Tuesday, July 8, 2014

The 5 Biggest Challenges for Stakeholders in the Oncology Value Chain

Interview with Rebecca M. Shanahan, CEO of Avella Specialty Pharmacy, a speaker at IIR's upcoming Annual Summit for Oncology Management, July 21-23, in Philadelphia.
What are the 5 biggest challenges for stakeholders in the Oncology Value Chain? And why?

Despite tremendous advancements, there remain significant challenges in the Oncology Value Chain.

First, there remains a lack of meaningful integration of the stakeholders.

The silos that exist in this area of healthcare limit communication and, ultimately, patient health outcomes, whether by virtue of geography, subspecialization, organizational structure or fragmented data. 

One area this is evident in is the duplication of existing services capabilities by hospital networks. For example, primary care network management, pharmacy services, hospice, and other services lines are often redundant with those already existent in the provider community. “Big data” capabilities remain in repositories that are not driving insights to improve healthcare across provider segments.  Informatics pointed toward patients communicate/replicate medical terminology without flags, links or explanations comprehensible by the most highly educated laypeople.

Pharmaceutical manufacturers with patient assistance and nursing support programs, interactions with PBMs and Plans regarding formulary management, and aligned economic incentives are hampered by the “silo” approach when they tailoreprograms and pricing to differeing classes of trade, sometimes to their detriment.  As an example, a manufacturer of a new oral medication treating a disease previously less well treated by infused therapies experiences 75% dose titration in its clinical trial. To roll the drug out, it conducts Physician Advisory Boards, Physician Clinical Education and Healthcare Economic Outcomes Reviews of Prescribing Patterns.  As the drug is an oral therapy and most likely dispensed by a pharmacy, the manufacturer also established an 8 pharmacy Limited Distribution Network for the drug.  However, no program was instituted for the pharmacies and the prescribing physicians to share information and ask questions regarding dose titration.  Real world dose titration was 27%, thereby resulting in lower uptake of the drug and less benefit for patients.

Once data becomes ubiquitous and the tools to access and comment on the data are available through a user-friendly system, we will move to risk-sharing model that would benefit all stakeholders.

Second, there remains a lack of novel approaches to therapy management that improve patient empowerment. 

Value-based care has historically worked well with diabetic & cardiovascular patients.  Pitney Bowes and Safeway both have successfully implemented programs to align the interests and needs of employers and employees.  Similar practices could be further leveraged within the oncology treatment process.

Shoppers Drug Mart created a pharmacy benefit plan based upon a retail pharmacy services model wherein enrollees could qualify for a progressively enhanced series of incentives, benefits & rewards if they (i) completed an Health Sstatus Assessment, (ii) elected to participate in health management programs for one of 5 high cost diseases which they evidenced experiencing, (iii) progressed through milestones associated with disease-specific therapy management and (iv) sustained their health gains over a period of time.

Cardinal Health and P4 Pathways, as well as Wellpoint Aim, established Pathways Programs in Oncology wherein NCCN guideline-based Formulary, Interventions and Outcomes metrics drove Best Practices and savings at a rate of 5 to 15 percent, depending upon the flexibility of the pathway, the pre-existing Clinical Best Practices approach, etc.  Using a series of interventions, the program managed and documented cadence and content, exchanged generics for brands where appropriate, managed dosing, reduced combination therapy in later stages of therapy and provided regular clinical checks for patients.  These novel programs could gain more widespread utilization within the industry, provided collaboration occurs real time amongst physicians, pharmacists and disease therapy management providers.

Third, there is not a clear intersection / integration for providers, payors, patients and pharmaceutical manufacturers on healthcare coverage issues. 

There needs to be a shift from “Class of Trade” thinking to “Patient Engagement” thinking by the stakeholders.  There should be a standard of care, regardless of class of trade.  The appropriate treating provider based on clinical expertise, patient location and unique patient healthcare and socio-economic needs would have the data accessible to delivera consistently measured and reported standard of care.

Fourth, the cost of oncology therapy and care management continues to rise dramatically.
Currently, care management spending is $100B annually and is projected to be $200B by 2020.  This is compounded with the cost of specialty medications that, at $100B, represent 25% of pharmacy spend today.  By 2015, this is projected to reach over $180B and could trend over $400B by 2020.  A large driver of this cost is hepatitis-C treatment, but oncology is also making tremendous impact.
While  costs may be fueling  tremendous medication advancements, more focus needs to be place on the HEOR (health economics outcomes research) to better understand the end-to-end measurement of costs and health outcomes.  With greater transparency of data to measure results of therapy, we could better align incentives and savings and service models. 

Fifth, across all stakeholders, there needs to be an improved knowledge of the oncology value chain.

We are seeing gains in this challenge.  An example is the (recent) traction of the oral parity laws that ensure equal coverage for infused oncology therapies versus oral oncology therapies.  In a study done by Prime Therapeutics, it was found that one in six cancer patients with high out-of-pocket costs abandon their medication.  The same study found that patients with an out-of pocket cost greater than $200 were at least 3 times more likely to not refill prescriptions than those with OOP costs of $100 or less.  The technology has evolved, but because of cost differentials, patients may not reap the rewards of these advancements.

Improved knowledge would benefit the oncology community in the areas of drug safety, specifically pharmaco-vigilence programs and than transparency of reporting to provider and pharmacies.

How do specialty pharmacies like Avella assist with these issues?   

Specialty pharmacies are in a unique position to connect the stakeholders in the Oncology Value Chain.  Leveraging their position of having meaningful interactions with the many oncology stakeholders (patients, payors, manufacturers, healthcare providers), specialty pharmacies should serve as a “hub” for the stakeholders.  Formulary management, step therapy implementation, HIPAA-protected real time data collection and reporting, access to performance of patients across providers, payers and therapies – all these in one tool-based repository are available through Avella and its clinical pharmacy team.

With a deeper connection between the stakeholders, the data each group is collecting and measuring becomes more transparent and useful.  Harnessing the data, specialty pharmacies can become a leader in health economics outcomes research and ultimately find additional cost savings solutions.

Finally, through increasingly meaningful patient engagement, specialtypharmacies can improve communication, adherence levels, patient literacy levels, and clinical outcomes.  This short video highlights several of the ways Avella and specialties pharmacies benefit patients:  https://avella.wistia.com/medias/fksa6j9ntg

About Rebecca M. Shanahan:

As Chief Executive Officer of Avella Specialty Pharmacy, Ms. Shanahan brings extensive healthcare and specialty pharmacy experience to Avella Specialty Pharmacy. Ms. Shanahan served as Executive Vice President and Head of the Aetna Specialty Pharmacy from 2005 - 2007 and as a member of Avella Specialty Pharmacy’s board of directors from 2010 – 2013.

Prior to joining Avella Specialty Pharmacy, Ms. Shanahan was president of Shanahan Capital Ventures, LLC, (SVC) a consulting firm that built strategic business initiatives and programs for a number of healthcare entities in the United States and Canada. SVC clients included Cardinal Healthcare Specialty Solutions, Shoppers Drug Mart, Rite Aid Pharmacy, US BioServices, Bayer Pharmaceuticals, Bristol-Myers Squibb, Inspirational Biologics, MedSolutions, and Reliant Rehabilitation.

To learn more about Rebecca and the other members of Avella leadership, please visit www.avella.com/leadership

Rebecca will be a speaker at the upcoming Oncology Management Summit held July 21-23, 2014 in Philadelphia. Register now and save 15% when you use the code: XP1914BLOG.

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