In-Office Dispensing Is Better Value

Brandon Tom, PharmD

Over the last several years, the proliferation of oral cancer drugs has caused many oncology practices to establish in-house pharmacies using either a board of pharmacy or physician’s medical license.

Today, almost half of US community oncology practices have an in-office dispensing (IOD) program, and that number continues to grow. However, due to the burgeoning volume of pricey oral oncolytics coming to market, IODs are now competing with retail pharmacy chains, pharmacy benefit managers (PBMs), and a growing number of independent specialty pharmacies.

With increased competition, the challenge IOD practices now face is to prove the value of what they do. Why should drug manufacturers continue to allow them access to their drugs? Why should health plans and pharmacy benefit managers allow them in their networks? What benefits do IODs offer that other pharmacy channels cannot deliver?

Fortunately, as value-based reimbursement models emerge in the oncology market, including the recently launched Oncology Care Model (OCM) pilot, IODs are well positioned to demonstrate their superiority to other pharmacy channels.

Benefits of a Pharmacy Closer to the Patient

In broad terms, IODs can provide better patient care and outcomes—at lower cost—through a more clinically integrated and streamlined process. It is useful to describe the value IOD brings to physicians, patients, payers, or manufacturers in two ways: having the pharmacy closer to the patient and having the pharmacy closer to the physician.Having the pharmacy closer to patients allows them greater convenience and improves their overall healthcare experience. Because cancer treatment can be exhausting, patients often do not have the time, energy, or mobility to search for and coordinate with a pharmacy that can fill their prescriptions. It is important to recognize that costly oral oncolytics usually cannot be found at the local pharmacies most patients use regularly. These drugs are only available through a limited number of pharmacies, which are knowledgeable on specialty medications and equipped with the capabilities to support patients before and after they begin therapy. These pharmacies are often selected by the manufacturer or payer. Consequently, it’s often confusing to patients which pharmacy must be used.

Cancer care for patients can be greatly simplified and better coordinated at a practice with IOD. Using pharmacy management software, staff can help patients determine insurance coverage, complete payer-imposed prior authorizations, and most important, find copay assistance when very expensive therapies are needed. All of this can be done while the patient is in the clinic receiving other treatment or visiting the oncologist. In addition, the actual dispensing of the drug can be synchronized with other elements of the patient’s regimen, whether it be surgery, radiation, or infusion. These examples of better coordinated care equate to a faster treatment time and greater patient convenience—a shared goal of all healthcare stakeholders.

A common challenge to payers is oral oncolytic drug waste. This waste is usually created because pharmacies will typically fill a 30-day supply that is more than needed because the patient will frequently discontinue or delay therapy for a myriad of reasons, such as intolerance or tumor progression.

Everolimus (Afinitor), for example, can cause severe stomatitis within five days of treatment initiation. Depending on the toxicity grade, the oncologist may choose to either discontinue, delay, or dose-reduce the therapy, leaving a supply of unused pills that cannot be returned to the pharmacy. Practices with IODs can help payers solve this problem by “split filling” the order, dispensing a portion of the amount to coincide with the patient’s office visits. Because the pharmacy is in the oncology clinic where the patient sees the physician, it is possible to give just enough supply to last to the next appointment, where tolerance will be evaluated, dose adjustments made, and a new prescription written, if needed. This greatly reduces waste and is perfectly aligned with patients returning to the office for follow-up care. Although other specialty pharmacy channels have attempted to create “split fill” programs that dispense a 14-day supply, an IOD program is the only setting where the pharmacy can dispense an amount that correlates to the physician’s monitoring of a patient.

The second dimension—having the pharmacy closer to the physician offers key clinical benefits that support the physician’s ability to deliver optimal care and improve patient outcomes. Chief among these is the opportunity to closely monitor and manage side effects. The more proactive physicians can be in adverse event management, the longer they can keep the patient on the desired therapy, potentially improving outcomes and quality of life.

What differentiates IOD from other pharmacy models is the quickness with which a physician can be notified of a patient’s adverse event, triage appropriately, and implement a change. If we go back to the previously example of the patient on everolimus who develops stomatitis, a physician would typically reduce the dose by 50%. In an IOD model, the pharmacist who learns of the patient’s intolerance can literally walk down the hall of the office, discuss an action plan with the physician, obtain a new prescription, and dispense the new dose to the patient, all within a few hours. A physician’s ability to quickly respond to adverse reactions is critical to improving adherence and reducing hospitalizations. In our experience, outside pharmacies take significantly longer to deal with situations like this, as their only connection to the prescribing physician may be a fax machine, and dose adjustments require new prescriptions, which the pharmacy must then mail to the patient’s home. The savings in time is critical for cancer patients, whose reactions could become significantly worse if required medication changes are delayed.

Lastly, when the patient’s treatments are happening under one roof, all the activity is documented in the electronic health record (EHR), providing a significant benefit to the physician. Accurate real-time documentation gives physicians a full line of sight into what is happening with the patient at all times, enabling informed decisions that lead to optimal care. When drugs are provided outside the clinic, the physician is often unsure whether the patient actually started therapy or if some barrier to access exists. Having full visibility is important when coordination is required with other aspects of the patient’s treatment regimen. It’s also critical in any kind of value-based reimbursement model where the oncologist is at risk for the patient’s total healthcare costs.

Practices must invest in their IOD to ensure ongoing success How IODs will fare in the future remains to be seen. The competition is only going to increase, as will the expectations of the pharmacies looking to dispense oral oncolytics. Practices that want to ensure their IOD succeeds must focus on this aspect of their business, investing in the resources necessary to develop their dispensing operation so it can ultimately show value to all healthcare constituents.

Although many practices have started IOD programs, many have not adequately invested in these elements of their business, nor have they become truly knowledgeable about pharmacy in order to prepare for the coming challenges. Consequently, over the past year, we have concentrated on providing tools, technologies, and expertise that empower practices to build a robust, world-class IOD pharmacy that can drive improved financial performance and patient care excellence. We recently enhanced our in-office dispensing program and launched an Optimization Toolkit, which includes performance tracking through data and analytics, marketing, workflow support, and dedicated oncology pharmacy expertise to drive operational efficiency. These types of products and services enable practices to create a strong foundation for their pharmacy and be better positioned for the era of value-based reimbursement.

Brandon Tom, PharmD, is vice president of Self-Administered Products & Services for McKesson Specialty Health.