Cancer: The Next Frontier in Chronic Care Management
As with care for any chronic condition, the goals for advanced oncology therapies should be improving outcomes, containing costs, and increasing medication adherence.
SIGNS POINT TO CANCER becoming a chronic condition in the near future.
According to a study by Wei Zheng, MD, PhD, and others, published in the Journal of the American Medical Association as reported by Reuters in 2015, “For men and women ages 50 to 64, who were diagnosed in 2005 to 2009 with a variety of cancer types, the risk of dying from those cancers within five years of diagnosis was 39 to 68 percent lower than it was for people of the same age diagnosed in 1990 to 1994, researchers found.”
Increasing survival rates are a leading indication that the future of cancer treatment may start to mirror the treatment of chronic conditions. Such a shift will have massive effects on payers, and will accelerate incredibly difficult conversations and decisions about the value of extending life. Oncology patients on new immunotherapies are demonstrating 3- to 5-year survival rates and 30% remissions.
However, not nearly enough is known about when it is safe for many patients to stop treatment. There exists a massive difference for the continuum between paying $120,000 or more for 1 year of therapy with 6- to 12-month survival rates for cancer patients compared with the same $120,000 per year for an indefinite number of years as treatment efficacy grows.
According to an article by Alice Park in the April 4, 2016 edition of Time, there are currently 3400 ongoing immunotherapy trials in the United States. As reported in late March by the Washington Post, Michael Bloomberg and others recently gave $125 million to Johns Hopkins University for a new institute focused solely on immunotherapy research seeking a cure for cancer.
Concurrent to the growth of immunotherapies for oncology patients, oral oncolytics are also on the rise. But, like a large number of specialty medication therapies, adherence rates are frustratingly low. While many industry experts believe the future of oncology drugs are infused immunotherapeutics, oral oncolytics represent about 50% of oncology drugs currently in use and about 25% of drugs in the pipeline.
Oral oncolytics are convenient for patients who do not have to travel to their oncologist for a session in the infusion chair, and they can be a psychological boost due to the commonality of oral medications. However, that convenience ends with the patient. The physicians no longer have eyes on the patient to assess their condition, and they do not know about true levels of compliance to therapies that can have toxic, swift side effects.
Patient care is further impacted by the financial offset that is absent when physicians cannot bill for infusion time to support the funding of critically needed staff to ensure adherence. Overall adherence to oral oncolytics is in the neighborhood of 50%. There is evidence that suggests for some groups, adherence rates are much, much lower.
As long as immunotherapy requires infusion, the payment responsibility remains, for the moment, on the medical side. This provides the opportunity for oncologists to have close eyes on patients. But oral immunotherapeutics will eventually enter the market; what then?
Payers and pharmacy benefit managers run the greatest risk of bearing the brunt of the financial burden, as cancer shifts toward a chronic condition treated increasingly by oral oncolytics, and eventually, oral immunotherapies. The consequences for payers could be enormous.
If cancer treatment trends toward HIV or hepatitis C, we will see a slew of combination therapies while the industry works steadily towards a 1-pill, once-a-day treatment. If adherence were to remain in the 20% to 50% realm, it would be disastrous for all concerned, and lead to significant increases in the existing $100 billion to $300 billion in wasted health care spending due to medication nonadherence.
What’s Needed to Prepare: A Hard Look at the Chronic Care Management Team
As with any chronic condition, the goals for advanced oncology therapies should be improving outcomes while containing costs, reducing drug waste, and increasing adherence rates. What will be needed is a holistic approach to chronic care management with clinical pharmacists playing a larger role within the entire team.
As we have seen in multiple studies for patients with difficult-to-treat chronic conditions, such as HIV and hepatitis C, enhanced medication therapy management protocols, led by clinical pharmacists and robust patient support services, accomplish these goals.
For those payers and manufacturers seeking the greatest value for ALL stakeholders, their plan sponsors, shareholders and the patients, there are 3 key tools that must be part of the toolbox.
1. Patient support or assistance
Within the pharmaceutical realm, patient support or patient assistance is traditionally defined as financial or copay assistance. Due to the shift in burden away from the medical coverage afforded to oncology drugs administered within the providers’ facilities, manufacturers are going to have to provide traditional financial assistance for oral oncolytics in order for patients to gain access.
Similar to myriad treatments for chronic conditions such as HIV and hepatitis C, this will remain a necessary provision from manufacturers, as cancer becomes a chronic condition.
2. Patient education and counseling
These 4 commonly used words in the pharmaceutical realm describe adherence support, as our team knows it. Continuity of the person providing support is key here.
Far from a call center experience, dedicated patient care coordinators who speak with the same patient on a frequent basis, generate trusting relationships during the time a patient is not in their physician’s or oncologist’s office.
Gathering and archiving data, especially as it relates to lifestyle and barriers to adherence, provides a level of understanding and the ability to influence adherence and outcomes for chronically ill patients that lie with no other member of the patient services or care management team.
3. Improved sharing of information
Providers tell us that patients frequently start therapies when they want and stop when they want. This does not work for any health care stakeholder.
Adherence to medication protocols is paramount to their efficacy. Physicians should be alerted when refills are requested and shipped.
As value-based contracts for high-cost therapies between payers and manufacturers proliferate, not only does agreement upon outcome metrics become critical, the acquisition of data points and sharing of information among chronic care team members becomes critical. Every member of a cancer patient’s care team should have visibility into the factors that influence access, adherence, and outcomes. SPT
is chief operating office for Curant Health, a provider of enhanced medication therapy management and specialty pharmacy services proven to improve patient outcomes and reduce total health care spending. Marc is also a board member of the Team Type 1 Foundation, an organization whose mission is to “instill hope and inspiration for people around the world affected by diabetes.”