Oncology Pharmacy Services

Transcript

• 00:00Support for Yale Cancer Answers
• 00:02comes from AstraZeneca, dedicated
• 00:05to advancing options and providing
• 00:07hope for people living with cancer.
• 00:10More information at astrazeneca-us.com.
• 00:14Welcome to Yale Cancer Answers with
• 00:16your host doctor Anees Chagpar.
• 00:19Yale Cancer Answers features the
• 00:21latest information on cancer care by
• 00:23welcoming oncologists and specialists
• 00:24who are on the forefront of the
• 00:27battle to fight cancer. This week
• 00:29it's a conversation about medication
• 00:31assistance programs with
• 00:33Nancy Beaulieu and Brenda Sepulveda.
• 00:34Nancy is associate director
• 00:36of oncology pharmacy services.
• 00:37And Brenda is
• 00:40medication Assistance program coordinator.
• 00:42Doctor Chagpar is a professor
• 00:44of surgical oncology at the Yale
• 00:47University School of Medicine.
• 00:50Nancy, maybe I'll start with you.
• 00:52Tell me a little bit more about
• 00:56yourself and what it is you do.
• 00:59We essentially mix chemotherapy and
• 01:01assure that all medication safety
• 01:04practices are in order for all of our
• 01:07patients within our
• 01:08network.
• 01:11Brenda, how about you?
• 01:13I am the medication assistance program coordinator.
• 01:14I am part of a group that
• 01:16assists patients with medication
• 01:18programs that require copay
• 01:21or foundation funding.
• 01:22So Nancy,
• 01:23from a big you know 30,000 foot picture,
• 01:27how often is it that patients actually
• 01:30have issues in paying for medications?
• 01:32I think that on this show we've
• 01:36often talked about novel therapies,
• 01:38the latest in clinical trials,
• 01:40new targeted drugs.
• 01:42But all of that comes at a cost.
• 01:45How much of a problem is it?
• 01:48The financial
• 01:49burden of many of the new
• 01:51medications that come out?
• 01:53All patients
• 01:55with long term chronic diseases,
• 01:57cancer included, have
• 01:59significant stressors to deal with.
• 02:01They have emotional stress.
• 02:02They have mental, physical stress,
• 02:04but one of the greatest stressors
• 02:06that they deal with that's a burden
• 02:09not only to the patient themselves
• 02:11but also their family is the stress
• 02:14of the financial component of how
• 02:16they're going to pay for their therapy,
• 02:19their treatments.
• 02:20Financial toxicity is a newer buzz
• 02:23term that we are using to describe
• 02:25the some of the financial side affects
• 02:28associated with the economic burden
• 02:30of care and medications placed on
• 02:33these patients and their families.
• 02:35It is a significant issue and that is
• 02:38one of the reasons why as long as
• 02:4112 years ago we went into developing
• 02:44a mechanism to assist patients with
• 02:48some of this financial burden.
• 02:50And just staying with you on that,
• 02:53I mean aren't many of
• 02:56these therapies covered by insurance
• 02:58or are people still having
• 03:00Financial hardship despite insurance?
• 03:03We have many patients who have either
• 03:06inadequate health care insurance or
• 03:08they have health care insurance
• 03:10but the out of pocket costs of many of
• 03:14these therapies can be extreme and a
• 03:17severe burden on their financial outcome.
• 03:20There are significant rising
• 03:22costs and medications.
• 03:23All new meds that do come out,
• 03:26and certainly they provide hope for
• 03:29many patients, but they
• 03:32do come with a cost,
• 03:33and that is one of the things
• 03:36that we really need to work with.
• 03:38And we have been doing that
• 03:41for over 10 years.
• 03:42For our patients,
• 03:43both here and in the
• 03:45outpatient specialty pharmacy,
• 03:47they also have medication
• 03:49assistance program coordinators.
• 03:50Brenda tell us a little
• 03:52bit more about how that works.
• 03:54I mean, I can imagine that cancer patients
• 03:58are faced with a diagnosis of cancer,
• 04:01which is enough of a burden,
• 04:03physically, mentally, emotionally.
• 04:05And then
• 04:07their doctor prescribes a chemotherapy
• 04:09regimen or certain medications,
• 04:11and then whether they have insurance or not,
• 04:15they are faced with a rather large bill.
• 04:18So how do you help them to get around that?
• 04:23And is there a difference between
• 04:25the assistance that's available
• 04:27for uninsured patients versus
• 04:28the assistance that's available
• 04:30for people who have insurance
• 04:32but might not be adequate?
• 04:37And staying with that topic,
• 04:39we know that the financial burden
• 04:42is a big concern and part of what
• 04:44we do within our program is to
• 04:48ensure that the patient is able
• 04:50to remain on the preferred course
• 04:52of therapy while focusing on their
• 04:54health care journey and so for
• 04:57the patients that are insured but
• 04:59maybe under insured because they
• 05:01still have high out of pockets,
• 05:04we assist with those copay
• 05:06assistance programs.
• 05:07There are manufacturer sponsored Copay
• 05:09Foundation funding or replacement programs.
• 05:11There's a difference with the
• 05:14patient that is insured and also
• 05:17that has no insurance and so we will
• 05:20go depending on what the status is
• 05:24to the preferred program to ensure
• 05:26that they are able to remain on
• 05:29that therapy without interruptions
• 05:31and without having to deplete their
• 05:34own personal income throughout
• 05:36their therapy journey.
• 05:38Tell me more about that, Brenda,
• 05:40because I'm sure that
• 05:43many of our listeners are really
• 05:46rather intrigued about how
• 05:48there is assistance available,
• 05:50so let's take the two examples.
• 05:52So the first is for people who have
• 05:55insurance but they are still under insured.
• 05:58Their out of pocket costs are
• 06:01too much for them to bear,
• 06:03so how do they access these programs
• 06:06and what programs are available?
• 06:08Would they cover all of their
• 06:11out of pocket costs?
• 06:12You mentioned that these are programs
• 06:15available through the manufacturers.
• 06:16Can you tell us more about that?
• 06:20Sure, so patients are able
• 06:23to access the manufacturer
• 06:24sponsored programs as soon as they
• 06:27identify what medications they're
• 06:29having a financial concern with.
• 06:32Typically it can go through providers
• 06:35where they will also have access to
• 06:38this pharmacy services and will be
• 06:41contacted to then do a little more
• 06:44research within the manufacturer program.
• 06:46So someone who has insurance
• 06:49but is underinsured,
• 06:50means that they still have a high out
• 06:53of pocket cost to that medication and
• 06:56this can occur many times
• 06:58within the treatment.
• 06:59So what we do is take care of the portion
• 07:02that is pertaining to the medication.
• 07:05A lot of programs may allow the financial
• 07:08eligibility to go towards other costs
• 07:10during that appointment,
• 07:11but typically will go geared
• 07:13towards the medication, and
• 07:15that's our main focus because we
• 07:17know that that's where the out
• 07:20of pocket costs tends to fall under,
• 07:22and that's where it's mostly
• 07:24when it comes to the treatment.
• 07:27So for someone who is
• 07:30underinsured or uninsured, then
• 07:32we will follow the same protocol.
• 07:34If there's a concern that's been extended
• 07:37to the provider and we are aware of that,
• 07:41or the patient may have been
• 07:42able to gather some information
• 07:44through the manufacturer's website,
• 07:47then we go ahead and become sort of
• 07:49a gateway for the patient in the
• 07:52programs and our providers to make
• 07:55sure that they are properly enrolled
• 07:57and that the process of submissions
• 07:59for those out of pocket costs
• 08:02are processed correctly and the patient
• 08:04doesn't have to worry about any of
• 08:07that during the course of their therapy.
• 08:09So someone who is uninsured may be
• 08:12eligible to actually have access to
• 08:15the medication replacement programs
• 08:17through the insurance as well.
• 08:20By us having to go through the
• 08:22programs for the
• 08:24manufacturers.
• 08:25Nancy, it sounds like there are
• 08:27some programs through manufacturers
• 08:29that patients can become familiar
• 08:31with through their website,
• 08:33but I'm just wondering how many
• 08:35patients actually
• 08:37have done the research,
• 08:38have gone to manufacturers websites
• 08:40to figure out whether or not they
• 08:43would be eligible for assistance.
• 08:45I mean, I'm not sure that if I was a
• 08:48patient I would necessarily know to do that.
• 08:53I think that was one of
• 08:55the reasons for us to
• 08:57actually develop this program,
• 08:59because patients weren't aware,
• 09:01it's not well publicized.
• 09:02If you go to the programs website,
• 09:08you can certainly see everyone
• 09:10has a patient assistance tab.
• 09:12But quite often patients are unaware
• 09:14of that and that is why we chose to
• 09:18make it a formalized program and
• 09:20not another burden on the patient
• 09:22for them to have to manage.
• 09:26We have currently 7 medication
• 09:28assistance program coordinators
• 09:30and over 16,000 currently enrolled
• 09:33active patients in the program
• 09:35that I oversee with my MAP
• 09:38program coordinators.
• 09:41Brenda, it's great that there is this
• 09:44program through the Smilow network,
• 09:47but I'm just thinking about other
• 09:51patients who may be listening to this
• 09:54who may not be linked in to
• 09:57the Smilow network if they were to
• 10:00go to the websites of all
• 10:03of the drugs that they are on and
• 10:06I agree with you Nancy,
• 10:09that is yet another burden for patients,
• 10:12but can you give us a little bit
• 10:15of guidance in terms of
• 10:18who would be eligible?
• 10:19Are there certain income guidelines or
• 10:22certain employment guidelines?
• 10:24How do these programs decide
• 10:27who gets assistance and who doesn't?
• 10:31With the programs,
• 10:33if a patient identifies that burden,
• 10:36and knows that there's something
• 10:38there that they need assistance with,
• 10:41and it's not within this community
• 10:44they can definitely ask for assistance
• 10:46with their providers or their
• 10:49preferred office for their treatment area.
• 10:52What that does is that the manufacturer
• 10:56gives the information to the patient on
• 10:59how to go about the application process and
• 11:02involving the providers office as well.
• 11:06So it's definitely geared to assist
• 11:08the patient and have the providers
• 11:11office be able to be a part of
• 11:14that with the patient so that the
• 11:18enrollment process is successful.
• 11:20A lot of the income criteria is
• 11:22based on whether there is employment,
• 11:25whether there is a retirement
• 11:28or household size.
• 11:29So a lot of the programs will have
• 11:32that kind of criteria for patients to
• 11:35be able to be eligible.
• 11:39As long as they're on that therapy
• 11:41income household size are some of
• 11:43the things that they will look at.
• 11:46Especially true for people who are insured
• 11:48that the therapy has been approved
• 11:50by the insurance in order to proceed.
• 11:53If we're talking about copay assistance,
• 11:57and Nancy back to you,
• 12:00I'm just wondering,
• 12:02there are people out there who are
• 12:05underinsured, but they may be making
• 12:07the income or barely making the
• 12:09income requirement such that they
• 12:11would not qualify for assistance,
• 12:14but they may be doing that
• 12:16by working three jobs,
• 12:18and trying to make ends meet.
• 12:22And so it kind of begs the question
• 12:25when these patients are going
• 12:27through cancer and they are
• 12:30automatically in a situation where they
• 12:32may be losing some of that income.
• 12:35But they are still quote employed,
• 12:39but especially if they were making
• 12:41income based on an hourly wage.
• 12:43So while they may have employment status,
• 12:46and if the application said
• 12:49show me what your income was in
• 12:52the past year, they may have been
• 12:54scraping by with more than the
• 12:58bare minimum that's required for assistance.
• 13:00Is it something that you advise
• 13:03people to actually quit one of their
• 13:05jobs or reduce their income so that
• 13:07they can avail themselves of this
• 13:10assistance or how does that work?
• 13:25I think the first part of
• 13:28that question that I'd like to
• 13:31address has to do with what the
• 13:35income requirements are and
• 13:38historically, for many of these programs,
• 13:41the income requirement is quite high,
• 13:44so that should be of comfort
• 13:47to anyone who wants to
• 13:49apply for these programs as
• 13:51well as continue to work.
• 13:53Many of them are extremely high and
• 13:55I don't know how many patients
• 13:57currently that we have that don't
• 14:00get accepted because of their income,
• 14:02but the majority do get accepted.
• 14:06I guess I could say that I wouldn't
• 14:09recommend anyone quit a job unless that
• 14:11is their personal choice to do so.
• 14:14And a lot of our patients,
• 14:16if you are being treated for chronic disease,
• 14:19often have
• 14:21issues with working anyway because
• 14:24you are in constant treatment and
• 14:29even if it's a temporary time frame,
• 14:32we can also petition these companies as well,
• 14:35or the patient can for exceptions
• 14:38so their tax return last year may
• 14:40be far higher than it is this year
• 14:43because they unfortunately
• 14:45became ill and they they cannot
• 14:48hold their job any longer.
• 14:50So there are other options.
• 14:52There are also foundation programs as well,
• 14:55so the manufacturers are one.
• 14:58There are grant programs which
• 15:00fall under the foundation category.
• 15:02That's another option as well for patients.
• 15:05All good information.
• 15:07We're going to pick up this
• 15:09conversation right after we take a
• 15:12short break for medical minute.
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• 15:24This is a medical minute
• 15:26about colorectal cancer.
• 15:27When detected early,
• 15:28colorectal cancer is easily treated
• 15:30and highly curable and as a result
• 15:33it's recommended that men and women
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• 15:57You're listening to Connecticut public radio.
• 16:03Welcome back to Yale Cancer Answers.
• 16:05This is doctor Anees Chagpar
• 16:07and I'm joined tonight
• 16:09by my guests
• 16:11Nancy Beaulieu and Brenda Sepulveda
• 16:14and we are talking about oncology pharmacy services and particularly
• 16:16the financial toxicity that many patients
• 16:19face when undergoing cancer therapy.
• 16:21Right before the break we
• 16:23were talking about some financial
• 16:25assistance programs and Nancy,
• 16:28it was so great to hear that
• 16:31the income requirements
• 16:34for assistance are actually quite high,
• 16:38so if you are in financial distress
• 16:42when you get the bill for your medications,
• 16:46you can go to the
• 16:50pharmaceutical manufacturers website to
• 16:53try to find a patient assistance program.
• 16:57Talk to your provider and
• 17:00certainly at Smilow there is the
• 17:03Medication assistance program that
• 17:06you mentioned. Brenda, my question to
• 17:09you is are all medications covered?
• 17:11So for example,
• 17:13are all chemotherapies covered?
• 17:15Does that only include IV therapies?
• 17:18What about oral therapies?
• 17:20Are there certain medications that
• 17:23don't have a patient assistance program
• 17:26like novel immunotherapies?
• 17:30What's included and what isn't?
• 17:33While there are hundreds of
• 17:36medications that are covered and
• 17:38we often find a lot of eligible
• 17:41programs to assist our patients with,
• 17:43there will be some that will have some
• 17:46type of restrictions or some requirement.
• 17:49We find that a lot of the immuno
• 17:52therapies are eligible for these programs,
• 17:55but it's really something that
• 17:57we will research and know at the
• 18:00time of the current treatment,
• 18:02so there will be other factors there
• 18:04that will have to look
• 18:06at and see if there's an eligibility
• 18:09requirement that will allow them to
• 18:11participate in the manufacturer programs,
• 18:14but there's definitely hundreds
• 18:16of programs available for the
• 18:18chemotherapies.
• 18:21Nancy, is this something that is
• 18:23discussed with the patient and
• 18:25the provider before the provider
• 18:27makes a treatment regimen?
• 18:29Or is this something that the
• 18:32patients are then scrambling to do
• 18:35after the provider has written
• 18:37out their recommended treatment?
• 18:41The providers generally write out
• 18:43what's recommended because that
• 18:45is where we want to go with the
• 18:49therapeutic direction for the patient.
• 18:51After that, however,
• 18:52quite often we have to assure that the
• 18:55patient's medications are going to be covered.
• 18:58That's the first step.
• 19:00If a patient is insured and if
• 19:03we get denials, then we step in.
• 19:06We do have what's called a medication
• 19:08assistance program brochure that we
• 19:11provide in all of our offices so they
• 19:14are available to patients before they
• 19:17ever even go into the physician practice.
• 19:21Many times the
• 19:25program coordinators are working
• 19:27on the back end,
• 19:29so in our program we work with
• 19:34determining how much of a
• 19:38bill that the patient may have
• 19:40once insurance has gone through
• 19:42and then we go and pinpoint certain
• 19:45programs for those patients.
• 19:47We actually have a software that
• 19:50assists us with that as well
• 19:52in the general population.
• 19:54Again, as you had mentioned,
• 19:56patients can go to websites.
• 19:58Always include your provider on what
• 20:01forms you have filled out to
• 20:04make sure there's not
• 20:06duplicative work going on there,
• 20:08which has happened to us in the past.
• 20:12So that these patients can get the
• 20:15most out of these programs.
• 20:17To do a little bit of a spin in regards
• 20:20to your previous question about
• 20:23availability and drugs that have programs,
• 20:26what we find is anything that
• 20:28is new and highly expensive.
• 20:30Definitely have patient assistance programs.
• 20:32Many of the older therapies that are.
• 20:36Generic at this point may not.
• 20:39It's really focused quite often on the
• 20:42higher cost or higher end medications,
• 20:45and there are definitely medication
• 20:48assistance programs for oral medications.
• 20:50Even at your
• 20:53local CVS or Walgreens patients
• 20:56should always be asking what's
• 20:58out there to assist them.
• 21:01If they can't afford any
• 21:03medication that they may need.
• 21:07And so when you determine
• 21:10upfront what the cost of therapy would be,
• 21:14is that done before the therapy
• 21:17actually starts?
• 21:21Brenda are you intervening before
• 21:24a treatment starts to say OK,
• 21:26this is what the cost would be.
• 21:29Can you afford it or can you not?
• 21:33Can we get all of these programs
• 21:36and the applications into
• 21:38assistance before you start so
• 21:40that the damage is
• 21:43going to be financially afterwards?
• 21:46Or is this something that is
• 21:49kind of being done
• 21:51after I've already started therapy
• 21:53and in tandem with that so that I
• 21:55don't really have a choice except
• 21:57to hope that I get accepted.
• 22:01Typically, as Nancy
• 22:02mentioned, once the treatment plan
• 22:04is in place by the provider,
• 22:07and we know that this is the
• 22:09preferred course of therapy,
• 22:11it's going to undergo that if there's an
• 22:14insurance involvement or lack of insurance,
• 22:16it'll go through that process of referral,
• 22:18and that will sort of let us know
• 22:21when we necessarily need to step in,
• 22:24and if there will be high cost
• 22:27towards the treatment plan.
• 22:30We do have our own software where we
• 22:33on the back end try to capture as many
• 22:37patients beforehand, when this isn't possible,
• 22:40what's great about the programs is
• 22:43that some of them have look back
• 22:46periods that go up to 180 days.
• 22:49So even if a patient has
• 22:52initiated the treatment,
• 22:53there's still time for enrollment and
• 22:56to capture that date of service that
• 22:59was already served or infused
• 23:02prior to the enrollment for the
• 23:04programs.
• 23:06Nancy, my question is,
• 23:08it's great that there's a look
• 23:10back program in that maybe
• 23:12you'll be able to apply for that
• 23:15assistance going backwards.
• 23:16But what if, even with assistance,
• 23:19it is still too expensive?
• 23:23One would anticipate that
• 23:25making all of those applications
• 23:27to these pharma companies and
• 23:29getting all of the
• 23:31T's crossed and I's dotted to
• 23:33get assistance takes some time.
• 23:35So meanwhile,
• 23:36you're starting therapy without
• 23:38knowing whether you're going
• 23:39to get assistance and how much
• 23:41and so at the end of the day,
• 23:43you may still be left with the bill.
• 23:46On the other hand,
• 23:47if you try to apply for all
• 23:50of the assistance up front,
• 23:52you're now delaying your treatment,
• 23:53and it's kind of a bit of a tug.
• 23:57How do you work
• 23:59around that?
• 24:01The way we process treatment plan orders
• 24:04once the physician decides what the
• 24:06best course of therapy is, they go to
• 24:09what's called a patient account Rep.
• 24:11That person does an insurance
• 24:13verification on the patient's therapy.
• 24:15So before a patient gets treated,
• 24:17they have to have a pre
• 24:20certification of those meds.
• 24:22If, for example, an insurance says no,
• 24:24we're not paying for a certain Med
• 24:26that is a trigger for the MAP program.
• 24:29All of the providers are fully well
• 24:31aware of our MAP program coordinators,
• 24:34and they know that they can reach
• 24:36out if they think this
• 24:38patient needs a specific
• 24:39drug they will reach out to the
• 24:42MAP program coordinator and say,
• 24:43hey this got denied by insurance.
• 24:45Can you help and those are some
• 24:48of the routes we go down,
• 24:50but in patients whose insurance
• 24:51companies say they're not going to,
• 24:55we'll know upfront before they
• 24:56ever get treated.
• 25:00When we enroll patients in the MAP programs
• 25:04that is usually an acceptance,
• 25:06or at least the coordinator knows
• 25:08that the patient meets criteria.
• 25:11So there is some level of comfort there
• 25:14that that person will get into that
• 25:16program before they start being treated.
• 25:19Some of the programs we actually have to
• 25:22treat the patient first, have the insurance
• 25:25deny the bill before the program.
• 25:28One of the ways we get assistance
• 25:31is they actually send us the
• 25:33physical drug vials back
• 25:35to replenish our supply so the patient
• 25:38never gets billed for that particular drug,
• 25:41so that's another way there's
• 25:43copay assistance where they
• 25:45actually assist with insured copay.
• 25:47There's also the medication vial assistance
• 25:50where the actual physical drug gets
• 25:53replaced after the patient gets it,
• 25:55and is insurance denied.
• 25:57Yeah, but that
• 25:58must be scary for the patient to you
• 26:01know now gets their insurance denied
• 26:04and are thinking Oh my God, am I
• 26:08responsible for that cost.
• 26:11So back to you Brenda.
• 26:14You know we've talked a little
• 26:17bit about the outpatient,
• 26:19the infusion chemotherapy.
• 26:20Nancy mentioned that oral
• 26:22therapies are covered.
• 26:24What about in emergent situations
• 26:26where patients are in the hospital
• 26:30and may not be having these in-depth
• 26:34conversations with their physician
• 26:36about how much this is going to cost?
• 26:40Do these programs cover patients
• 26:43in that situation?
• 26:44And if not,
• 26:46how do they deal with that on top of an
• 26:49overwhelming cost of hospitalization?
• 26:53A lot of the programs are geared towards
• 26:57the outpatient ambulatory status,
• 26:59where MAP can essentially interfere
• 27:01or give some advice.
• 27:05If there is already a discharge
• 27:08plan and we need to look ahead for
• 27:11that treatment course when there
• 27:13is a hospitalization already taken
• 27:15place and it requires treatment,
• 27:18there may be other financial assistance
• 27:20that can go through billing too.
• 27:25But the manufacturing programs are
• 27:27essentially here to our outpatient
• 27:29infusion status with the oral
• 27:31medications going towards the pharmacy
• 27:34medication assistance program.
• 27:35So there is a difference there
• 27:38when it comes to an inpatient and
• 27:41outpatient and who is eligible
• 27:43for these types of programs.
• 27:46So Nancy, what
• 27:48advice do you have for patients
• 27:50who might be facing
• 27:53a cancer diagnosis and
• 27:55might be worried
• 27:57not only about their cancer,
• 27:58but also about the cost?
• 28:00What should they do?
• 28:01My greatest advice would be to become
• 28:04as informed as you possibly can.
• 28:07Know the names of your drugs you're getting.
• 28:09Get on to those websites, see what their
• 28:12patient assistance programs offer.
• 28:14Talk with your physicians,
• 28:15their nurses, their front desk staff.
• 28:18And hopefully then they can actually
• 28:21assist and know what they are able
• 28:23to get up front and know that there
• 28:26is a way and a safety net for them
• 28:29when those bills do come in to
• 28:31avoid this financial toxicity.
• 28:33Nancy is associate
• 28:35director of oncology pharmacy
• 28:37services for the Smilow network.
• 28:39And Brenda Sepulveda is medication
• 28:41assistance program coordinator.
• 28:42If you have questions,
• 28:44the address is canceranswers@yale.edu
• 28:45and past editions of the program
• 28:48are available in audio and written
• 28:50form at yalecancercenter.org.
• 28:51We hope you'll join us next week to
• 28:54learn more about the fight against
• 28:57cancer here on Connecticut Public Radio.