Payer Barriers, Adherence Challenges, and the Future of ILD Pharmacy: Insights From Kyle Fischer, PharmD, APh

In interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH), pharmacists are often responsible for clinical outcomes even when they are not the dispensing pharmacy. In this second part of an interview with Pharmacy Times, Kyle Fischer, PharmD, APh, a clinical staff pharmacist at Keck Medicine of USC Specialty Pharmacy, discusses how he approaches complex payer dynamics, supports adherence when visibility is limited, and envisions a more connected model of care between specialty pharmacies, health systems, and pulmonology practices.

Q: Prior authorizations, step therapy requirements, and formulary restrictions can vary dramatically depending on which pharmacy is dispensing. How do you navigate those payer dynamics when you're not the dispensing pharmacist but you're still clinically responsible for the patient?
Kyle Fischer, PharmD, APh: Yeah, so I think the biggest example of how I work with this is probably prior authorizations and appeal letters for ourselves here. All of the new specialty prescriptions or antifibrotics that come to our pharmacy—we initiate the prior authorization, and we will take care of an appeal on behalf of the provider. I am involved in almost all of those.

If it is approved, it is approved — that is great. Take the path of least resistance, right? If it is not, then we typically have to write an appeal letter, and that does take some time. So you have to really learn how to navigate: How am I going to get this drug approved for this patient? A lot of it is investigating. You have to deep dive into the chart, and the model now is that we are seeing the newer antifibrotics that we want to start as a first-line therapy for patients. Insurers are not wanting to approve that as a first-line therapy right now.

So we have to think of arguments for why we want to use this first-line, and a lot of that is driven by clinical data—that the drug actually does benefit the patient more as a first-line therapy as opposed to some of our other ones. Sometimes it is the side effects of the older medications—the risk might outweigh the benefits—and that is typically how we can get the newer medications approved.

One thing to mention: we also do have to rely on manufacturer support. Drug manufacturer support programs can help expedite patients getting drugs while we are in the process of an appeal or things like that, making sure the patient has access to medication even if it is not approved by their insurance. The drug manufacturers help us in that sense, and usually by the time the appeal is completed or the prior authorization (PA) is approved, the patient is already on therapy. Then we can start going through their insurance to continue that.

Q: Adherence monitoring and follow-up are core to managing these patients well. When the dispensing pharmacy is somewhere else, how do you maintain visibility into whether a patient is actually taking their medication, and what do you do when that information just isn't coming?
Fischer: Yeah, this is a good question. I do not know if I have a good way to track adherence or whether people are taking their medications if they are not using our specialty pharmacy. But I will say I do assist with a lot of questions for patients from all of the clinic patients.

If a patient is experiencing a general side effect from a medication, if their copays are high, or something like that, I usually take that on for a lot of patients at the clinic. Most of the time I get a good gauge of whether this patient is actually taking the medication or not. Sometimes you have to be direct — like, “Are you taking the medication?” So just asking them.

I think the biggest thing for nonadherence, historically and now, is side effects. Most of the time, patients will contact their doctor’s office if they do have a side effect, and then usually that gets relayed to me. I am able to address those concerns and create a plan with the provider and the patient on how we can mitigate or reduce those side effects to improve adherence.

Ways we can improve adherence include reducing doses or introducing drug holidays. So we create a plan with the patient—we have a couple of different things we can do. What do you feel most comfortable with?

Q: If you could change one thing about how specialty pharmacies, health systems, and pulmonology practices coordinate care for ILD and PAH patients, what would it be, and what would better look like?
Fischer: I think the model that we have now — this direct collaboration between the pharmacist and the physician and all being integrated into one health system — really, really benefits the patient. The prior authorizations are done very fast. The appeals are done faster. You have connections made and developed with patients, so the patients trust me because I work with their physician, and the physician can bounce off ideas with me.

It is a really good model that we have, and I think you do not have this outside of academic institutions. If we could expand this model across all systems, it would be great, but that is obviously not feasible for everyone outside of that.

I do think that if insurers would approve medication a little bit easier, we would have a better system as well. Clearly, these medications are to reduce disease progression, and I think a lot of the time insurers look at it as high-cost medications they do not want to pay for, without understanding the disease-modifying capabilities of it. So I think that would be my answer: a little more flexibility and approvals from the insurance side.