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. The current structure for pharmacy price concessions fails to allow for meaningful price comparisons, does not encourage price transparency, and is not optimal for producing the lowest overall prescription drug costs for beneficiaries.
Some pharmacy benefit managers (PBMs) employ anticompetitive tactics that increase patient cost-sharing or restrict patient access to MID facilities resulting in delays and higher treatment costs. The current use of retroactive pharmacy price concessions serves 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. If all pharmacy price concessions were reflected as part of the negotiated price, the net beneficiary costs would decrease by approximately $21.3 billion over 10 years according to CMS.
Furthermore, 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, MID and physician-owned pharmacies are looking to CMS to provide additional regulatory guidance to strengthen their inclusion as in-network Part D providers.
The Network supports transparency and oversight of the PBMs to ensure patients are able to access their medications in a timely, affordable, and convenient manner. Any broad-based exclusion of MID physicians from Medicare Part D in-network provider status would have potentially disastrous effects on the quality of patient care and costs. The Network encourages CMS to consider regulatory language or commentary that establishes that duly licensed providers authorized by the health practice laws of their state to dispense outpatient drugs to the patients are afforded the same treatment as a pharmacy for the purposes of Part D’s any willing pharmacy requirement.