Advances and Best Practices in the Utilization of Novel Agents in Metastatic Breast Cancer - Episode 6
Medically Integrated Dispensing Service Best Practices
Michael Reff, RPh, MBA, highlights best practices for managing oral oncolytics within a medically integrated dispensing service.
Joyce O’Shaughnessy, MD: The other thing is, of course, the monitoring. Is it working? How long is it going to work for? Unfortunately, people need a change in therapy. That timing is quite variable and different factors go into that. But if somebody has already received a refill and their disease has progressed, again, that’s another area of waste, right?
Michael Reff, RPh, MBA: Right.
Joyce O’Shaughnessy, MD: And the medically integrated pharmacy team can look at scans, results, and markers, for example, right?
Michael Reff, RPh, MBA: Yes. We do that. Whether it’s breast cancer or prostate cancer, based on the indication and based on the package insert and information that you glean from journals, you know what that expectation might be for a patient who starts a therapy. But as you mentioned, that’s one thing to keep in mind. Obviously, you go right to the EMR [electronic medical record] and you can see when a scan is coming up. Or you see the markers and you make a determination. But things may not be looking like they’re going well. We may need to make another decision on a drug holiday due to adverse effects, or switch therapies. The medically integrated team at the practice does do that—taking waste and cost off the table and doing what’s right for the patient and the payer.
Joyce O’Shaughnessy, MD: Incredible. The savings strike me as enormous.
Michael Reff, RPh, MBA: Yes.
Joyce O’Shaughnessy, MD: I was even thinking about with IV [intravenous] therapies with the use of hematocrit growth factors, for example. Pharmacists are experts with these things. They can see the pattern. The nurses and the physicians in the practices are very, very busy. We obviously do the best that we can. But there is always fine-tuning that can be done. So I can see the cost savings of this. Obviously, we should do more and more of this.
Michael Reff, RPh, MBA: Yes.
Joyce O’Shaughnessy, MD: Can you speak a bit about how the integrated pharmacy team might be able to help patients with access? I know it’s a complex area, with co-pays, co-pay cards, vouchers, and foundations. It’s quite complicated. There are a lot of practice resources to track. Does the integrated medical team get involved with this too?
Michael Reff, RPh, MBA: Yes, absolutely. One of the best practices that we had at the practice that I was at, and what I’ve seen at several NCODA [National Community Oncology Dispensing Association] practices, is developing a process flow. It starts with a prescriber initiating a prescription, ultimately ending or culminating in the dispensing of that prescription. It includes all of the folks in between—internal and external stakeholders that interact with that prescription, so to speak, from concept or writing the prescription, electronically, certainly, to the dispense. What does that look like and who touches that prescription? And how does that affect the outcomes at the dispense? We have this idea that when you do have the opportunity to dispense an oral oncolytic to a patient, you minimize or eliminate every single surprise. Right?
So we talked about education, but we also mentioned financial toxicities. When our patients come to the window to pick up their prescription, they already know that they have a co-pay of $800. Yet, our medically integrated team, based on training and our mission, have looked for foundation support or have found a co-pay card, if they’re a commercially insured patient. And so, we’ve scoured and looked under every rock possible for financial assistance to eliminate the financial toxicities that are associated with oral oncolytics. Plenty of studies show how adherence diminishes when co-pay allegations go up, right?
Joyce O’Shaughnessy, MD: That is a complete barrier. It’s basically a no-go.
Michael Reff, RPh, MBA: Exactly. And so, what we’ve done across the NCODA network is emphasize the importance of looking for financial assistance to the folks who are a part of this process—the oral oncology nurse, or the pharmacy technician, or the pharmacist within that space. Then we track that financial assistance. At the end of the month, or at the end of the quarter or year, we know how many millions of dollars we’ve supported our patients with to help them be eligible for treatment and to try to eliminate the financial toxicities so that they can start a life-enhancing or life-extending therapy.
Joyce O’Shaughnessy, MD: Yes, that’s really good. It’s complicated. Plus, the patient knows who to call.
Michael Reff, RPh, MBA: Exactly.
Joyce O’Shaughnessy, MD: They can call the nurse navigator if they run into trouble, or if their financial situation changes, or if their insurance changes. This is important so that they’re not going to be without their therapy. Well, there are an amazing number of advantages here. What is PQI [positive quality intervention]? Why is it important? Are these things getting more mandatory as things go on? How does that relate to the integrated medical pharmacy team?
Michael Reff, RPh, MBA: A positive quality intervention, or PQI, is one of our 4 quality standards. Again, there are 4. Foundational is the first, patient-centered is the second, positive quality intervention is the third, and then health information technology is the fourth. As I mentioned earlier, the quality standards are a roadmap or a framework for practices to be more medically integrated when we’re referring to oral oncolytics. And positive quality intervention, quite simply, is a concise formula or stepwise procedure.
The positive quality intervention is a quality standard that is an education and communication platform. There are 2 elements to the PQI—education and communication. What we’re doing is trying to educate, in a concise format, all of the internal stakeholders who are responsible for patients who are receiving oral therapies. NCODA has developed close to 20 positive quality interventions and we’re working on more. We have a committee that works on these positive quality interventions. Again, it’s an education and a communication platform to help elevate the standard of care within the medically integrated pharmacy team.
Joyce O’Shaughnessy, MD: Can you provide some examples?
Michael Reff, RPh, MBA: One of the first examples I can think of for a positive quality intervention occurred about 4 years ago when the first CKD4/6 [cyclin-dependent kinases 4 and 6] inhibitor was approved. When a pharmacist within the medically integrated team receives a prescription for an aromatase inhibitor, so to speak, they may ask themselves a question. They may say, “Is this patient eligible for a CKD4/6 inhibitor?” They know that one was just approved a week ago or a month ago, but the drug is relatively new to the market. There is so much going on within the practice. If you are a practice that does not have specialists who just treat breast cancer, as an example, you may not be aware that a week ago this new life-enhancing, life-extending therapy was approved.
So practices will take the time, utilizing electronic medical records, to say, “Hey, is this patient ER/PR [estrogen receptor/progesterone receptor]-positive? Are they HER2 [human epidermal growth factor receptor 2]-negative? Are they metastatic? Do they hit these kinds of criteria?” And so, we’ve documented those bullet items. This goes back to 4 years ago, but that was the first PQI. The light bulb went on and we said to ourselves, “It’s incumbent upon us to not just fill the aromatase inhibitor.” You could do that. You could fill the aromatase inhibitor prescription and send the patient on their way. But it’s really incumbent upon the medically integrated team to go 1 step further to check and see if the patient is eligible for this or that. They may not be eligible, and that’s fine.
Joyce O’Shaughnessy, MD: But it never hurts to raise the question.
Michael Reff, RPh, MBA: It doesn’t.
Joyce O’Shaughnessy, MD: That’s incredible. I could never be a general oncologist. I can barely keep up with breast cancer. It is a huge issue.
Michael Reff, RPh, MBA: Right. And so, that’s the importance of the quality standards. They help elevate our game with the oral oncology nurse, the pharmacy technician, the financial counselor, and the pharmacist. We are taking a look at all of the elements that make the patient’s journey on oral therapies better.