NCODA Patient Surveys Support the Need for Medically-Integrated Pharmacies

Oral oncolytics have significantly impacted the treatment of cancer while enabling patients the convenience of management in their homes. Despite the rapid growth, therapeutic advances, novel mechanisms of actions, and improved outcomes associated with these agents, the dispensing process of oral chemotherapy drugs remains inadequate. As a result of rising drug costs and healthcare expenditure, payers have forced a “medically-disintegrated” model of dispensing, limiting patients and practices to fill prescriptions through external mail-order pharmacies. Significant barriers have emerged from such a model leading to treatment initiation and refill delays, inefficient monitoring practices, delays in care with insurance changes, miscommunication between patient, pharmacy, and physician, decreased patient satisfaction, delayed recognition and management of adverse events, increased incidence and under reporting of adverse events, inability to assess adherence and compliance, and increased waste. Although mail-order pharmacies have a significant role in maintenance therapies for non-oncologic indications and may help minimize cost, the high acuity and monitoring needed for patients with cancer does not align with mail-order dispensing.

The National Community Oncology Dispensing Association, Inc. (NCODA) has continued to advocate tirelessly, to payers, industry, and legislators and has partnered with professional organizations on behalf of patients and practices to stress the values of in-office dispensing of oral chemotherapy. As part of the numerous initiatives demonstrating the importance of the medically-integrated pharmacy (MIP), NCODA Patient Satisfaction Surveys (PSS) have supported the need for in-office dispensing. The PSS is a paper survey that is completed by patients with cancer who receive treatment with oral cancer medications at respective NCODA-member practices taking part in the program. The PSS aims to evaluate the patient’s overall satisfaction with the pharmacy model from which they receive therapy, convenience, timing to receive drug, interaction with staff, and if financial assistance was available.

There are approximately 360 NCODA-member practices nationwide that are advocating for the MIP model. Over the course of three years, NCODA has collected >1200 PSS from these pharmacies nationwide. The results demonstrate that patients prefer to receive their oral chemotherapies from their physician’s office. Within this model, patients were most satisfied by the interaction with staff, convenience of receiving prescriptions, continuity of care, and the time to receive their prescriptions.

The value of in-office dispensing enables providers to continually manage the prescription through an in-house pharmacist/pharmacy. The multidisciplinary team approach is fueled through the use of the same electronic medical record (EMR) and tools to streamline the quality assurance process, patient safety, and every aspect of the oral oncology care continuum. The NCODA PSS have supported the need for the MIP through the voice of the patient.

Interaction with Staff:

The NCODA PSS demonstrated that patients significantly prefer direct interactions with their providers and pharmacists than calls from a mail-order pharmacy. Patients on oral chemotherapies often have complex regimens and schedules, in addition to the impact the disease has on their social, mental, and physical health. As a result, face-to-face interactions with healthcare providers are integral components to patient care. Telemedicine plays a limited role in the cancer care continuum. Within the MIPs, pharmacists and staff have the ability to interact with patients, assess adherence and compliance, gauge nonverbal cues, and provide improved education through feedback. There are significant barriers in communication within mail-order dispensing that cripple best practices in oncology care. Simple adherence and compliance assessments are measured by refill dates, though the patient could be taking the medication completely wrong. Adherence and compliance to oral chemotherapies is directly linked to improved outcomes; once a prescription leaves the clinic, the healthcare team is in the dark regarding its status. Additionally, mail-order pharmacies utilize call centers and technicians providing a very impersonal experience and limited resources to the patient.

Our surveys demonstrated that patients prefer and value the interactions with their pharmacist within the MIP. Patients reported that they were able to better comprehend their treatment regimen, were more inclined to discuss complications with their pharmacists, and fewer had issues obtaining their medication in a timely manner. MIPs are able to utilize the EMR to communicate with patient pertinent information from their providers, discuss medication changes and interactions, assess adherence and compliance, and optimize safety practices.

Convenience of Receiving Prescriptions and Continuity of Care:

Several barriers to care have resulted from mail-order pharmacy dispensing of oral oncolytics; two major barriers include the time coordination required with mailing prescriptions and if patients experience any insurance changes.

Patients on oral chemotherapies require frequent lab assessments and provider visits. In order to ensure safe practices, providers often limit the number of refills on oral chemotherapy (majority give no refills) and limit the dispensing to one cycle at a time. Mail-order pharmacies have made safety practices difficult due to time required in processing the prescription and receiving therapy via mail. Providers and clinics are often forced to send in prescriptions early to avoid treatment delays regardless of the patient being seen; if a patient is seen too early, they may not have had adequate hematologic recovery. In contrast, if the prescription is held until the appointment then there is likely to be a delay from mail-order dispensing. Other patients may require dose changes and the need to receive different medication strengths leading to increased waste and delays in initiating subsequent cycles.

Oral oncolytics require extensive benefits coordination to ensure affordability for patients. Many patients on treatment are faced with changes in health benefits due to various factors. This has resulted in increased delays in receiving prescriptions, particularly with mail-order pharmacies. Often, the mail-order pharmacy fails to reach out to the clinic to inform them of processing errors, the need for prior authorizations or additional documentation. Having a MIP, allows prompt recognition of insurance changes and streamlines the process in reobtaining approval. MIPs significantly decrease the amount of time it takes for an oral oncolytic to reach the patient.

A significant portion of patients reported that they prefer to receive their prescriptions from a MIP and have had little to no issues with continuity of care. The MIP allows for patients to be seen by a provider immediately prior to their cycles without resulting in treatment delays. MIPs allow patients to receive their oral chemotherapies “within the hour.” Any treatment changes are efficiently coordinated through MIPs rather than trying to manage the prescription the patient may have received a week early from the mail-order pharmacy. Coupled with staff interactions, MIPs are able to coordinate a safe dispensing process allowing for adherence assessments, minimizing waste of oral oncolytics, optimizing treatment changes, coordinating financial procurement, and providing education within a timely manner.

Future Direction

Despite the numerous advantages and patient satisfaction with MIPs, most payers still favor mail-order pharmacies. There is a clear practice gap on the payer side in understanding the negative implications of mail-order dispensing on patient outcomes, timing to receive therapy, waste, increased healthcare expenditure, and clinical assessments.

The NCODA PSS demonstrates that patients prefer to receive prescriptions through an MIP due to positive interactions with staff, convenience of receiving prescriptions, continuity of care, and the time to receive their prescriptions. A planned analysis of all collected surveys is underway and results will be made available later in 2019/early 2020.

Kirollos S. Hanna, PharmD, BCPS, BCOP, is an assistant professor of pharmacy, Mayo Clinic College of Medicine, and a hematology/oncology clinical pharmacist, University of Minnesota Medical Center & Mayo Clinic.