Pearl 4: Using a Collaborative Care Plan for the Treatment of MM

2019-07-11 18:07:00
Tags: Practice pearls,specialty pharmacy



Peter Salgo, MD: How long does it take for you to get a prior authorization for a patient, typically?

Noa Biran, MD: 48 hours.

Peter Salgo, MD: That’s not bad, really.

Noa Biran, MD: I don’t think anybody is like that in the community. You know, that’s with all the staff that helps to obtain it.

Peter Salgo, MD: I was going to say, what are the staff? Describe your staff.

Noa Biran, MD: I would say most oncology practices take about a week.

Peter Salgo, MD: All right, but describe your staff. What are the functions you’ve got on staff?

Noa Biran, MD: First of all, we all sit together, so it’s extremely efficient.

Peter Salgo, MD: Big room?

Noa Biran, MD: Yes, a big room, 2 sleeves. We all talk immediately, but we have a woman who does only IV [intravenous drugs with] prior authorization. We have 1 person who does only imaging with prior authorizations. We have 1 or 2 women or men who do oral drugs with prior authorization.

Peter Salgo, MD: It sounds like an army.

Noa Biran, MD: It is an army.

Peter Salgo, MD: Is it the best use of our health care dollars to require this huge staff to do this? Honestly?

Cheryl Allen, BPharm, MBA: Well, we are supporting appropriate utilizations, so that’s for sure. And to the point of 48 hours, that’s like, you know, that’s a great time.

Peter Salgo, MD: Sure it is.

Cheryl Allen, BPharm, MBA: And I think in oncology, what most payers want to see is an on-label indication.

Noa Biran, MD: Right.

Cheryl Allen, BPharm, MBA: And then what other qualification, you know? Is there genetic testing or some other type of qualifier for that patient? Have we appropriately supported that patient with all the documentation? And I will tell you, the majority of the time, it’s taking 7 days, 10 days, 14 days—the first authorization doesn’t have enough documentation to support it, so the payer denies it.

Peter Salgo, MD: So what you’re saying is most offices do a terrible job with the paperwork.

Noa Biran, MD: We also have people who check our notes to make sure that all the documentation is proper.

Peter Salgo, MD: Again, you’re massaging paper here.

Noa Biran, MD: More people to do massaging.

Cheryl Allen, BPharm, MBA: Yes.

Peter Salgo, MD: I mean, I understand that you need documentation, but—I’m going to ask a really unfair question, so here it comes—is it more important to take care of the patient or the paper?

Cheryl Allen, BPharm, MBA: Well, obviously the patients.

Peter Salgo, MD: Thank you.

Cheryl Allen, BPharm, MBA: Obviously the patient. But the payer is the one footing the bill, and these today are the payer requirements.

Peter Salgo, MD: Is every piece of paper—and this is an archaic form—is every key click that the third-party payer requires equally important? Is there some of this stuff you could just ditch?

Noa Biran, MD: I mean, it’s getting more and more. We spend the majority of our day clicking on a computer and looking. When we go into a patient room, you should see: We have to have a nurse who’s only clicking, clicking, clicking, clicking. She doesn’t even look at the patient.

Peter Salgo, MD: I’ve seen this.

Noa Biran, MD: She doesn’t even, or he doesn’t even, make eye contact with the patient. And I’ve been at centers, academic centers, where there’s no time to even look at the patient, and they bring the computer in the room, and the physician is sitting in front of the computer going like this. [Looks at computer and demonstrates clicking.] Did you have this? Did you have that?

Peter Salgo, MD: I’ve seen this too, and it’s not just oncology.

Noa Biran, MD: And they don’t; it’s terrible.

Peter Salgo, MD: It’s not just oncology, right?

Noa Biran, MD: It’s terrible. We don’t bring our computer in the room because it’s just…

Peter Salgo, MD: But have you ever seen?

Noa Biran, MD: We hire a person to do that for us.

Peter Salgo, MD: Have you ever seen a housecleaning and documentation?

Noa Biran, MD: Uh-huh.

Peter Salgo, MD: Where a third-party payer says, “You know, we took a look. We don’t need a third of this stuff. Get rid of it.” Or is it, “I want a third more.”

Cheryl Allen, BPharm, MBA: I actually have.

Peter Salgo, MD: Really? Where?

Cheryl Allen, BPharm, MBA: I actually have. There are payers who are continually monitoring the prior authorization and the utilization-management process to see where they are wasting resources. And if there’s a drug category that they’re approving 90%-plus, then they’re going to step that down hopefully, right? If they’re very cognizant payers.

Peter Salgo, MD: What percentage of the patients that you apply for get approved, eventually?

Noa Biran, MD: I would say most.

Peter Salgo, MD: So more than half?

Noa Biran, MD: Yes.

Peter Salgo, MD: Is it 90%?

Noa Biran, MD: No, I would say 70%, 80%.

Peter Salgo, MD: So where’s your critical cutoff? Dr. Allen said 90. Dr. Biran said 70. What about 80? What about 75 at that point? Let’s get rid of some of this.

Cheryl Allen, BPharm, MBA: Yeah, well at least, you know, still you’re working with individual payer organizations, and I can say that the better that the staff who’s working understands the payer mandates, the payer mandates make sense. You know?

Peter Salgo, MD: To payers.

Cheryl Allen, BPharm, MBA: No, really. At the end of the day it’s appropriate utilization.

Peter Salgo, MD: OK.

Cheryl Allen, BPharm, MBA: And if we are supporting appropriate utilization, then the drug product is paid for the majority of the time. Where we need to do our diligence, and where we’re, you know, running into a wall, is when we have a patient who we’re advocating for appropriate utilization, but it’s not meeting the payer requirements.

Peter Salgo, MD: All right, let me ask you kind of a meatball question here. You get a script. What is the best practice? How could you best ensure this—from the provider first—that you’re going to get this drug, whatever that drug may be, into the patient’s hands as quickly and efficiently as possible?

Noa Biran, MD: You first get the patient to sign the script, to…give you your insurance information. Obtain a prior authorization as quickly as you can and enroll the patient into the REMS [Risk Evaluation and Mitigation Strategies] program.

Peter Salgo, MD: OK. And from the payers’ perspective?

Cheryl Allen, BPharm, MBA: I think the pharmacy perspective on this is just to be very cognizant about the authorization timelines with the REMS products, right? So we understand the prior authorizations. We get them done pretty quickly for oncology. I think 1 of the stumbling blocks that we have that is mandated by the FDA is this REMS program, with the agents in multiple myeloma. So that initial authorization for some patients is only 7 days. The others are 30 days, so we have a little bit more time. But for a patient of pregnancy potential, those are the patients who we really have to make sure that it’s like clockwork. The authorization is given. The prescription gets written. There’s a risk category that gets assigned, the prescription comes over, and the fulfillment starts. So it’s a rush to the end on those 7-day authorizations.

Peter Salgo, MD: The job is not done till the paperwork is through.