At the 11th Annual Summit of the Association for Value-Based Cancer Care in 2021, a panel of experts, moderated by Michael Reff, RPh, MBA, Founder and Executive Director, National Community Oncology Dispensing Association (NCODA), Cazenovia, NY, discussed the current and future state of Medically Integrated Pharmacy (MIP) and the benefits of this approach in oncology.
The MIP model is designed to empower the treating physician, ideally coordinating with a pharmacist in the same facility to provide oversight regarding drug selection and administration, side-effect management, and the monitoring of patients throughout the course of treatment. The model consists of a medically integrated team that may include providers, nurses, pharmacists, pharmacy technicians, administrators, financial counselors, genetic counselors, and social workers and therapists, among others. “It comes from primary care, where it has been validated,” said Bhavesh Shah, RPh, BCOP, Associate Chief Pharmacy Officer, Specialty and Hematology-Oncology Pharmacy, and Senior Director, Specialty Pharmacy Strategy and Market Access, Boston Medical Center, MA. “Oncology is pretty new to this, and it’s just now that we’re seeing health systems put this together where oncology needs to have a nurse, a pharmacist, a social worker, and a financial coordinator to serve patients who are very complex, especially in our health system.”
In a MIP model, patients may be asked questions that a specialty pharmacy would not ask, he continued. “For example, we know that patients with food insecurity have a significant issue with taking a medication that is affected by food,” he said. “Specialty pharmacy won’t ask patients if they have issues getting food. But a health system is going to do that. We can make sure that that patient is taking that medication right but that they also have access to the food that they need for absorption of the medication for it to work. The model involves more than teaching and sending the drug to a patient.”
Benefits of the MIP Model
Oncology therapy has become exceedingly complex, with doublets and triplets becoming standard. Managing these regimens requires care coordination that may not be available outside of a MIP, where every member has access to the patients’ electronic medical record (EMR), the panelists agreed.
“If you have one drug that goes through the medical benefit and another drug that must go through the pharmacy benefit, and the financial assistance is different for the two, you have to make sure the patients have access at the same time they come into the clinic to start their therapy,” said Ray Bailey, BPharm, RPh, Senior Vice President, Pharmacy Services, Florida Cancer Specialists & Research Institute, Ft. Myers. “You can’t do that unless you have access to the EMR. It takes a tremendous amount of coordination, and I would see it being very difficult to do that outside of a practice that did not have a MIP if they’re handling the oral component of that regimen.”
Having access to the EMR can make the prior authorization process faster for infused and oral therapies, said Chris Marcum, PharmD, Vice President, Enterprise Pharmacy, Cancer Treatment Centers of America, Cleveland, OH. “If I’m trying to get support for an oral, I can go back into the patient’s history, see their labs, and see whether they’ve been compliant,” he said.
Robust patient education is another benefit of a MIP. “We have a proprietary platform that we use for oral adherence,” said Mr Bailey. “We have our pharmacy care plans structured in that platform for each individual drug. So, when a drug comes to market, we’re able to build those internally into the platform so we’re ready from day 1.” Part of the education is getting the patient to buy into the benefit from an oral therapy with recognition of potential toxicities before they occur, and the awareness that the care team will help with side-effect management, he said.
One goal of a MIP is to improve clinical outcomes. Measures such as medication adherence have served as poor surrogates for outcomes, said Mr Shah, who is trying to change that paradigm. “We looked at our CML [chronic myeloid leukemia] data specifically over 5 years and looked at adherence rates and complete molecular response in those patients managed in our pharmacy in our integrated model versus the outside specialty pharmacy,” he said. “We noticed that adherence was the same, but the complete molecular response was different.” The education, social support, and other offerings of MIP may be driving the better outcomes, he suggested.
A MIP may have economic benefits as well by reducing accumulation of expensive therapies, again a function of EMR access, Mr Bailey added. “If we see that a patient needs a dose reduction [or holiday], we’re not going to fill another 30 days. We track that so that’s an intervention where we save the system money. That’s because we have access to the EMR,” he said.
Looking Ahead
Moving forward, a new NCODA Center of Excellence MIP accreditation promises to be more patient-centric, said Stacey McCullough, PharmD, Senior Vice President, Pharmacy, Tennessee Oncology, Nashville.
“It’s going to be collaborative with the practice and the quality and value that it brings,” she said. “It’s going to be across the board to all stakeholders, making sure that each activity is focused on the outcome of the patient.” In the past, the cost of accreditation itself could be prohibitive for smaller practices, but the new accreditation will be budget neutral and will allow smaller practices to demonstrate their value.