Third Party Support for Oral Oncolytics in CLL


Regarding chronic lymphocytic leukemia management, experts review the role of such management organizations as the National Community Oncology Dispensing Association (NCODA), the PAN [Patient Access Network] Foundation, and Good Days in providing oral oncolytics.


Troy Trygstad, PharmD, PhD, MBA: There was this poster presentation at the National Association of Specialty Pharmacy, and it talked about what happens when you go beyond pure provision or pure dispensing and you wrap around these medication use supports for these oral oncolytics. So we don’t just release them into the wild and say whatever happens, happens. We actually provide these supports around it that indicate that maybe additional work and additional programs could be fruitful, not only from a patient outcomes and humanistic perspective but even from an outcomes perspective. So tell me about this body of work. Where does it need to go? What are the early indications in this space about the cost benefit and the results of adding these medically integrated services to the act of dispensing?

Michael Reff, RPh, MBA: There’s plenty of opportunity to talk about this topic, and the poster that you mentioned is 1 example of many that have been published in papers or posters on the medically integrated dispensing service and of the benefits of having that prescription at the site of care and that continuity of care. We’ve had several that have been published at the NCODA meetings and some that were published in the Journal of Pharmacy Practice talking more specifically about the cost avoidance that can occur by having a practice better manage their oral oncolytics for their patients and also the waste that’s associated.

So what I mean by tracking of waste is when a mail-order pharmacy automatically mails a prescription of an oral oncolytic that can be on an average from $10,000 to $15,000 per month and that prescription has already been stopped by the provider. We all have probably had situations where a patient or a caregiver will bring in a bag of these medications and say, “I don’t know what to do with these. They keep sending them to me even though I call them to tell them to stop.” And so we track that, and that’s been published in several posters and publications talking about how it’s just building cost into the system.

Troy Trygstad, PharmD, PhD, MBA: And into our rivers and streams.

Michael Reff, RPh, MBA: Yes.

Troy Trygstad, PharmD, PhD, MBA: Now you go on Twitter during drug take-back day, and you’ll see 147 unopened boxes of inhalers and whatever else, right, because the good news is we realized as a system and now appreciate adherence. The bad news is we associate automated filling with adherence. And so there is a cost-effectiveness aspect to that but also on the outcomes side, right?

Michael Reff, RPh, MBA: Sure.

Troy Trygstad, PharmD, PhD, MBA: So the National Community Oncology Dispensing Association, NCODA, is deeply involved with that obviously. What is it you do for patients, providers, plans, and policy?

Michael Reff, RPh, MBA: So quite simply it’s providing quality standards, and there are 4 specific quality standards. They fall under 4 different domains that help really set the framework or the benchmark of what a medically integrated dispensing service looks like.

Troy Trygstad, PharmD, PhD, MBA: Ah. So it’s an association of advanced practice pharmacy in these practices, if you will.

Michael Reff, RPh, MBA: Yes.

Troy Trygstad, PharmD, PhD, MBA: And you’re setting the learning collaborative and the standards around this particular space.

Michael Reff, RPh, MBA: Exactly.

Troy Trygstad, PharmD, PhD, MBA: Give me an example of a standard.

Michael Reff, RPh, MBA: So there are 4 domains, as I mentioned. One is foundational, the second is patient centered, the third is positive quality intervention that Kirollos is intimately involved in, and the fourth is health information technology. And I’ll just briefly say the benefit of operationalizing these quality standards is it not only provides the practice a heightened level of care for their patient, which we all want, but it also gives the right to the practice to have that discussion of quality and value with payers and other stakeholders to say, “We deserve that shared risk of keeping that prescription here within the confines of our 4 walls because we are doing what we know we can do best for the patient.” And it’s that continuity of care.

Troy Trygstad, PharmD, PhD, MBA: So this feels like the HOV [high-occupancy vehicle] lane to me. Here’s the regular highway, but we’re the HOV lane. We’re economically and environmentally sound, and we have emission standards and so on and so forth. Fair enough?

Michael Reff, RPh, MBA: Yes.

Kirollos Hanna, PharmD, BCPS, BCOP: And to speak to some of these things that Mike brings out, in NCODA, there are several initiatives that help patients, pharmacists, and providers. So some of these include the oral chemotherapy education sheets. This was an NCODA initiative where HOPA partnered with ONS, ACCC [Association of Community Cancer Centers].

Troy Trygstad, PharmD, PhD, MBA: HOPA?

Kirollos Hanna, PharmD, BCPS, BCOP: HOPA is the Hematology Oncology Pharmacy Association; ONS is the Oncology Nursing Society. So several of these large recognized organizations partner up. The chemotherapy education sheets are standard education for patients. So what’s behind it is to standardize the education that we give to patients across the country.

Troy Trygstad, PharmD, PhD, MBA: So would this feel like the VIS [vaccine information statement] sheets for immunizations?

Kirollos Hanna, PharmD, BCPS, BCOP: Very similar.

Michael Reff, RPh, MBA: Very similar.

Kirollos Hanna, PharmD, BCPS, BCOP: Very, very similar, and it’s tailored to each drug. And the fact is that you have all these national organizations; you have several eyes that look at these educational documents. These are constantly being reviewed and updated based on new indications because these oral oncolytics are often updated. In addition to that, HOPA also does the PQIs, which are the positive quality interventions. So these are tailored to providers and pharmacists about a specific drug or a specific adverse effect. How do we manage chemotherapy-induced nausea and vomiting? How do we manage diarrhea?

NCODA also provides a new intervention called the TSKs, the treatment support kits. So sometimes some oral oncolytics may need supportive cares. There are certain oral oncology drugs that may require antidiarrheal prophylaxis or may require certain creams or lotions, as with capecitabine. And this TSK initiative is to provide clinics with these kits that you can provide to patients at no charge, and then these patients will have these supportive care medications, again to minimize cost and then for patients to have these supportive care items at home. So there are tons of exciting things coming out of NCODA really tailored to everybody involved: the patient, the provider, the pharmacist. So it’s been very exciting working with NCODA.

Troy Trygstad, PharmD, PhD, MBA: What’s next on the table for NCODA? Most important things in the next 2 years?

Michael Reff, RPh, MBA: So publication is one of the initiatives that we’re going to be starting and pulling through the treatment support kits. We’ve conducted a pilot study at 24 practices, 240 kits, 10 at each of the practices, and we’re getting feedback from the patients and also from the practices to make sure that we’re hitting the market we want. And it’s always centered on 2 guiding values that NCODA maintains. It’s patient centered and being collaborative, and those are the 2 things that define NCODA.

Troy Trygstad, PharmD, PhD, MBA: Do you also interact with or make emerging policy suggestions around patient assistance programs?

Michael Reff, RPh, MBA: We do. We have a policy committee that’s starting, so you would ask what’s new for NCODA.

Troy Trygstad, PharmD, PhD, MBA: When I say you have a magic elder wand, you say, “Well, here’s what our policy committee says.”

Michael Reff, RPh, MBA: Yes. The policy committee is 1 of about 4 other committees that we’re starting up fourth quarter 2018, but they are really getting their legs in 2019.

Troy Trygstad, PharmD, PhD, MBA: So, with respect to these patient assistance programs, there’s the PAN Foundation. PAN meaning what? Kirollos?

Kirollos Hanna, PharmD, BCPS, BCOP: That’s a great question.

Troy Trygstad, PharmD, PhD, MBA: Patient Access Network. Patient Access Network, Good Day, others. At the association level or the practice level, what does that interaction look like? These are organizations. Are they coordinated, not coordinated? Where are these heading? Is there a learning collaborative around these entities?

Kirollos Hanna, PharmD, BCPS, BCOP: So speaking to the PAN Foundation itself, 1 thing I really, really like about the PAN Foundation is that foundational coordinators, or anyone who goes on their website and looks, are able to find financial assistance for patients. And 1 thing that’s really good for the PAN Foundation is that if funds are closed, it will actually direct you to other sources that could be available for patients, such as the Lymphoma & Leukemia Society and several other organizations that may provide funding. So the PAN Foundation has been really a good resource, and it’s often one of the first resources utilized by our financial coordinators, simply because of its ability to direct if it doesn’t have options there.

Troy Trygstad, PharmD, PhD, MBA: Really, it sounds to me almost like a SHIP [state health insurance assistance program] office in some ways. I’ve got patients who come in with needs, they don’t know what they’re eligible for, and I’m helping in whatever way I can help based on that patient’s circumstance. Good Days, similar circumstance?

Michael Reff, RPh, MBA: Yes. I think all of these are great examples and the Patient Associate Network Foundation is part of the executive advisory board of NCODA. We’ve got a very good working relationship with the PAN Foundation. We consider them good friends. They’re patient centered like we are, and they’ve been a very good collaborative partner for NCODA and our practices to help us help our patients.

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