Difficulties of the Multiple Myeloma Treatment Continuum

Peter Salgo, MD: All right, let’s bring this to an obvious question. Is that a good idea? Shouldn’t there be centers of excellence for multiple myeloma? Shouldn’t people who have this disease see people like you?

Noa Biran, MD: I think they should.

Peter Salgo, MD: You see about a trillion of these per day, and not the lone physician out there in the wilderness somewhere.

Noa Biran, MD: I do.

Peter Salgo, MD: Is that best practice?

Noa Biran, MD: Yes, I think patients get better care when they’re seen—and this isn’t just my opinion, this is a fact—patients live longer when they’re seen by specialists. Now those community oncologists, I have all the respect in the world for them. They walk into a room and they see breast cancer, colon cancer, MDS [myelodysplastic syndrome], thrombocytopenia; they see every disease and they have to know a little bit about every disease. I only have to worry about 1 disease. But I think if you’re only seeing 1 patient a year with a disease, as a physician, you probably should at least refer them and have a second opinion from somebody who’s a subspecialist.

Peter Salgo, MD: Let me then throw this model out there. From a payer’s standpoint and from a provider’s standpoint, we have a certain number of real experts in multiple myeloma. These are centers of excellence. They could, if everybody went to them, they pay for their airfare, they could see enough patients that they could do in-office dispensing in a cost-effective way. They could be certified by the third-party payers, they could be certified by the manufacturers. Would this be the best-case scenario for patients with multiple myeloma?

Noa Biran, MD: I don’t know if it would drive down cost.

Peter Salgo, MD: Cost, yes, maybe. But what about patient care? Would that be better?

Noa Biran, MD: I think it would be more efficient in that patients would get their drugs immediately. We have to usually give patients other treatments until we get our hands on the IMiDs [immunomodulatory drugs].

Peter Salgo, MD: So what you’re telling me is that one of the advantages of in-office dispensing is you have the drug and you can get it today, you don’t need this prior authorization.

Cheryl Allen, BPharm, MBA: You can’t get that drug today.

Peter Salgo, MD: Not even if she can.

Cheryl Allen, BPharm, MBA: You’re not going to give that drug today.

Peter Salgo, MD: Really?

Cheryl Allen, BPharm, MBA: No. That drug, that’s $15,000 sitting on the shelf. You’re going to make sure the payer’s going to pay for it before you give that drug.

Peter Salgo, MD: But if your office prescribes that every day, all the time.

Noa Biran, MD: No, you need to get a prior authorization.

Cheryl Allen, BPharm, MBA: Specialty drugs are going to require prior authorization. I think though, getting back to your point, anything within the overall system that we can do to help support the continuum of care and the collaboration between the health care providers would help. Some of the specialty pharmacies have online portals that the prescriber or the physicians can come into, they can see all of the track of what’s happening with their patients within the system. Who’s gotten filled, who’s still waiting on a prior authorization, who may for whatever reason be in appeal; all of that is out there for the prescriber office to see.

Peter Salgo, MD: Who pays for that portal?

Cheryl Allen, BPharm, MBA: The specialty pharmacy is the one funding that.

Peter Salgo, MD: We keep coming back to the specialty pharmacy. The more we hear about the specialty pharmacy, the more absolutely critical it seems to be to this process.

Cheryl Allen, BPharm, MBA: Well, with respect to the portal, when you think about it you’ve got a portal where all of the interaction is electronic. There’s a click-to-chat function, so you’re not tying up the phone; you’re not getting someone in her office on the phone who takes 20 minutes to grab the chart.

Peter Salgo, MD: Oh, she’s got plenty of people on the phone, don’t worry about it.

Cheryl Allen, BPharm, MBA: Here you’ve got a click-to-chat feature and you can resolve something, you can answer the chat in 5 seconds and then resolve an issue in 20 minutes, when it would have taken a day and a half.