7 questions with Dr. Christie Smith
By Christie Smith, PharmD, MBA
Discussing the real-world value of medically integrated dispensing
What inspired this research?
From the moment I started at AmerisourceBergen, now Cencora, medically integrated dispensing has been top-of-mind. And once I get enough data accumulated through studies, I'd like to be able to demonstrate to payers—not just Pharmacy Benefit Managers (PBMs), but plan sponsors or employer groups, benefit sponsors, all types of payers — that there is value when a pharmacist sits inside a medical practice.
What are the key takeaways from your research?
We did a retrospective study, looking back over a five-year period using Oncology Care Model (OCM) data. OCM was initiated by the Centers for Medicare & Medicaid Services (CMS) with specific purposes to incentivize physicians. If they participated, they would get this care coordination fee. As you could probably imagine with cancer drugs, there's a lot going on for that patient.
We did a retrospective study, looking back over a five-year period using Oncology Care Model (OCM) data. OCM was initiated by the Centers for Medicare & Medicaid Services (CMS) with specific purposes to incentivize physicians. If they participated, they would get this care coordination fee. As you could probably imagine with cancer drugs, there's a lot going on for that patient.
At Cencora, one of the teams that sits under our umbrella is IntrinsiQ Specialty Solutions. They are our data aggregator, within the specialty group. And they housed all that data. I reached out to one practice with a pharmacist, that sits inside Hematology Oncology of Central New York. They agreed to participate, so I was able to use their data in this study.
We had some very aggressive endpoints. The main one was to show improved adherence across three or four different therapeutic classes of drugs. The second endpoint was to show decreased waste with those therapeutic drugs, because the drugs cost can average $20,000 a month. Finally, there was a lower total cost of care. So those were our three endpoints.
We were able to prove one, which was better adherence. The second endpoint, we were not able to prove out with a statistically significant difference because our patient population wasn't large enough. And so therefore, that last endpoint we did not get to, but we were very encouraged with what the data did show.
Does it matter what type of cancer or what stage patients are in?
The OCM covered all different cancers. The interesting thing about the research was we didn't know what drug was going to bubble up. So, when we were separating out all the fields and the data, it ended up being the breast cancer drug, IBRANCE® (palbociclib), and the prostate cancer drugs XTANDI® (enzalutamide) and ZYTIGA® (abiraterone acetate).
What limitations were in place for the study?
One of the things we had to do to prove that a medically integrated dispensing care setting provides better adherence for those drugs was separate the data.
Imagine you are a cancer patient, and you receive the diagnosis. Your doctor says, we’re going to put you on therapy. It's going to be a year of treatment. The doctor writes the prescription and they start filling it. Well, in some of those cases, they are not able to fill inside their practice. For example, you were on therapy for about six months, and your prior authorization expired, but you lived far away from the practice. They get the Prior Authorization (PA) in place, but you need to start treatment. So, you fill one of those scripts outside of the practice at your local pharmacy.
If you were supposed to be on therapy for 12 months but you filled one prescription of that cycle outside of that practice, we had to exclude that data.
We also had to consider individuals who smoke and may develop cancer. Based on criteria like that, we had to exclude some people from the start so we could prove that our target impacted the outcome.
Was there anything in the research that was surprising, that you didn't expect, that you found out?
When we look at length of therapy, the Medically Integrated Dispensing (MID) pharmacy practice kept the patient on the drug longer. Now at a glance, is that ideal for a payer or not? Someone looking at that data may ask, why did the physician practice MID have so many more fills than specialty pharmacy, overall length of therapy? And that part really was troublesome until I talked to the practice’s pharmacist about it, and he confirmed that’s what they wanted.
When treating cancer, it is important for the patient to remain on the drug for the entire course of treatment. And factors that could contribute to that could include if the patient's having side effects, nausea, vomiting, diarrhea, to an extent that the physician's reacting in real time and making those adjustments in his dispensing pharmacy. With a mail-order-pharmacy, it's just not real time. It just can't be. You may have dose reductions in MID, but patients did not have to stop the therapy. A longer duration is ideal according to National Comprehensive Cancer Network (NCCN) guidelines of a particular drug.
What’s next for this research?
The OCM study is over, but we are engaging practices to join the expansion study, which will include about 20 practices. ger duration is ideal according to National Comprehensive Cancer Network (NCCN) guidelines of a particular drug.
Are patients allowed to be a part of this study and take this drug for your study purposes and get radiation and surgery too?
Absolutely. It just really depends on the type of cancer that you have. With breast cancer, you might have surgery and radiation and post-adjuvant therapy, meaning you continue on medication for five years to stop recurrence or to prevent recurrence. There are so many different options now, and we continue to learn things about drugs that are already out on the market, and they get more indications. IBRANCE® used to be just for metastatic breast cancer, now it has expanded indication to start treatment sooner in advanced cancers. So, there's a lot of technology going on in this therapeutic category of oncology. And the most interesting thing is that a lot of the drugs are now oral. They used to be all intravenous.It's a very exciting area of study in a pharmacy practice, but it's also very costly. We have to try to figure out a way to manage both. You want access to the best treatments, but somebody's got pay for it. Medically integrated dispensing is a way you can help provide the best treatments in a cost-effective care model.
View Christie's poster here
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