As costs of cancer care continue to escalate,1 all stakeholders—healthcare providers, private and government payers, and patients—are compelled to identify strategies that balance high-quality cancer care with cost-efficiency. Patients in particular are influencing treatment decision-making, largely because they are now more financially invested in their own care. In recent years, market demand for affordable benefit plans has increased dramatically, partly due to the passage of the Affordable Care Act in 2010.2 In response, private payers now offer (and increasing numbers of employers prefer) high-deductible health plans.3 High deductibles and copayments are designed to ensure that people with cancer have “more skin in the game.” However, it is well documented that when these patients are considering options for therapy, they may not prioritize quality care, and instead trade off for other factors such as efficacy, toxicity, and cost. A recently published study found that patients with chronic myeloid leukemia (CML) who had the highest drug-related copayments, defined as the top quartile among the people in the insurance claims database, were 42% more likely to be nonadherent to imatinib therapy than patients with CML who had lower copayments.4 This is clearly cause for concern, as nonadherence to imatinib and other tyrosine kinase inhibitors (TKIs) affects rates of disease progression and treatment resistance in CML.4 Because patients with cancer now shoulder a larger portion of their healthcare costs, they are required to navigate their disease—a sufficiently daunting task—as well as the many practical aspects of insurance coverage. Are their treatments covered under the benefit plan? Are they eligible for Medicare, Medicaid, or Social Security insurance? Is copay assistance available under their pharmacy benefit? Do they qualify for pharmaceutical manufacturers’ patient assistance programs? What other resources are available to manage cancer-related finances? For patients and caregivers, as well as cancer care providers, centralized sources of comprehensive reimbursement information and support become critical when answering these questions. Onyx 360 for Patients with Multiple Myeloma Onyx Pharmaceuticals 360TM (Onyx 360) is one example of a comprehensive patient and caregiver support and services program. It was designed by Onyx Pharmaceuticals, Inc., an Amgen subsidiary, based on extensive market research conducted prior to launch, which involved Health Connect Partners advisory boards and patient and caregiver focus groups, to determine unmet needs in patient support programs. The goal of this program is to help patients with multiple myeloma (MM) and their caregivers navigate the treatment journey by providing reimbursement and payment support, treatment support, and referrals to third-party organizations for day-to-day and emotional support.5 Enrollment in Onyx 360 is offered to patients with MM for whom Kyprolis® (carfilzomib) has been prescribed. Kyprolis is a proteasome inhibitor that is administered intravenously, and is indicated for the treatment of patients with MM who have received at least 2 prior therapies, including bortezomib and an immunomodulatory agent, and have demonstrated disease progression on or within 60 days of completion of the last therapy.6 The program offers free one-on-one support for patients with MM and their caregivers through dedicated nurses, known as oncology nurse advocates (ONAs). These nurses connect patients and their caregivers with key resources that other individuals have deemed helpful.5 Specific services offered by Onyx 360 are summarized in the Table. Another oncology drug marketed in the United States by Onyx is Nexavar® (sorafenib), an orally administered TKI. This agent is approved by the US Food and Drug Administration for the treatment of patients with unresectable hepatocellular carcinoma, patients with advanced renal cell carcinoma, and patients with locally recurrent or metastatic, progressive, differentiated thyroid carcinoma refractory to radioactive iodine treatment.7 Patient support for Nexavar is provided through REACH® (Resources for Expert Assistance and Care Helpline), a free support program that offers drug information and options for financial assistance.8 Spotlight on Practices with Onyx 360 Experience: Moffitt Cancer Center Established in 1986, Moffitt Cancer Center is the third largest cancer center in the United States, based on patient volume. The center is focused on translating research discoveries from onsite research laboratories directly to patients.9 Located in Tampa, Florida, Moffitt is the only National Cancer Institute–designated comprehensive cancer center based in the state. The center focuses exclusively on the management of cancer, and its multidisciplinary teams offer personalized and compassionate care, as well as cutting-edge clinical trials, with the goal of optimizing patient outcomes.9 Patients with MM can receive cancer care in the Myeloma Program in Moffitt’s Malignant Hematology Department. The program specializes in the evaluation, treatment, and comprehensive care of patients with plasma cell disorders, including MM, Waldenström’s macroglobulinemia, and monoclonal gammopathy of undetermined significance. The multidisciplinary team of specialists at Moffitt includes medical oncologists, bone marrow transplant physicians, hematopathologists, and radiation oncologists, as well as physicians who specialize in infectious diseases, orthopedics, and neurosurgery. Moffitt physicians partner with oncology nurses, pharmacists, advanced practice professionals, and administrative staff who support patients with services that address medical, physical, spiritual, and emotional needs.9 Moffitt works with the ONAs of Onyx 360 to assist patients with MM who are undergoing treatment with Kyprolis. Kimberly Galloway, RPh, CPh, of Moffitt’s Patient Resource Center, said the Onyx 360 program is highly valuable for a large cancer center such as Moffitt. “Onyx 360 is a very professional, very timely program. It conducts its own benefits review for our patients, and focuses on fulfilling requested services. The ONAs really understand the need for our patients to start treatment as soon as possible. Their mission is to expedite that process.” Beth Finley, RN, OCN, an oncology nurse who works directly with 2 myeloma specialists at Moffitt, had similar observations. “You can tell that the ONAs are very well educated. They know the drug, insurance issues and guidelines, and how to successfully navigate through the complex healthcare system.” Both Ms Finley and Ms Galloway stated that virtually all patients who receive Kyprolis at Moffitt enroll in the Onyx 360 program. Ms Finley explained, “Every patient that we have [on Kyprolis] are involved in Onyx 360. Once patients learn about the program, they want to get involved, primarily for the financial support that they will receive. They appreciate the help with copays, gas money, and lodging.” Ms Galloway agreed, “One of the biggest benefits of Onyx 360 is the copay help. Onyx 360 does a terrific job of setting up patients with financial and travel assistance. The foundation that they use for copay assistance is quick to review and approve requests. Their process is extremely user-friendly and fast. We have touted Onyx 360 to other pharmaceutical companies, suggesting that they consider a similar process for their patient-assistance programs.” Ms Finley also highlighted the value of the emotional support programs that Onyx 360 provides to patients and their caregivers. “Addressing emotional aspects is huge for some of our patients with MM. It gives them comfort when they realize that there is another person on their healthcare team….Onyx 360 also provides counseling services for caregivers. Many times, people forget about the caregivers, but they play such an important role. The support and counseling that they receive has been so helpful….Caregivers are often the ones responsible for all of the logistic details and conversations regarding finances.” The Onyx 360 program also benefits Moffitt personnel. Ms Galloway predicted that as healthcare and insurance models continue to evolve, a growing proportion of patients with cancer will require copay help. “Everything is moving to cost-sharing.” For Moffitt’s pharmacy and central office personnel, ONAs at Onyx 360 add value by serving as a “double check” regarding patients’ drug benefits and copay obligations. “As the number of underinsured patients grows and the Medicaid population expands—not just here at Moffitt but at other offices and hospitals—Onyx 360 services will be especially valuable,” Ms Galloway said. “Cancer care providers who are considering the use of Kyprolis for their patients can feel comfortable that this program is in place to help them sort through available services and support options.” For oncology nurses, Onyx 360 reduces concerns about their patients’ financial burdens. As Ms Finley explained, “Knowing that patients are receiving financial assistance is reassuring for us. If patients cannot afford to come here or if they cannot afford their copays, that is worrisome. In addition to helping patients with their finances, Onyx 360 takes the burden off nurses and others caring for patients with MM….It saves time because it reduces the amount of paperwork that we need to process. We hand our patients the form and they follow up with Onyx 360 on their own. The patients have control.” Both of the Moffitt employees touted the time-savings associated with utilizing the Onyx 360 program. According to Ms Galloway, “One of the key benefits is that it frees up our time so that we can help more patients. We spend a significant amount of time completing and submitting paperwork, as well as communicating patients’ needs. Onyx 360 takes all that and runs with it. The benefits are tremendous for our institution as well as our patients.” References
1. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010–2020. J Natl Cancer Inst. 2011;103:117-128. 2. Patient Protection and Affordable Care Act of 2010. Public Law 111-148, 124 Stat 119, 2010. 3. High deductible health plans and rising consumerism negatively impact ratings endorsement policy [press release]. Fitch Ratings website; February 19, 2014. www. fitchratings.com/creditdesk/press_releases/detail.cfm?pr_id=821034. Accessed June 17, 2014. 4. Dusetzina SB, Winn AN, Abel GA, Huskamp HA, Keating NL. Cost sharing and adherence to tyrosine kinase inhibitors for patients with chronic myeloid leukemia. J Clin Oncol. 2014;32:306-311. 5. Onyx Pharmaceuticals 360TM (Onyx 360). Patient access. www.onyx.com/therapies/ patient-access/onyx-360. 6. Kyprolis® (carfilzomib) for injection, for intravenous use [prescribing information]. South San Francisco, CA: Onyx Pharmaceuticals, Inc. July 2012. 7. Nexavar® (sorafenib) tablets, oral [prescribing information]. South San Francisco, CA: Onyx Pharmaceuticals, Inc. November 2013. 8. REACH®. How the REACH® program works. www.nexavar-us.com/scripts/pages/ en/patient/patient-support/reach/. 9. Moffitt Cancer Center. www.moffitt.org/the-moffitt-experience/about-us. Accessed August 20, 2014.