PBM are like-minded with the same priority on the patient. Every day we hear statements such as this from oncology practices: “We sent a referral into a specialty hub and we have no idea why the patient has not received their medication.” Community specialty pharmacies are a viable alternative in providing excellent care for oncology patients. Manufacturers should choose specialty pharmacies for these hubs based on quality of care—and not only number of covered lives. SPT
About the Author
Nicholas Karalis, RPh, is a specialty pharmacist and co-owner of Elwyn Specialty Care, which offers specialty pharmacy services in HIV, oncology, hepatitis C, multiple sclerosis, rheumatoid arthritis, Crohn’s disease, psoriasis, and other areas. A leading voice in community pharmacy, he is a founding member and board member of the Community Specialty Pharmacy Network (CSPN), as well as a board member of the Cardinal Health National Home Health Care Advisory Board. Mr. Karalis is an editorial board member of Specialty Pharmacy Times.