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AIS's Health Business Daily
Featured Story, April 21, 2010
Coverage of Oral, IV Oncology Drugs Can Hinder Patient Compliance Reprinted from SPECIALTY PHARMACY NEWS, a monthly newsletter designed to help health plans, PBMs, providers and employers manage costs more aggressively and deliver biotechs, infusibles and injectables more effectively. By Angela Maas, Managing Editor Although oral chemotherapy drugs can be more convenient for patients than physician-administered intravenous therapies, a variety of barriers can make access to them difficult, according to a recently released study. Since about 25% of the oncology therapies in development are oral, stakeholders should consider both short-term and long-term solutions to these access issues.
For the report, Avalere Health surveyed 54 oncology stakeholders.
When it comes to patient compliance with oral oncolytics, “it’s not as easy as writing a prescription” and telling the patient to take the drug, says Patrick Cobb, M.D., president of Community Oncology Alliance, which sponsored the study. These drugs are “more targeted, less toxic and better accepted by patients” than older intravenous therapies. “But the way oral oncolytics are paid for puts an unnecessary burden on patients,” he contends.
Oral Oncolytics/Addressing the Barriers to Access and Identifying Areas for Engagement examines the “fractured coverage environment” and the confusion that can arise due to inconsistencies in oral oncolytic coverage. Many plans cover these drugs under the pharmacy benefit, but some place them in the medical benefit with the infused chemotherapy drugs. Avalere noted that there is even a difference between how Medicare and some private payers cover them.
“The fact is the difference in how insurers cover oral and intravenous drugs is a big problem,” contends Cobb, who is also managing partner of Hematology-Oncology Centers of the Northern Rockies in Billings, Mont. Plans “cover intravenous chemotherapy fairly well,” he says. But “we don’t think it’s fair” that many plans push the high-cost oral drugs to the highest formulary tier and require members to pay coinsurance, which often is about 20%, while patients receiving office-administered infusions are often responsible for only an office visit copayment.
According to Elan Rubinstein, Pharm.D., founder and principal of consulting firm EB Rubinstein Associates, having oral and intravenous oncology drugs in separate benefit structures “is a growing concern because unlike drugs administered in the office setting, oncologists do not typically have data regarding patient compliance with oral drug therapy.” High cost sharing, whether through private plans or Medicare Part D, can hinder patient compliance, he says, and with more oral oncology agents slated to hit the marketplace, “this problem will get worse.”
Cobb maintains that “the point of insurance is to share risk,” so “there should be parity between IV and oral drug” costs for patients.
However, he maintains, it is important to “make sure that the parity issue is not too blunt of an instrument. We don’t want there to be unintended consequences of covering the drugs the same,” such as imposing 20% coinsurance for both.
The study suggests four short-term solutions to the access issues:
Avalere also developed some longer-term areas of engagement, including the creation of a universal patient-assistance program and an oncology-specific benefit, as well as shifting oral oncolytics from the pharmacy benefit to the medical benefit.
Ideally, says Rubinstein, oral and intravenous oncology drugs “would be covered in the same benefit with the same rule set, with information going back to the prescriber regarding compliance with oral medication instructions.”
Limits Exist to In-Office Oral Drug Dispensing
According to Bill Sullivan, principal consultant for Specialty Pharmacy Solutions LLC, “The report is well intentioned but makes some unrealistic claims.” The first issue he cites is dispensing oral oncolytics from in-office pharmacies. “This concept is not new, and the proof of concept is that it actually works — but only for large offices with a sufficiently large patient census in multiple tumor/therapy categories to cover operating costs, which, for an oncology practice, are very large compared to a specialty pharmacy. Small practices simply do not have the volume to spread those costs efficiently, especially considering very large inventory carrying costs.”
Cobb agrees that “for one- or two-doctor practices, this is not practical.” Additional issues can arise in some states that do not allow dispensing, he says.
According to Sullivan, shifting all oral oncology drugs to the medical benefit “is counter-intuitive.” Under the pharmacy benefit, claims are adjudicated using the National Drug Code (NDC) system, while the medical benefit uses Healthcare Common Procedure Coding System J codes. “One would think that the added specificity and data tracking enabled through the NDC adjudication process would be significantly preferred to the antiquated J-code billing system, which most agree is ill-suited for care management purposes,” he tells SPN.
Sullivan also takes issue with the report’s suggestion that “the healthcare system is ill-equipped to handle the growing oral oncolytics market.” That claim, he says, “is simply wrong. Specialty pharmacies have already responded to the challenge of oral oncolytics and are very capable of providing these therapies [by] working collegially with the oncologist to enhance therapy and achieve desired clinical outcomes. Simply stated, these pharmacies have more than enough capacity to support the growing oral oncolytics market.”
To view the report, go to http://avalerehealth.net/wm/show.php?c=1&id=842. |
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