Practice Changes in Management of Patients Receiving Oral Chemotherapy

As developments in cancer treatment shift toward oral agents, new processes, procedures, and strategies must be developed to help healthcare providers maintain the same level of interaction with patients. Traditionally, patients are seen by their oncologists and then sent to an infusion center for their intravenous chemotherapy where they interact with nurses and/or pharmacists. These interactions allow for early assessment and intervention of medication- related issues, side effects, and tolerability.

In the shifting paradigm, patients see their oncologist, are given a written prescription, and then sent home. This transfers a bulk of the responsibility onto the patient, with no true indicator of adherence. In addition, the patient has no interaction with other healthcare providers regarding adverse reactions and other medication-related concerns. One solution is to design and implement a pharmacist-managed oral chemotherapy program, which will ensure that patients can still interact with practitioners between their oncologist visits.

The ProcessThe St. Luke’s Mountain States Tumor Institute created a pharmacist- managed program to help deal with the emerging issues surrounding oral chemotherapy. When a new prescription is written, it is transferred to the oral chemotherapy pharmacist. The pharmacist then evaluates it for accuracy of dosing, as well as indication, drug interactions, and side-effect management. Each patient is counseled directly by an experienced oncology pharmacist about the drug and the process for filling the prescription.

Next, the script is sent to a closedaccess pharmacy, which can be used solely by staff and patients of the health system. The prescription then is run through insurance and filled. Once filled, it gets delivered to the patient at the nearest infusion center (or mailed to a select subset of patients with transportation restrictions).

If issues arise regarding high co pay, denial of coverage, or lack of insurance, the cancer center’s financial advocates are brought into the pro cess to help with copay assistance or free drug programs. Finally, after the patient starts the medication, the pharmacist calls the patient on a weekly basis for the first cycle, then monthly 1 week before each refill date.

Factors Break-Even Point Analysis
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Justification An institution must be able to justify the staffing requirements of the program. Start by creating a breakeven point analysis, in which you figure the costs and rev-enue potential. Then, evaluate the salary requirements, estimated number of pre scriptions expected, and average costs/ income of each prescription to show the required break-even point. Next, implement a 2- to 3- month pilot to verify the assumptions in the initial analysis. Pilot data can then be annualized to justify the long-term program (Figure).

Barriers to Overcome

One of the biggest barriers is overcoming your current processes. Someone must be able to meet with prescribing oncologists to ensure that prescriptions pass through the oral chemotherapy pharmacist. We use registered nurses who work with each physician to act as gatekeepers to oral chemotherapy prescriptions. In addition, we use standardized order forms, which help remind prescribers that there is something special that needs to happen with these patients.

Another barrier is insurance issues. A variety of issues may need to be addressed, such as prior authorization forms and requirements to use mail order pharmacies. We had our pharmacy billing specialist analyst set up contracts with third-party payers, which has helped reduce our total population using mail order pharmacies to approximately 10% to 15%.

Clinical Impact The program has proved beneficial to patients, staff, and the health system. Without guidance, patients can have difficulty obtaining their drug, a huge cause of medication nonfulfillment. For example, a patient with pancreatic cancer came to our program stating that a pharmacist at a retail pharmacy told her that “this drug will be about $5000 per month.” Hearing something like this on top of her diagnosis was hugely detrim ental. Our financial advocates, however, were able to help this patient find copay assistance.

Furthermore, patients have come to our program asking for help with insurance issues, refill tracking, and monito ring. Many pat i ents have expressed great satisfaction with the processes. One patient made note th at whe n it c am e to her oral chemotherapy, she “knew that it would be taken care of and done right.” I n addition, nursin g and provider surveys have been overwhelmingly positive regarding the program’s benefits. Sometimes, it only takes one difficult case for a prescriber to realize these benefits and begin to follow the process.

The pharmacists have been able to help m anage significant drug interactions as well; to date, there have been interventions on approximately 75 major drug interactions.

Economic Impact

The early break-even point analysis proved to be a great underestimate of the potential of this program. Early estimates expected about 500 prescriptions per year, and our current numbers are nearly triple. Our pharm acy business an alyst showed that our actual revenue generated greatly outweighed costs. This revenue has been able to justify the salary of a pharmacist (1 FTE) and technicians (1.5 FTEs).

The program has been able to acquire more than $1 million of free drug and $200,000 of copay-assistance funds for patients. The program also has been able to reduce write-offs to less than 1% of total drug costs, while making sure nearly every patient has received his or her prescribed medication. By putting the proper controls in place and ensuring proper staffing, institutions can guard against the shifting paradigm of oral chemotherapy leaving them in the lurch.

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