Oncology therapeutics continue to be a dominant component of the treatment paradigm, and thus, specialized oncology pharmacy programs play an ever-increasing role in the complex delivery of care. Oncology pharmacy activity needs to be harmonized, not fragmented, with the patient’s overall core care team efforts. At the 2021 Summit of the Association for Value-Based Cancer Care, a panel moderated by Michael Reff, RPh, MBA, Founder and Executive Director, National Community Oncology Dispensing Association (NCODA), discussed the current and future state of medically integrated pharmacy (MIP) and the benefits of this collaboration.1
According to NCODA, a MIP is “a dispensing pharmacy within an oncology center of excellence that promotes a patient-centered, multidisciplinary team approach. The medically integrated dispensing pharmacy is an outcome-based collaborative and comprehensive model that involves oncology health care professionals and other stakeholders who focus on the continuity of coordinated quality care and therapies for cancer patients.”1
The MIP model is designed to empower the treating physician, and ideally coordinating with a pharmacist in the same facility to provide oversight on drug selection, administration, and side-effect management, as well as monitoring patients throughout the course of their therapy.
The MIP model consists of a medically integrated team that can include providers, nurses, pharmacists, pharmacy technicians, administrators, financial counselors, genetic counselors, and social workers/therapists, among others. “It comes from primary care, where it has been validated,” said Bhavesh Shah, RPh, BCOP, Director of Specialty Hematology/Oncology Pharmacy, 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. I’m on this panel because we serve a significantly high amount of Medicaid patients; 50% of our patients are covered by Medicaid, their income is under $20,000, their health literacy is low, and English is not a first language. Serving those patients in a specialty pharmacy with that complexity is very challenging,” Mr Shah said.
In a medically integrated 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 impacted 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 med 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 the patient.”
Oncology therapy has become exceedingly complex, with 2- and 3-drug combinations becoming standard of care. 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 2, 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, Pharmacy Director, Florida Cancer Specialists. “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 for oral therapies, said Chris Marcum, PharmD, Vice President, Enterprise Pharmacy, Cancer Treatment Centers of America. “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 one.”
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, Mr Bailey said.
One goal of the MIP is to improve clinical outcomes. Measures such as medication adherence have served as poor surrogates for outcomes, argued 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 integrated pharmacy model versus the outside specialty pharmacy,” Mr Shah said. “We noticed that adherence was the same, but the complete molecular response was different.” The education, social support, and other offerings of the MIP may be driving the better outcomes, he suggested.
The superior drug initiation turnaround time with a MIP may also be responsible, said Mr Bailey. “It’s important to get that patient started quickly and on the right foot and the MIP model has been the only one proven to do that,” he said.
A MIP may have economic benefits as well by reducing accumulation of expensive therapies, again a function of EMR access, he added. “If we see that a patient needs a dose reduction [or a 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.
Moving forward, a new NCODA Center of Excellence MIP accreditation promises to be more patient-centric, said Stacey McCullough, PharmD, Senior Vice President of Pharmacy, Tennessee Oncology.
“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.
- National Community Oncology Dispensing Association. NCODA announces the defining of the Medically Integrated Dispensing Pharmacy. January 27, 2020. www.ncoda.org/medically-integrated-dispensing-pharmacy/. Accessed November 22, 2021.