PBM Oversight

Over the past decade, the availability and use of oral oncolytics as an effective cancer treatment option has significantly increased. In comparison to traditional intravenous (IV) chemotherapy treatment, oral oncolytics present an easier, more convenient route of administration for patients. Oral oncolytics have been shown to be safer and more effective than traditional IV chemotherapy treatments. However, despite the increased effectiveness of oral oncolytics, patient access and adherence has remained a key barrier to positive patient outcomes.

To improve patient access and adherence, many community-based cancer clinics have established medically integrated dispensing (MID) platforms. Under these models, patient care is more responsive and tailored to the state of the patient’s health allowing for improved education, reduced time-to-treatment and enhanced coordination of the care plan. Patients are able to conveniently access their oral chemotherapy prescriptions or other medications at the point-of-care. MID has proven effective at improving adherence to complex regimens and patient health outcomes, while also reducing total costs, patient copays, and drug waste.

As effective as MID programs are, patients continue to face barriers in accessing necessary medication at the pharmacy of their choice. As the nation’s largest insurers, pharmacy benefit managers (PBMs), and specialty pharmacies have consolidated and grown, they are able to determine pharmacy networks, establish utilization management policies, set reimbursement rates, and then present independent community oncology practices with a “take it or leave it” approach to contracting. While the PBM industry claims they maximize negotiated savings for their covered beneficiaries and plan sponsors, the real-world evidence suggests PBMs interfere with the doctor-patient relationship, drive up healthcare costs, and delay delivery of life-saving treatments.

PBM Steerage in Oral Oncolytics

As the nation’s largest insurers and PBMs consolidated, it became increasingly common for commercial health plans or plan sponsors to require their members to use the mail order or specialty pharmacy that the plan or its PBM owns and operates. Restrictive networks not only hurt patients by preventing them from taking full advantage of an integrated care team but they also hurt practice viability.

Even further, some PBMs have shown a willingness to misinterpret Medicare Part D and define pharmacy too narrowly in order to exclude MID and physician-owned pharmacies from their networks. In 2016, one PBM also went so far as to issue notices to MID physicians of the same, alerting that the physician dispensing class of trade would no longer be included in the PBM’s Part D network. Though the PBM reversed its decision after strong backlash, additional regulatory guidance is needed to strengthen their inclusion as in-network Part D providers.

Direct and Indirect Remuneration Fees

DIR fees have grown exponentially over the past decade and threaten the success of practice-based pharmacies. According to CMS, pharmacy price concessions, net of all pharmacy incentive payments, grew more than 107,400 percent between 2010 and 2020. DIR fees serve as a disincentive to practices wishing to establish or expand MID platforms and practice-based pharmacy operations, thereby impeding the growth of integrated care models that have been proven to improve patient outcomes.

Burdensome Utilization Management Requirements

As community cancer providers, we are dedicated to ensuring our patients receive access to timely and personalized care. Unfortunately, this is often disrupted by PBM prior authorization (PA) requirements, which burden physicians and clinical staff, increase practice operating costs, and delay time-sensitive care for patients.

TRICARE Reimbursement

Network practices were recently forced to decline the TRICARE/ Department of Defense contract under Express Scripts due to reimbursement terms that were not economically viable. This change will disrupt ongoing cancer treatment and may lead to delayed care. The Network wrote to the Senate and House Armed Services Committees, urging them to conduct additional oversight over the TRICARE pharmacy network to ensure beneficiaries undergoing cancer treatment do not experience delays in care or reduced outcomes as a result of this decision. To view the letter, Click Here.

Oversight is Needed

The lack of transparency into PBM practices makes it nearly impossible to determine whether they are truly lowering costs for patients and the health care system. The Network supports greater transparency and oversight of PBMs to ensure patients are able to access their medications in a timely, affordable, and convenient manner.

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