Medically Integrated Dispensing Services in CLL


The panel of experts evaluate the role of medically integrated dispensing services in optimizing the administration of oral therapy for patients with chronic lymphocytic leukemia.


Troy Trygstad, PharmD, MBA, PhD: I’m going to draw an analogy, and you tell me if it’s a bad analogy. So in the anticoagulant space, warfarin was the standard of care for many, many, many years. And one of the unfortunate things for patients was that they would need to come in and have labs done. But one of the side benefits to that was oftentimes in anticoagulation clinics, because they were coming in, you had frequent contact with the patient and you were looking at other things and you were able to maintain continuity and follow up with them. Is that the same in the oral oncological space now that you’ve got these new agents and you’re releasing the patient? Have you come up with these services for frequent follow-up? Do you have to provide these extra supports because you’re not in front of them as often?

Michael Reff, RPh, MBA: Yes. And what you’re describing and paraphrasing is exactly the medically integrated dispensing service. That’s something that we all embrace at our practices and as an organization. What you just paraphrased is exactly the medically integrated pharmacy-care team model that we like to refer to, in which the right people, processes, and polices are in place and you have to leverage all your internal resources to take care of that patient the same way you would for an IV [intravenous]. You’re doing it for an oral agent. So you’re leveraging the EMR [electronic medical record], you’re leveraging all the health care providers, whether it’s to a physician, to the advanced practice, to the pharmacist, to the financial assistant who is investigating all the co-pay assistance they can provide that patient, or to the pharmacy tech. It’s that whole team approach. And I think somebody here mentioned the multidisciplinary team. It’s the same model but on the oral side.

Troy Trygstad, PharmD, MBA, PhD: Interesting. So a medically integrated dispensing service is this idea in which not only do you need to procure the product, not only do you need to provide the product, but there are also all these services that are typically more frequently on the floors or in the specialty clinic. You’ve got these wraparound supports, patient health care service, medication-support services, but maybe you act as an interesting bridge for the whole profession. Because what you’re saying is, we’ve been in a world in which we’ve had to have this clinical practice with an EMR and labs and follow-up. What’s happened is the manufacturers have innovated, so that now becomes this outpatient pharmacy activity, but we’re going to bring all this stuff that we’ve done as far as clinical practice to this outpatient circumstance. It feels a little like the Trojan horse to me, as somebody who works in a community pharmacy, but that’s really what you’re trying to accomplish. “Hey, we have them here, and we’re providing all these extra supports very necessarily and for all good reasons, but now we’re going to figure out how to extend that beyond the 4 walls of this practice”—medically integrated dispensing service.

Kirollos Hanna, PharmD, BCPS, BCOP: Yes, because, Troy, let me expand and tell you what’s currently happening when you don’t have this medically integrated model. You are sending off a prescription. A large payer is mandating you to send off a prescription to a mail-order pharmacy outside your institution, right? So at that point, when you have sent off that prescription, there’s a disconnect there immediately. You are no longer in control of that prescription. That large mail-order pharmacy will then begin processing that prescription. Whether they have correct contact information for the patient or not, if all the prior authorization paperwork has been completed or not, if they communicate that with the clinic in a timely manner or not—when they actually mail out the prescription to the patient, all these are things that are going to affect adherence, are going to affect initiation of therapy, and are going to affect the overall outcomes for the patient.

So with this medically integrated model—in which you’re able to have the provider communicate to the clinical pharmacist who might be running the oral chemotherapy program, in which an in-house pharmacy is able to dispense the medication—everyone is able to access the electronic medical record, and everyone is able to access the patient’s lab values to make sure that there are no pertinent issues that need to be addressed or drug-drug interactions that need to be addressed or avoided or adjusted. So it’s really an ideal model to provide that optimal care for the patient.

Troy Trygstad, PharmD, MBA, PhD: So that sounds like a medically disintegrated model if you’re breaking that. So if the whole idea is, we used to take care with direct observation, and now with these new therapies, we’re going to extend beyond the 4 walls of the practice and provide these medication-use supports. If that gets cut off, it’s not medically integrated. It’s medically disintegrated, frankly. And so you’re a physician’s assistant who works in the exam room, who has responsibilities there but also in this medically integrated dispensing service. Tell me about circumstances in which you have patients who have disintegrated. What does that look like then?

Christina Patterson, PA-C: Like a big mess.

Troy Trygstad, PharmD, MBA, PhD: OK, what kind of messes occur? I’m that patient, now I’m medically disintegrated, what am I going to worry about?

Christina Patterson, PA-C: Patients received medications before they were supposed to start.

Troy Trygstad, PharmD, MBA, PhD: Sure, I can see that.

Christina Patterson, PA-C: There was miscommunication.

Troy Trygstad, PharmD, MBA, PhD: Same day delivery, right?

Christina Patterson, PA-C: Yes. They set up a delivery. We told them, “Don’t start until you have your class.” But because we worked with all the specialty pharmacists, the mail-order pharmacies took a prior authorization and filled a script off that. They delivered that prescription to the home. The patient was to come in for education class and get their labs that day to start, but they started ahead of time because they’re anxious, they’re scared. They have this diagnosis of metastatic breast cancer. They want to start their medication. They started it. They come in a week later for their class and say, “Oh, I already started.” You check the labs, and they’re all off.

Troy Trygstad, PharmD, MBA, PhD: So you’ve ruined your baseline and your treatment plan.

Christina Patterson, PA-C: Yes.

Troy Trygstad, PharmD, MBA, PhD: So what you’re saying is the United States Postal Service doesn’t come with a care plan?

Christina Patterson, PA-C: Right.

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