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Looney B, Crumb J, White S, Jones G, Moore RP, Choi L, Zuckerman AD, Whelchel K. Financial impact of integrated specialty pharmacy efforts to avoid oral anticancer medication waste. J Manag Care Spec Pharm 2024; 30:465-474. [PMID: 38701029 PMCID: PMC11068656 DOI: 10.18553/jmcp.2024.30.5.465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND The growing number of oral anticancer medications represents a significant portion of pharmacy spending and can be costly for patients. Patients taking oral anticancer medications may experience frequent treatment changes following necessary safety and effectiveness monitoring, often resulting in medication waste. Strategies to avoid medication waste could alleviate the financial burden of these costly therapies on the payer and the patient. OBJECTIVE To evaluate the impact on waste and cost avoidance of reviewing the amount of medication patients have on hand and the presence of upcoming follow-up (ie, provider visit, laboratory testing, or imaging) before requesting a prescription refill renewal for patients taking oral anticancer medications through an integrated health system specialty pharmacy. METHODS We performed a retrospective review of patients filling oral anticancer medications prescribed by a Vanderbilt University Medical Center provider and dispensed by Vanderbilt Specialty Pharmacy between January 1, 2020, and December 31, 2020. Specialty pharmacists received a system-generated refill renewal request for oral anticancer medications when the final prescription refill was dispensed, prompting the pharmacist to review the patient's medical record for continued therapy appropriateness and to request a new prescription. If the patient had a sufficient supply on hand to last until an upcoming follow-up (ie, provider visit, imaging, or laboratory assessment), the pharmacist postponed the renewal until after the scheduled follow-up. Patients were included in the analysis if the refill renewal request was postponed after review of the amount of medication on hand and the presence of an upcoming follow-up. Medication outcomes (ie, continued, dose changed, held, medication changed to a different oral anticancer medication, or discontinued) resulting from the follow-up were collected. Cost avoidance in US dollars was assigned based on the outcome of follow-up by calculating the price per unit times the number of units that would have been unused or in excess of what was needed if the medication had been dispensed before the scheduled follow-up. The average wholesale price minus 20% (AWP-20%) and wholesale acquisition cost (WAC) were used to report a range of costs avoided over 12 months. RESULTS The total cost avoidance over 12 months associated with postponing refill renewal requests in a large academic health system with an integrated specialty pharmacy ranged from $549,187.03 using WAC pricing to $751,994.99 using AWP-20% pricing, with a median cost avoidance per fill of $366.04 (WAC) to $1,931.18 (AWP-20%). Refill renewal requests were postponed in 159 instances for 135 unique patients. After follow-up, medications were continued unchanged in only 2% of postponed renewals, 56% of follow-ups resulted in medication discontinuations, 32% in dose changes, 5% in medication changes, and 5% in medication holds. CONCLUSIONS Integrated health system specialty pharmacist postponement of refill requests after review of the amount of medication on hand and upcoming follow-up proved effective in avoiding waste and unnecessary medication costs in patients treated with oral anticancer medications at a large academic health system.
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Affiliation(s)
- Brooke Looney
- Vanderbilt Specialty Pharmacy, Vanderbilt Health System, Nashville, TN
| | - Jared Crumb
- Vanderbilt Specialty Pharmacy, Vanderbilt Health System, Nashville, TN
| | - Stephanie White
- Vanderbilt Specialty Pharmacy, Vanderbilt Health System, Nashville, TN
| | | | - Ryan P. Moore
- Department of Biostatistics, Vanderbilt Health System, Nashville, TN
| | - Leena Choi
- Department of Biostatistics, Vanderbilt Health System, Nashville, TN
| | | | - Kristen Whelchel
- Vanderbilt Specialty Pharmacy, Vanderbilt Health System, Nashville, TN
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Lichtenstein MR, Beauchemin MP, Raghunathan R, Lee S, Doshi SD, Law C, Accordino MK, Elkin EB, Wright JD, Hershman DL. Association Between Copayment Assistance, Insurance Type, Prior Authorization, and Time to Receipt of Oral Anticancer Drugs. JCO Oncol Pract 2024; 20:85-92. [PMID: 38033273 PMCID: PMC10827292 DOI: 10.1200/op.23.00205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 12/02/2023] Open
Abstract
PURPOSE Oral anticancer drugs (OACDs) have become increasingly prevalent over the past decade. OACD prescriptions require coordination between payers and providers, which can delay drug receipt. We examined the association between insurance type, pursuit of copayment assistance, pursuit of prior authorization (PA), and time to receipt (TTR) for new OACD prescriptions. METHODS We prospectively collected data on new OACD prescriptions for adult oncology patients from January 1, 2018, to December 31, 2019, including demographic and clinical characteristics, insurance type, and pursuit of PA and copayment assistance. TTR was defined as the number of days from prescription to OACD receipt. We summarized TTR using cumulative incidence and compared TTR by insurance type, pursuit of copayment assistance, and PA activity using the log-rank test. RESULTS Our cohort of 1,024 patients was 53% male, and 40% were younger than 65. Twenty-six percent had commercial insurance only, 16% had Medicaid only, and 59% had Medicare with or without additional insurance. Eighty-six percent of prescriptions were successfully received. Across all prescriptions, 69% involved PA activity, and 21% involved the copayment assistance process. In unadjusted analyses, prescriptions involving the copayment assistance process had longer TTR compared with those not involving assistance (log-rank P value = .005) and OACDs covered by Medicare/commercial insurance had a longer TTR compared with Medicaid (log-rank P value = .006). The PA process was not associated with TTR (log-rank P value = .124). CONCLUSION The process for obtaining OACDs is complex. The copayment assistance process and Medicare/commercial insurance are associated with delayed TTR. New policies are needed to reduce time to OACD receipt.
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Affiliation(s)
- Morgan R.L. Lichtenstein
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Melissa P. Beauchemin
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
- School of Nursing, Columbia University Irving Medical Center, New York, NY
| | - Rohit Raghunathan
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Shing Lee
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| | - Sahil D. Doshi
- Division of Medical Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Cynthia Law
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Melissa K. Accordino
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
- School of Nursing, Columbia University Irving Medical Center, New York, NY
| | - Elena B. Elkin
- Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| | - Jason D. Wright
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
| | - Dawn L. Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
- Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
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Shah NB, Zuckerman AD, Hosteng KR, Fann J, DeClercq J, Choi L, Cherry L, Schwartz DA, Horst S. Insurance Approval Delay of Biologic Therapy Dose Escalation Associated with Disease Activity in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2023; 68:4331-4338. [PMID: 37725192 DOI: 10.1007/s10620-023-08098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 08/26/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Dose escalation of self-injectable biologic therapy for inflammatory bowel diseases may be required to counteract loss of response and/or low drug levels. Payors often require completion of a prior authorization (PA), which is a complex approval pathway before providing coverage. If the initial PA request is denied, clinic staff must complete a time and resource-intensive process to obtain medication approval. AIMS This study measured time from decision to dose escalate to insurance approval and evaluated impact of approval time on disease activity. METHODS This was a single-center retrospective analysis of adult patients with IBD prescribed an escalated dose of biologic therapy at an academic center with an integrated specialty pharmacy team from January to December 2018. Outcomes included time to insurance approval and the association between approval time and follow-up C-reactive protein (CRP) and Short Inflammatory Bowel Disease Questionnaire (SIBDQ) scores. Associations were tested using linear regression analyses. RESULTS 220 patients were included, median age 39, 53% female, and 96% white. Overall median time from decision to dose escalate to insurance approval was 7 days [interquartile range (IQR) 1, 14]. Approval time was delayed when an appeal was required [median of 29 days (IQR 17, 43)]. Patients with a longer time to insurance approval were less likely to have CRP improvement (p = 0.019). Time to insurance approval did not significantly impact follow-up SIBDQ scores. CONCLUSION Patients who had a longer time to insurance approval were less likely to have improvement in CRP, highlighting the negative clinical impact of a complex dose escalation process.
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Affiliation(s)
- Nisha B Shah
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - Autumn D Zuckerman
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA.
| | - Katie R Hosteng
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - Jessica Fann
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - Josh DeClercq
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - Leena Choi
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - Laura Cherry
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - David A Schwartz
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
| | - Sara Horst
- Vanderbilt University Medical Center, 784 Melrose Avenue, Nashville, TN, 37211, USA
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Zuckerman AD, Mourani J, Smith A, Ortega M, Donovan JL, Gazda NP, Tong K, Simonson D, Kelley T, DeClercq J, Choi L, Pierce G. 2022 ASHP Survey of Health-System Specialty Pharmacy Practice: Clinical Services. Am J Health Syst Pharm 2023; 80:827-841. [PMID: 36999452 DOI: 10.1093/ajhp/zxad064] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Indexed: 04/01/2023] Open
Abstract
PURPOSE Results of the first ASHP national survey of clinical services provided by health-system specialty pharmacies (HSSPs) are presented. METHODS A survey questionnaire was developed by 26 HSSP contacts after reviewing available literature on the role and services of HSSPs. After pilot and cognitive testing resulting in a final questionnaire of 119 questions, a convenience sample of 441 leaders in HSSPs was contacted using email and invited to participate in the survey. RESULTS The survey response rate was 29%. Almost half of respondents (48%) had offered pharmacy services for 7 years or more, and most (60%) dispensed more than 15,000 prescriptions annually. Respondents most commonly (42%) reported a specialist model wherein staff are dedicated to specific specialty disease states. Over half of respondents reported providing several medication access, pretreatment assessment, and initial counseling services to patients referred to them, regardless of whether the HSSP was used for medication fulfillment. All HSSP activities were noted to be documented in the electronic health record and visible to providers frequently or always. Almost all respondents noted that HSSP pharmacists have a role in specialty medication selection. Disease-specific outcomes were tracked in 95% of responding HSSPs, with 67% reporting that outcomes were used to drive patient monitoring. HSSPs were often involved in continuity of care services such as transitions of care (reported by 89% of respondents), referral to other health-system services (53%), and addressing social determinants of health (60%). Most respondents (80%) reported providing clinical education to specialty clinic staff, including medicine learners (62%). Though only 12% of respondents had dedicated outcomes research staff, many reported annually publishing (47%) or presenting (61%) outcomes research. CONCLUSION HSSPs are a clinical and educational resource for specialty clinics and have developed robust patient care services that encompass the patient journey from before specialty medication selection through treatment monitoring and optimization.
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Affiliation(s)
- Autumn D Zuckerman
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Amy Smith
- University Specialty Pharmacy, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Melissa Ortega
- Tufts Medicine Specialty Pharmacy, Tufts Medical Center, Boston, MA, USA
| | | | | | - Kimhouy Tong
- Outpatient Pharmacy Services, Yale New Haven Health, Hamden, CT, USA
| | | | - Tara Kelley
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Josh DeClercq
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gabrielle Pierce
- American Society of Health-System Pharmacists, Bethesda, MD, USA
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Beauchemin MP, Lichtenstein MR, Raghunathan R, Doshi SD, Lee S, Law C, Accordino MK, Elkin EB, Wright JD, Hershman DL. Impact of a Hospital-Based Specialty Pharmacy in Partnership With a Care Coordination Organization on Time to Delivery and Receipt of Oral Anticancer Drugs. JCO Oncol Pract 2023; 19:e326-e335. [PMID: 36473132 PMCID: PMC10022875 DOI: 10.1200/op.22.00451] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/04/2022] [Accepted: 10/24/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Oral anticancer drug (OACD) prescriptions require extensive coordination between providers and payers, which can delay drug receipt. Specialty pharmacies facilitate communication between multiple entities. In 2018, our cancer center partnered with a freestanding organization to implement a hospital-based specialty pharmacy (HB-SP). We evaluated the time to drug receipt (TTR) before and after HB-SP implementation. METHODS Data were prospectively collected on all new OACD prescriptions for adult oncology patients from January 1, 2018, to December 31, 2019. In fall 2018, a HB-SP was initiated. We collected patient sociodemographic, clinical, and prescription data. TTR was the number of days from OACD prescription to drug receipt. We used multivariable logistic regression to examine factors associated with TTR ≤ 7 days before and after HB-SP implementation. RESULTS In total, 954 patients were included, representing 1,102 new OACDs. The majority of prescribed drugs were targeted OACDs (56%, n = 617), and 71% (n = 779) required prior authorization. Of all prescriptions, 84% (n = 960) were successfully received with an overall median TTR of 7 days. In unadjusted analysis, HB-SP implementation, drug class, race and ethnicity, and prior authorization requirement were significantly associated with TTR. Adjusted analyses found that patients were more likely to receive their drugs ≤ 7 days after HB-SP implementation (53% v 47%; adjusted odds ratio [aOR], 1.29; 95% CI, 1.00 to 1.68; P = .05). CONCLUSION The implementation of a HB-SP in partnership with a collaborative care model contributed to a decrease in TTR for OACDs. This difference is in part attributable to improved care coordination and communication. A centralized approach may improve overall efficiency due to fewer practice disruptions.
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Affiliation(s)
- Melissa P. Beauchemin
- School of Nursing, Columbia University Irving Medical Center, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Morgan R.L. Lichtenstein
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Rohit Raghunathan
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Sahil D. Doshi
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Shing Lee
- Department of Biostatistics, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| | - Cynthia Law
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Melissa K. Accordino
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Elena B. Elkin
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| | - Jason D. Wright
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
| | - Dawn L. Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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Marineau A, St-Pierre C, Lessard-Hurtubise R, David MÈ, Adam JP, Chabot I. Cyclin-dependent kinase 4/6 inhibitor treatment use in women treated for advanced breast cancer: Integrating ASCO/NCODA patient-centered standards in a community pharmacy. J Oncol Pharm Pract 2022:10781552221102884. [PMID: 35642282 DOI: 10.1177/10781552221102884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Outpatients treated with oral anti-cancer drugs, including selective cyclin-dependent kinase 4/6 inhibitors (CDK4/6i), may benefit from a pharmacy practice setting adapted to support proper oral anti-cancer drug monitoring. This real-world study aimed to characterize patient-centered pharmacy practice aligned with American Society of Clinical Oncology (ASCO)/National Community Oncology Dispensing Association (NCODA) standards and to describe its impact on CDK4/6i treatment use. METHODS This retrospective study included women with confirmed hormone receptor-positive/human epidermal growth factor 2 negative locally advanced or metastatic breast cancer treated with either palbociclib, abemaciclib or ribociclib combined with letrozole or fulvestrant. Pharmacists collected patient characteristics, clinical activities, and treatment patterns using data from the pharmacy chart. CDK4/6i treatment adherence rates were estimated based on medication claims data. Time-to-treatment discontinuation, a proxy for time-to-event, was assessed using the Kaplan-Meier estimate. RESULTS Of the 195 patients assessed for eligibility, 65 were included in this study. The median observation duration was 13.6 months. An average of seven pharmaceutical care activities (range 2.8-21.7) per patient was documented for each treatment cycle. The mean proportion of days covered was 89.6%. The median time-to-treatment discontinuation was estimated at 44.2 months in patients treated with CDK4/6i + letrozole and 17.0 months in patients treated with CDK4/6i + fulvestrant. The average relative dose intensity was 85%, and the benefits of treatment were maintained regardless of the relative dose intensity levels. CONCLUSION A structured patient-centered pharmacy practice model integrating the ASCO/NCODA patient-centered standards and ongoing communication with patients and healthcare providers ensure timely refills, close monitoring, and allows patients to achieve high adherence and persistence rates comparable to those reported in clinical trials.
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Affiliation(s)
| | | | | | | | - Jean-Philippe Adam
- Department of Pharmacy, Centre hospitalier de l'Université de Montréal, Montréal, Canada.,CHUM Research Center, CHUM, Montréal, Canada
| | - Isabelle Chabot
- Faculty of Pharmacy, Université de Montréal, Montréal, Canada
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Zuckerman AD, Shah NB, Perciavalle K, Looney B, Peter ME, DeClercq J, Moore R, Choi L, Reynolds VW. Primary medication nonadherence to oral oncology specialty medications. J Am Pharm Assoc (2003) 2022; 62:809-816.e1. [DOI: 10.1016/j.japh.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/14/2021] [Accepted: 01/04/2022] [Indexed: 11/28/2022]
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