First Issue, Series Two
Stakeholder’s Perspective: Nursing
Dr Hansen’s article brings to light financial aspects of healthcare that we do not often consider. A recent economic analysis showed the total cost of cancer care in the US reached $209.9 billion in 2005.1 The high costs of chronic cancer care come in second to cardiac disease (23% and 38%, respectively).2,3 However, increased costs do not yield longer life. Americans have a shorter life expectancy at 80 years than residents of other countries.2
Drugs such as imatinib can be taken from the laboratory bench to the patient’s bedside, transitioning cancer into a chronic illness. However, effective treatments come at a price and contribute to rising healthcare costs.4 For patients with cancer who have access to newer technology and advanced treatment options, one questions how a balance between health and healthcare spending can be achieved? Thus the topic of cost containment in US cancer care becomes an important issue.
Insurers have addressed cost containment by utilizing the specialty pharmacy provider (SPP). Dr Hansen provides an excellent review of the role of SPPs and how it relates to the cancer patient. She mentions that 77% of health plans classify oral oncology agents as specialty drugs that require special handling, monitoring, and dispensing. This directly impacts nurses and providers who are charged with refilling specialty medications in a timely manner. Employing SPPs that focus solely on the delivery of specialty medications eliminates overuse of high-cost medications and streamlines prescription refills. The SPP staff become expert in the handling of each medication. The staff learn to anticipate potential problems and facilitate care. But is it true that the SPP helps to contain costs and provides services that a local oncology pharmacy cannot?
I have extensive experience dealing with SPPs that has been mostly positive. Sure, SPPs are often not located in the same state, but most strive to ensure that patients receive their medication in a timely manner without dose delays. One of my biggest challenges is refilling monthly oncology medications, so I am pleased when the SPP sends an electronic reminder (usually by fax) to notify our staff when prescription refills are due. In addition, some SPPs do an excellent job of sending electronic reminders when prior authorizations are needed to minimize dose delays.
One of the most beneficial services of the SPPs is in regard to copayment assistance. The SPPs will look into various financial aid organizations (such as the Chronic Disease Fund) if the patient is uninsured or underinsured. It is such a relief to me (and the patient) when SPPs are willing to help with the paperwork to seek funding for the patient.
I agree with the challenges Dr Hansen mentions. These place the patient at risk for missed doses. Dispensing the oncology drug from a different geographic location can be stressful for the patient who forgets to request a medication refill until the last minute. It would be easy to write a prescription and hand it to the patient so he or she can retrieve the medication locally. When an SPP is in a remote location, it requires more effort to make sure the patient receives his or her medication. Also, many SPPs require patients to sign for the medication delivery, which can lead to a balancing act on behalf of the busy patient.
In addition, specialty oncology agents (eg, lenalidomide) have a complex dosing schedule or require special testing prior to refill (such as human chorionic gonadotropin for women of childbearing potential and monthly complete blood counts to assess for dose adjustments). Provider and pharmacist counseling is also mandated prior to each prescription refill. Waiting for test results and providing counseling prior to each monthly refill increase the likelihood of missed doses. Coordinating all of these activities on a monthly basis for 1 or many patients can be time-consuming for the nurse.
In general, I find SPPs to be helpful, and that can increase patient satisfaction. Patients who receive lenalidomide through an SPP are often contacted monthly by the same pharmacist to complete mandated safety counseling. Patients have remarked that although they never met “the voice on the other end of the phone,” the pharmacist was willing to listen to personal stories such as a daughter’s wedding, provide side effect management strategies and reassurance, and secure additional funding for medications when needed. Navigating healthcare can be overwhelming for our patients, and these services make a difference. But I am confident that local oncology pharmacy staff would be at least as successful in this and other areas.
The role of the oncology clinician has evolved over time. When I began working as a nurse, I was charged with scheduling appointments, managing side effects, and making sure the treatment was administered as recommended by the practitioner. Intravenous treatments have been replaced by newer oral agents that require special handling. Nurses are the critical link between patients and insurance providers to help get the oncology care medications needed to treat their illness. SPPs have emerged as a cost-containment structure and to manage the flow of expensive cancer medications. Additional services include medication counseling and financial assistance to patients who are emotionally and financially burdened by the cancer diagnosis. With ever-increasing healthcare costs, it is relatively certain the role of the SPP, like the role of the nurse, will continue to evolve over time.
- Meropol NJ, Schulman KA. Cost of cancer care: issues and implications. J Clin Oncol. 2007;25:180-186.
- World Health Organization. WHOSIS (WHO Statistical Information System): a guide to statistical information at WHO—World health statistics 2009. http://www.who.int/gho/countries/usa/country_profiles/en/index.html. Accessed February 4, 2012.
- Bodenheimer T. High and rising health care costs. Part 1: seeking an explanation. Ann Intern Med. 2005;142:847-854.
- Lee TH, Emanuel EJ. Tier 4 drugs and the fraying of the social compact. N Engl J Med. 2008;359:333-335.
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