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18 Oncology IssuesMay/June 2011
Dispensing Pharmacy: An Option for Private Practices
Q. Can you briefly describe your practice setting, your patient volumes, and payer mix?
Hennessy. The Kansas City Cancer Center is a 34-physicianmultidisciplinaryoncologypracticewith9officesinthegreaterKansasCityarea.Ourfirstpharmacyopenedin2001.Ourprogramseesabout6,000newcancerpatientseachyear.Intermsofvisits,wehaveapproximately100,000patientvisitsannually.
Ourmixisabout60percentcommercialpayersand40percentpublicorgovernmentpayers.WeincludeMedicare+Choice with the commercial payers. Our practice has aprettydiversecommercialpayermix.BlueCrossBlueShieldmakesupabout35percent,andtherestisscatteredamonganumberofnationalpayers.Thegoodnewsisourpayermixisdiverse;thebadnewsisthatit’smorepoliciesandregula-tionstokeepupwith.
Kovach. IowaCancerSpecialistsisathree-physicianprac-ticewith two locations, includingone atGenesisCancerCenter, an ACCC-member program. Our practice seesbetween400and500newpatientseachyear.
Our payer mix is about 60 percent Medicare and 30percentBlueCrossBlueShield.
Gerards-Benage. TheQuincyMedicalGroupisamulti-specialtypracticewith120-providers.Wehave4medical
oncologistsand2 radiationoncologists.Ourpracticeseesabout700newcancerpatientsannually,withabout19,000officevisitsperyear.
Thepayermixforthemultispecialtygrouppracticeisabout50percentMedicareand50privatepayers.Thepayermixforouroncologypracticeis65percentMedicareand35percentprivatepayers.
D’Amato. MaineCenterforCancerMedicinehas13medi-caloncologistsspreadover4sites.Weseeover2,400newpatientsayearandhaveapproximately42,000 patientvisitsayear.
Mypracticeseesabout55percentMedicare,25percentAnthemcommercialpayers,asmatteringofotherprivatepayers,andonly1to2percentMedicaidorstate-aid.
Why Open a Dispensing Pharmacy?
Q. What made your practice look into opening a dispensing pharmacy?
Hennessy. OurpracticeisaffiliatedwithUSOncology,sowehadtheadvantageofseeingwhatotherpracticesweredoingaroundthecountry.Andmanypracticesweregoingin the direction of dispensing medications. Our practiceunderstoodthatitspharmacywasnotgoingtobeaneco-nomicwindfall.Instead,wesawapharmacyasadifferen-tiator in termsof thepatient experience. Inotherwords,ourpatientswouldhaveaccess totheagents theyneededwithouthavingtomakemultiplestopsorextratrips.Bot-tomline:ourdecisiontoopenadispensingpharmacywasabsolutelyaboutpatientconvenience.
Kovach. Ourpracticedidnotconsideropeningadispens-ing pharmacy until we were approached by our GPO(grouppurchasingorganization)attheendof2006.Itwasanewconceptforourpractice,andweoriginallythoughtthathavingaretailpharmacywouldmeanhiringanFTEpharmacist.
Gerards-Benage. QuincyMedicalGroupwentbackandforthonthedecisiontoopenadispensingpharmacy.Thepracticeinitiallydecidedtoopenadispensingpharmacyin2008,thenchosetoholdoff,andhasnowmovedforwardwiththeproject.
D’Amato. Ourpracticesawapharmacyasanotherpoten-tialsourceofrevenue.Moreimportantly,apharmacywillallow Maine Center for Cancer Medicine to develop apatientadherenceprotocolandprovideconveniencetoitspatients—iftheysowishandareeligibletohavetheirpre-scriptionsfilledinouroffice.
A final report on ACCC’s Educational Projectby Monique J. Marino
nJan.13,2011,theAssociationofCommunityCancerCenters(ACCC)heldawebinarentitledDispensing Pharmacy: An Option for Private Practices. Theexpertpanelforthiswebinarincluded:
SteveD’Amato,RPh,BCOP,directorofPharmacyServicesattheMaineCenterforCancerMedicineinScarborough,Maine,andmemberofACCC’sBoardofTrustees;DianeGerards-Benage,CMPE,directorofMedicalOncologyatQuincyMedicalGroup,theCan-cerCenteratBlessingHospitalinQuincy,Illinois;JohnHennessy,MBA,executivedirectoroftheKansasCityCancerCenterinOverlandPark,Kansas;andCarolKovach,RN,BSN,OCN,practiceadministratoratIowaCancerSpecialists,P.C.,Davenport,Iowa.
Theinformationpresentedatthiswebinaranddur-ingfollow-upcommunicationswiththeexpertpanelispresentedhereinaQ&Aformat.
O
Oncology IssuesMay/June 2011 19
Second, the option thatwas originally presented toourpracticewasamuchless-automated system than whatisavailabletoday.Therewerefewer oral agents. Addition-ally, the “package” that wasoffered to our practice didnotallowustoselectwhatwe
wantedtocarryinourpharmacy.Finally,ourcancercenterislocatedoff
campus from the rest of the practice, so Ididn’tseehowitwouldbeanadvantagetothe rest of the medical specialties to sendtheirpatientstothecancercenter.NordidIhavetherightstaffatthetime.Ihadtwopharmacistsinthecancercenter;bothwereconcernedaboutbeingresponsiblefordis-
pensing to patients outside of the cancer center, includingliabilityissues.
Forallofthesereasons,Icouldnotsupportopeningadispensingpharmacyatthattime.
Our practice has since reconsidered the decision. Asdirector of Medical Oncology, I oversaw the dispensingpharmacyprojectthatwentliveinFebruary2011.
D’Amato. Afterinvestigatingthedispensingmodelsavail-able, I brought the issue to our Leadership Team—com-posed of a nurse manager, a pharmacist, our operationsmanager,ourCEO,aleadphysician,andourfinanceoffi-cer—and all of our physicians. It was important to havephysicianbuy-inandtogetauthorizationforadedicatedstaffmembertooverseetheproject.
Q. Did your practice collect data, such as payer mix, most frequent disease sites, and most prescribed treatment regi-mens to identify a break-even point for your pharmacy?
Hennessy. Ourpracticeidentifiedwhichpayersourphar-macywouldandwouldnotbeabletocontractwith.Usingthatdata,wewereabletobackintothenumberofscriptsperdayourpharmacywouldneedtobreakeven.Interest-ingly,ourprescriptionnumbersincreasedwhenourprac-ticeaddednursepractitioners.Forsomereason,ournursepractitionersyieldfarmoreprescriptionsforourpharmacythanourphysiciansdo.
Kovach. Ourprocesswasmoreinformal.Asasmallprac-tice,weknowourpayermix—about60percentMedicare—andourtopdiseasesites.WealsolookedatSEERdataandthedatawegotbackfrompayersaboutthescriptsourphar-macywouldbeabletofill.
Decision-making Process
Q. Can you describe the team you brought together and your decision-making process?
Hennessy. Onceourphy-sicians made the decisionthat they wanted to opena dispensing pharmacy,I worked with our staffpharmacist on the project.Andbecauseourpharma-cisthadretail andcontractingexperience,we immediatelyhadagoodsenseofwhatbusinessourpharmacywouldandwouldnotbeabletocapture.Wealsoworkedcloselywithourpeergroup.Forexample,wemadea fewsitevisits topracticeswithintheUSOncologynetworkthatweredoingretailpharmacy.Itwasparticularlyhelpfultoseehowdis-pensingwasdoneatthepracticelevelandtotalktothepeopleinvolvedinthisserviceline.Forasmallfinancialinvestment,ourteamwasabletolearnalotofinformationveryquickly.
Adding a pharmacy was an easy decision to makebecauseourpracticeunderstoodthedownside—laborcosts.Aslongasourpharmacydidnotdispensedrugsthatwerenotgoing tobe reimbursed,ourpracticewouldbeokay.Ofcoursetheyearwas2001,soourpracticewasn’tlook-ingattheexpensiveoraloncolyticsyouseetoday.Wealsoweren’tdealingwithMedicaredonutholes.At that time,reimbursement to retail pharmacies was incredibly quickcomparedtotheoutpatientsetting,soopeningadispensingpharmacywas even lower risk from that standpoint.Butourpracticediditshomeworkbytalkingtoourmajorpay-ersaboutwhatitwouldmeantoadddispensingservices.
Kovach. As a small practice, all three physicians wereinvolved in decision making, along with administration,twokeynurses,andourbillingmanager,whoisourreim-bursementexpert.
Gerards-Benage. Oursituationisalittledifferent.QuincyMedicalGrouphadstarteddowntheroadofputtinginadispensing pharmacy prior to my hire. About four daysafterIstarted,theCFOaskedmeifIwasonboardwiththeproject,andIhadalistofreasonswhyIcouldn’tsay“yes.”
QuincyMedicalGroupisamultispecialtygroup,andIamonlyresponsibleformedicaloncology.Mypayermixisverydifferentfromtherestofthepractice.Bottomline:Ifeltthepracticewasbasingtheirdecisiononanentirelydif-ferentpayermixthanwhatoncologygenerallysees.
Dispensing Pharmacy: An Option for Private Practices
John Hennessy
Carol Kovach
Steve D’Amato
Diane Gerards-Benage
20 Oncology IssuesMay/June 2011
Gerards-Benage. Ourpracticelookedatitsoncologypayermixversusitsmultispecialtygrouppayermix.Usingdatamined from our EMR, I generated reports about whatwewerewriting inprescriptionsand thekindofvolumewe were generating. For three months, our practice alsotrackedthenumberoftimesandtheamountoftimeourpre-certificationandpre-authorizationstaffwerespendingonthephoneattemptingtoprocuredrugsforourcancerpatients.Thiswasstafftimeforwhichourpracticecouldnotrecoupitsoverheadcosts.
D’Amato. Our practice did analyze its patients’ benefitstodetermineourpayermixandpatienteligibility.Specifi-cally,wecollectedinsuranceinformationfrompatientsandsubmittedthatdatatoIONforanalysis.Wefoundthatourpracticewillbeabletofillprescriptionsforapproximately60percentofitspatients.Basedonthatcalculationandourprojected volume of prescriptions, our pharmacy shouldproviderevenuetoourpractice.
Itisimportanttocontractwithyourpayerstorecognizeyoursiteasaproviderand,ifpossible,maintainorincreasethenumberofpatientsyourpharmacycanserveovertime.
Implementation and Costs
Q. How long did the implementation process take? What costs were involved?
Hennessy. Forourpractice,establishingadispensingphar-macy was really a “process within a process.” We werebuilding a new cancer center, and the pharmacy was anelementthatwasrelativelyinexpensivetodesignin.Fromsketchestoopening,theprocesstookaboutoneyear.
BecauseofourrelationshipwiththeUSOncologynet-work,ourpharmacywasabletocarryaheavierinventoryonthefrontend.
Probablytheaspectthattookthemosttimewasfind-ingthepharmacisttostaffourpharmacy.Wewerelookingforthe“rightfit.”Ourpharmacyisnotavolumeshop.Andbecauseourpharmacistisnotfillingthatmanyscriptsperday,weneededsomeonewiththeappropriatepersonality,aswellasanunderstandingofthechallengesfacingoncol-ogypatients.Also,wefoundourselvesdoingalotofcom-poundingrightoutofthegatesothatwasanimportantskillforustohaveinourpharmacist.
Kovach. Theentireprocesstookbetween9and12months.Anditwasanexpensive investment,requiringmuchdis-cussionandplanning.
Our practice first looked at our state’s regulations.Iowadoesallowpracticestoopenadispensingunitunderthephysician’slicenseandNPI(NationalProviderIdenti-
fier).Thenwebroughtinlegalcounseltoanswerquestionssuchas:“What were the ramifications of opening a dispens-ing pharmacy?”and“How would our pharmacy fit in with our state laws?”
Nextwehadtoseeifourfacilityevenhadroomtoaddapharmacy.OurmainofficeislocatedinGenesisCancerCenter. The cancer center was expanding, but radiationoncologywastakingmuchofthenewspace.
Wealsoresearchedwhatitwouldcostourpractice.Todosowehadtoanswerquestionssuchas:What were the security issues?Who would staff the pharmacy?Should we use existing staff or hire new staff?
Finally, we looked at the list of oral agents that ourpharmacywouldhavetocarry.Ourpracticecameintothisprojectin2008whendrugswereveryexpensive.Wequicklyrealized,however,thatnothavinganexpensivedrugavail-ablewhenourdoctorfirstprescribedit—especiallythefirstregimen—was no different than if our patients filled thescriptataretailpharmacy.Inotherwords,mostpatientsonoraloncolyticswerewaitingatleast24hourstogettheirmedication because hospitals and retail pharmacies werenotstockingthemeither.
Asfarasimplementationcosts,weneededadedicatedcomputer,adedicatedprinter,andmiscellaneoussupplies,suchasmedicationlabels.Theinitialinventoryourphar-macystockedrequiredaninvestmentofabout$20,000to$25,000.Thehigher-priceddrugswerestockedasourprac-ticesawthepatientsandwrotethescripts.
Gerards-Benage. Whilewe’veonlybeendispensingforafewmonths,ourpracticehadstaffinplace.Ourfinancialcounselorsandourpharmacytechniciansworkinconjunc-tion.Ididhavetopurchaseadedicatedprinterforthephar-macy.
D’Amato. Ourprocesstookabout12months.Someofthedelaywasduetobudgetapprovalofadedicatedstaff.Thepractice alsohad to carveout space to accommodate thepharmacy.Expansionstartedin2011toprovidededicatedspaceforthepharmacy.
Thepharmacycostsincludedthehardware,software,andinventorydiscussedpreviously.
Withdedicatedstaffandequipmentinplace,ourphar-macy started dispensing in April 2011. ION helped usestablishpayercontractspriortothisdate.
Wearestillintheprocessofdevelopinganadherenceprogramandfinalizingourformulary.
Challenges
Q. What challenges have you faced that are a direct or indirect result of adding a dispensing pharmacy?
It is important to contract with your payers to recognize your site as a provider and, if possible, maintain or increase the number of patients your pharmacy can serve over time.
Oncology IssuesMay/June 2011 21
Hennessy. The original challenge our practice faced wasthatsomeofourphysicianswerenotusingtheirownphar-macy.Frommyperspective,ourpharmacynumbershavebeendrivenbyournursepractitioners.Forexample, it isnotuncommontoseeanursepractitionerwalkingapatientovertothepharmacy.
Thebiggestchallengewefaceincontrollingpharmacycostsismakingsurethatwhensomethingisgoingwrongthatthepatientcallsus.Wefindthatpatientsarereluctanttosayanythingiswrongforfearofnotgettingthenextche-motherapydose.Soourpharmacyoffersanotheropportu-nity tohaveaconversationwithpatientsandsay,“When you’re not feeling well, call us at noon.”Ifpatientscallusearlyenough,wecanbringthemin.Wecanhydratethem.Wecangetthemintoseeanursepractitioner.Iftheycallusattheendoftheday,we’rekindofstuck.
Kovach. Looking back, staffing was our biggest chal-lenge.Usingexistingstaffdidnotworkforourpractice.Once we hired the right staff person, a FTE pharmacytechnician, theprocessbecamemuchmoreeffective—forbothpatientsandstaff.Keepinmind,ifyouchoosenottohireapharmacist,asourpracticedid,youmustmakesurethatwhateverstaffisfillingmedicationsisfollowingyourstateregulations.
Withtherightstaffpersoninplace,wewerethenabletolookatthescheduleandanswerquestionssuchas:What patients were coming in that week? What treatment regi-mens were they on? Were patients continuing on the regi-men so that we could order drugs ahead of time? Were there patients that we wanted to see a physician before we ordered their medications?
Staffing Models
Q. What staffing model do you use for your in-house pharmacy?
Hennessy. OurstaterequiresthatanRPhorPharmDbepresent during all opening hours. If not, the pharmacyneedstobelocked.Soyourpracticeneedstohaveinfusiondrugsinanareaoutsidethe“lockablezone.”
Kovach. OurpracticehasanFTEcertifiedpharmacytech-nician.Wehavealsocross-trainedthreeotherstaffsothattheyareabletocarryoutpharmacy-relatedfunctionswhenthetechnicianisout,forexampleduringvacationorillnesses.
Gerards-Benage. Ourpracticestaffsitspharmacywithafinancialcounselorandapharmacytechnician.Itisconsid-eredaphysiciandispensingmodel,butthephysician’snursewillactuallymakethedrughandofftothepatient.
D’Amato. InMaine,wedonotneedapharmacisttodis-pense medications, so we also plan on using a registerednurseandapharmacytechniciantofillourprescriptions.Q.How many days a week is your pharmacy open?
Hennessy. Ourpharmacyisopen9amto5pm,fivedaysaweek—thesameasourofficehours.
Kovach. Ourpharmacyisopenfivedaysaweek.
Gerards-Benage. Weareopen MondaythroughFriday.
D’Amato. Ourpharmacyisopen MondaythroughFridayfrom8amto5pm.
Drug Inventory
Q. How does your pharmacy handle drug inventory? Do you dispense only oncology drugs or do you also dispense non-oncology drugs?
Hennessy. Ourpharmacy isunlikely tocarryaromataseinhibitors (AIs) and drugs like Xeloda unless we have apatientwithverygoodperformancestatuswhoiscominginmonthlytogetarefill.Amongallofourpracticesites,onlytwohaveretailpharmacies,sowemaysendthosepre-scriptionsfromothersitesiftheyfitthatcategory.
Maybeayearandahalf into theproject,ourpracticestartedgettingtightonitspharmacyinventory.Wewantedtomakesurethepharmacywascarryingwhatweweregoingtouseandnotjustcarryingproductbecausewecan.Andthosedecisionsaremostlyrelatedtocost-to-capitalfactors.
Ourpracticefiguredoutfairlyquicklywhatmedica-tionsweweregoingtouseinvolume.Wehaveaprettygoodsense—particularlywhensomeoneisonmaintenancemed-ication—ofwhatdrugswe’regoingtoneedandwhenwe’regoingtoneedthem.Weidentifywhatpatientsarecomingintotheofficeinthenexttwoorthreedaysandthenstockmedicationsaccordingly.
Our pharmacy dispenses both oncology and non-oncology drugs. We have a fairly broad inventory—lesshigh-dollar medications and more everyday medicationspatientsneedsothattheydon’thavetogosomewhereelse.Wearealsoflexibleaboutshiftingourinventorymixasourphysicianprescriptionpatternschange.
Intermsofvolume,ourpharmacymovesmorenon-oncologydrugs.Mostofourpatientsintreatmentseeusmorethanadozentimesayear.Freshoutof treatment,ourpatientsstillcomeinthreetofourtimesayear.Wedis-penseavastamountofchronicmedications,forexample,beta-blockers and medications that treat hypertension.
22 Oncology IssuesMay/June 2011
Wedonotstockthehigh-costoncolytics.Andwedonotcarrymedicationsforcoldsorflu.Weliketosendpatientsback to their primary care providers for those types ofmedications.Overall,ourphysicians aremanaginga lotofchronicandlong-termissues.Sowetryandmakesurethatourpharmacyisaone-stopshopforthosetypesofpatients.
Kovach. Ourpracticetrackswhichpatientsarecomingintoourofficeinthenextfewdays;ournursesorderfortheinfu-sioncenterandourpharmacytechnicianordersforthedis-pensingpharmacy.Incidentally,wedonotstocknarcotics.
Ourpracticestocksthefollowing:oraloncolytics,anti-biotics,antifungals,AIs,diuretics,steroids,antiemetics,war-farin,Arixtra,andsupplements,suchasironandMagOx.
Gerards-Benage. Ourpharmacyusesasimilarprocesstomanagedruginventory.
We dispense oncology and oncology support drugsonlyatthistime.Wearegettingmanyrequestsforwhite-bagging,forexample,theESAs,Neulasta,andNeupogen.Ourpharmacydoesstockthosemedications,andwewouldliketobeabletokeepthatrevenue.Wealsochosenottocarrynarcoticsinourdispensingpharmacy.
D’Amato. Our plan is to dispense all agents related tooncologycare,notjustoraloncolytics. Wearenotlikelytostockhigh-pricedmedicationswithlowturnover.Weplantocarryallproducts thatourphysicians routinelyorder.Ournurseshavecompiledalistofthemostcommonagentsprescribedbyphysicians.
Q. For what percentage of patients treated at your practice is your pharmacy able to fill prescriptions?
Hennessy. As of today, our practice can fill 100 percentof our patient prescriptions. We had difficulty gettingBlueCrossandBlueShieldonboardrightoutof thegate,butnowfouryearsintotheprocess,theyhaverolledover.Weaveragebetween20-25prescriptionsaday.
Kovach. Ourpracticeisonlyabletofillabout78percentofourpatients’scripts,whichareabout10to15prescriptionsdaily.
Gerards-Benage. Wearehopefulthatourpracticewillbeabletofillabout90percentoftheoralsagentswearenowsendingout.Dependingoninventory,ourpracticeantici-patesfilling10-20prescriptionsperweek.
D’Amato. Ourpracticeanticipatesfillingabout60percentofourpatientprescriptions,maybemore.
Q. Do you have to give your patients the option to go else-where to fill a prescription before you drive them to your pharmacy?
Hennessy. Yes.Infact,ourpracticehashadtodothatforimagingandforradiationservicesforsometime.Itseemslike every year CMS comes up with new regulations tomake it more challenging. We found that the physicianswerealittleupsetthefirsttimetheyhadtotellapatientthisinformation,butthatthevastmajorityofpatientsdonotcare.Patientsarelookingforconvenience.Theydonotpar-ticularlycarewhetherornotthephysiciansownthephar-macy; theywant toknowwhetherornotourpharmacystockstheirmedications.
Gerards-Benage. Our practice has posted the choice ofpharmacies in sign form.Wealsoprovide that informa-tionwhenourcounselorsdiscusscostandpre-certifica-tionissueswiththepatient,allowingpatientsthechoiceofobtainingthemedicationsatourpharmacy,atthephar-macyof theirchoice,or through themail if thatoptionisavailable.Wedo,however,explainthatithasbeenourexperiencethatlocalpharmaciesdonotoftenstockthesemedications.
D’Amato. Ourpracticeinformspatientsoftheirpharmacyoptionsandallowsthemtodecidewheretheywanttohavetheirprescriptionsfilled.
Billing and e-Prescribing
Q.What type of billing system are you using to post charges and payments for your retail pharmacy? Also, what EMRs are your practices using?
Hennessy.WeusetheRx3000PharmacyManagementSys-tem(http://www.newtechsys.com).
OurprogramdoesnotyethaveanEMR.Wehavealotofelectronicconnectivity,butwedonotyethavethat“middle”piece.
Kovach. WeareusingQS1(http://www.qs1.com) tobill.Ourpracticebuiltanin-houseEMR.
Gerards-Benage. WeuseQS1tobill.Ourpracticeismul-tispecialty,soourEMRisnotoncologyspecific.Ourprac-ticeusesMcKesson(http://www.mckesson.com).
D’Amato. We are also using QS1, with a beta interfacewith our Nucleus Solution product. My practice usesAltos Solutions for its EMR (http://www.altossolutions.com).
Oncology IssuesMay/June 2011 23
Q. How does your practice deal with e-prescribing?
Hennessy. Ourretailpharmacyopenedbeforee-prescribingbecamewidelyadopted.Thetechnologyhassimplifiedourprocessandmadeitalmosteasiertogetprescriptionsintoourpharmacybecausewecanputsomeformoftieringintothee-prescribing.OurpracticeusesRelayHealth(www.relay-health.com).
Kovach. E-prescribing is effective because the informa-tiongoesstraight intoourEMRsystemwhereourphar-macyandnursescanseeit.Overall,e-prescribinghasmadeitmucheasier to trackscripts—muchmoreefficient thanwhenthephysiciansusedtohandwritethescriptsandplaceacopyinthepatientchart.
Gerards-Benage.OurpracticedoeshaveanEMRinplacefor e-prescribing so our prescriptions come directly intoourpharmacy.
D’Amato. My practice switched to a new EMR (Altos/OncoEMR)inApril2011.Today,allprescriptions,exclud-ingnarcotics,whichwehaveelectednottofillinternallyatthistime,aregeneratedelectronically.Ithasmadetrack-ing medications easier and gives us an accurate medica-tionprofileforourpatients.Withphysiciandispensinginplace,wecannowverifyourpatient’smedicationliststoensureaccuracy.
Patient Compliance
Q.Does your pharmacy have a compliance program for patients who are on oral chemotherapy?
Hennessy. Notinanyformalsense.Fromthepayerper-spective,thislackofaformalcomplianceprogrammakesuslesscompetitivethanbigspecialtypharmacies.Ourphar-macycanidentifyifa30-daysupplyofmedicationislasting35days,butsomeofthebetterspecialtypharmaciesdoout-boundcallsinthefirstweek,particularlyformedicationswith a side-effect profile that might discourage patientsfromcompliance.
Kovach. OurcomplianceprogramisgeneratedfromourEMR.PatientsonoralchemotherapyhavemonthlyCBCs(completebloodcounts),anda“no-show”willbeflagged.Thenursethene-scribesourpharmacytechniciantorefillthemedication.AlsotheQS1ticklersystemletsthephar-macytechnicianknowtocheckifthepatientistocontinueonthemedicationoriftherehasbeenachange.
Gerards-Benage. The specialty pharmacies notify our
financialcounselorswhentheproductships.Thefinancialcounselorsletournursesknowthedrugshaveshipped,andournursesfollowupwithourpatients.
D’Amato. Wedevelopedacomplianceprogrampriortotheopeningofourdispensingpharmacy.
A Specialty Pharmacy?
Q. Has your practice applied to be a specialty pharmacy?
Hennessy. No. Our practice is not in the emergencymedicine business. We have about a 72-hour waitingperiod for patients who need an infused drug—unlessthere’sanemergency.Andifitisanemergencysituation,most of those patients need to be in the hospital. Oursystemgivesthepracticetimetoorderthedrug,allowsthepatientandfamilytimetoprepareforchemotherapy,and lets us conduct chemotherapy evaluation on thepatient. So the need to have drugs immediately—otherthanroutinerefillingofprescriptions—isnotanissueforourpharmacy.
Applyingtobecomeaspecialtypharmacywouldhavemeantgettingaccessfrombothapayerandadistributorstandpoint. US Oncology offers a large specialty phar-macythatourpracticesuseasmuchaspossible.Oneofthemainreasonswedothisisthenetwork’spatientassis-tanceprograms.Whenwehaveapatientassistanceissue,ourpractice can“outsource” it toUSOncology’s reim-bursementspecialists.Formanyofmypeers,dealingwithpatient assistance on the expensive oral oncolytics hasbeenoneof thebiggest challenges in the last fewyears.Andnowit’snotjusttheoralagents.Forourpracticeandpharmacy,itwasaquestionof:“Do we really want to be in the specialty pharmacy business?”Intheend,wedecidedthatwedidnot.
Kovach. Ourpracticecametothesameconclusionwhenwelookedintobecomingaspecialtypharmacy.Inaddition,itwouldnegatesomanyofourpharmacycontractsthatitwouldbedetrimentalforourpractice.Wehavegoodcon-tractingrelationships,sowedidnotseeanyrealadvantagestobeingaspecialtypharmacy.
Gerards-Benage. Ourpracticedidapplytobeaspecialtypharmacy,aswebelievethatspecialtypharmacyiswherepayersaresendingtheirbusiness.Wearealsoworkingwithourcontractrenewalstonegotiatebeingtheprimaryphar-macyforoncolytics.
D’Amato. My practice has not investigated the specialtypharmacyoptionatthistime.
With physician dispensing in place, we can now verify our patient’s medication lists to ensure accuracy.
24 Oncology IssuesMay/June 2011
Improvements and Effectiveness
Q. What programmatic improvements have you seen that are a direct or indirect result of adding a dispensing phar-macy?
Hennessy. Thebestbenefitforourpracticehasbeenhappypatients—pureandsimple.Havingadispensingpharmacyhasbeenadifferentiator.Ourpharmacy isnotmakingahugebumpinthebottomlineofourpractice,butthatwasnever our intention. And now we have the opportunitytotalktopatientsaboutwhattheycanexpectfromtheirmedications.Wehaveagoodsense—althoughitishardtomeasure—that we are creating conversations about sideeffectsandwhatthepatientcanexpect.
Kovach. Ourpatientsaremuchhappier.Ourpracticetreatsafairlyhighnumberofelderlypatients,sotheonsitephar-macyhasbeenagreathelptothem.Ourpharmacyreceivesasmanypatientlettersasournursesdo,thankingthemforalloftheirhelpandsupport.Patientsarejustveryapprecia-tiveoftheconvenience.
Q. What metrics does your practice use to measure the effectiveness and success of its dispensing pharmacy?
Hennessy. Ourpharmacylooksatthebottomlineeverymonth.Somemonthsthenumbersaregood;othermonthsthenumbersareratheralarming.Ifthepharmacybottomline was the only metric that our practice looked at, wewouldbeparticularlychallenged.However,wealsolookatpatientandprovidersatisfaction.Forexample,someofouremployeesgettheirmedicineatourpharmacy,sothereisastaffconveniencefactor.
Ourpracticedoesalotofsurveying,andwe’vefoundthatthereareanumberofpatientswhodonotaccessourpharmacy. But for the patients that do access our phar-macy,weare almost alwaysdoingabetter jobof servicethananyoneelse.Quite frankly,oneof thechallengesofconducting subjective surveys is that our patients almostalwayssaygoodthingsaboutourpractice.It’schallengingtoweedthroughallthe“good”andfindsomeopportuni-tiesforimprovement.
Kovach. Ourpracticelooksatthepharmacy’sbottomlinetoo—every month. We also look at patient satisfaction.Wedidapatientsatisfactionsurveyayearorsoago,anditcamebackwithglowingresponses. Butwearealsolook-ingatwaystoimproveourservices,asthereisalwaysroomtoimprove.Simplyput:aslongasourpharmacyremainsfinanciallysoundandithelpsourpatients,thenourpracticewillcontinuetodispensemedications.
Gerards-Benage. While our practice has only been dis-pensingmedicationsforashorttime,wearealsolookingatourbottomline.Wealsointendtoassesspatientsatis-factionandthetimelinesforinitiationoftreatment.Atthispoint,someofourpatientsarewaitingtwoweeksfordrugstoshipfromtheirpharmacies.
D’Amato. Asourpharmacyonlywentliveamonthorsoago,weareintheprocessofgettingsomeexperienceunderourbelt.Wearelookingatexpensesandrevenue,andexam-iningpatientadherencerates.Inthefuture,wewilllikelyconductasurveytogetpatientandstafffeedback.
Q. Looking to the future, how do you see oncology drug management trends, such as increasing the number of drug tiers, white bagging, and REMS, affecting your dispensing pharmacy?
Hennessy. If our pharmacy was heavily invested in thehigh-priceorhigh-margindrugs, itwouldbemorechal-lengingforourpractice.Oralagentshavebeenrapidlymov-ingtothefourthtier;co-insurancerateshavebeengoingup.PatientswhofallintotheMedicaredonutholehavebeenparticularlychallengingforus. Theotherchallengingpieceisthe“mini-med”policieswith$5,000and$10,000limits—enough for patients to be diagnosed, but not enough forthemtoaffordtreatment.AtsomepointIthinkthesavinggraceforourpracticewillbea“maximumout-of-pocket”benefit.Whileourpracticehasbeenverysuccessfulinget-tingpatientassistanceandmakingitpossibleforpatientstogetaccesstoexpensivedrugs,weworrythatthosetypesofresourcesaregoingtorunout.
Kovach. We’re all very worried about the future ofhealthcare—the cost of drugs, declining reimbursement,and how much of the costs are being passed on to thepatients.Butourpracticetakesitonedayatatimeandonepatientatatime.Ifyoulooktoofaroutintothefuture,youstartquestioningwhetherthepracticecanlast. Asyouallknow,asacountryweareaskingourselves:“Arewegoingtobeabletoaffordhealthcare?”
Gerards-Benage. The biggest challenges that my prac-ticeandpharmacyfacearepayer-related.Insurancecom-panieskeepmaking itmoreandmoredifficult toget thepatientsthemedicationsandtreatmenttheyneed.Mystaffnewhireshavebeenfinancialcounselors.Andthesestaffmembersarespendingalotofthetimeonthephone—withpayers,withspecialtypharmacies,withpatientassistanceprograms.I’mwaitingforpayerstostarttellingproviderswhatwecanorcannotdispense.Inthemeantime,Iworkwithourpayersandtrytostayaheadofthetrends.
Oral agents have been rapidly moving to the fourth tier; co-insurance rates have been going up.
Oncology IssuesMay/June 2011 25
D’Amato. Iammostconcernedaboutpayersdemandingtheuseoftheirownspecialtypharmacies,whichiswhyIthinkitisimportantforpracticestogetpayercontractsinplacetoallowthemtodispensetopatients.Inourmarket,wedonotallow“brown-orwhite-bagging.”REMS(riskevaluationandmitigationstrategies)area reality thatmypractice is already dealing with—although I expect thatadministrativeburdentoincrease.
Monique J. Marino is managing editor, Association of Community Cancer Centers, Rockville, Md.
Audience Q&A
AttheconclusionofACCC’swebinar,audiencemem-bershadtheopportunitytoaskquestionsofthepanel-ists.Here’swhatourpanelistshadtosay.
Q. What level of profitability did your pharmacy see last year?
Hennessy.Simplyput,ifyourpracticecanmanagethreecomponents—drugmargin,laborcosts,andbaddebt,yourpharmacywillbeingoodshape.Wedoseeapositivemarginonthedrugswedispense.Ourbiggestcostisthelaborcostforourpharmacistandpharmacytechnician, followedbybaddebt.
Kovach. Oneofthepositiveaspectsofdispensingmedicationsisthatyourpracticeknowsimmediatelywhetherornotadrugiscovered.Weknewthatifweputprocessesinplaceandfollowedthoseprocessesonadailybasisthatourpharmacywouldeventuallypayoffandbeawin-winforbothourpatientsandourpractice.Andthat’swhathappened.Ittookourpracticeabouttwoandahalfyears.Thefirstyearourpharmacybrokeeven.In2009—ourfirstfullyearofdispensingmedicationsbecausewedidnothaveadedicatedstafferin2008—ourpharmacyrealizedabouta$90,000profit.In2010wedoubledthatamountandsawan18percentmargin.
Gerards-Benage. Weanticipateamarginofabout$100,000.
D’Amato. Ourpracticedevelopedapro formabasedonwhatwehaveseeninotherpractices.Afterputtinginourdata—our14physicians,ourpatientmix,andthenumberofprescriptionswegenerate—aconservativeestimateisthatourpracticewillseeabout$100,000inprofitthefirstyear.Butwhatwe’veheardheretodayisthatifadispens-ingpharmacyismanagedcorrectlyandwithadequatestaffing,break-evenshouldbetheworstthatyoudo,whileprovidingagreatpatientservice.
Q. Do you have patients that frequently come back each month for medications like aromatase inhibitors (AIs), even though they might only see the provider yearly?
Hennessy. Werarelyhavepatientscomeinjusttouseourpharmacy.Andforalotofpatientswhoaregoingtobeonalong-termagent,wewouldprobablyhavetheprescriptionrunthroughaspecialtypharmacybecause
theywillgetreducedco-paysiftheyreceiveitquarterlyversusmonthlyatourpractice.Thechallengethere—asweallknow—isensuringthatourpatientsarestayingontheirmeds.We’veknownalongtimeaboutthechal-lengesrelatedtoAIs.Butit’sbeeninterestingtohearaboutthecomplianceissuesrelatedtochemotherapyagentsorbiologics.However,someofthespecialtypharmaciesarecomingupwiththeirownoutboundcallingprogramstomeetthatneed.
Kovach. OurpracticedoesfillmonthlyAIs.TheQS1systemhasaticklerfileasareminder,soweareabletotrackpatientcomplianceandanyissuesthatcomeup.
Gerards-Benage. Weleavethatdecisionuptoourpatients.Someofourpatientsarelocal;otherstravelquiteadistancefortreatment.Asaspecialtypharmacy,wecanofferthesamereducedco-pay,sothepatient’scostwouldbethesame.
D’Amato. Weobviouslywantthosepatientstouseourpharmacyonaregularbasis—notjusttohavetheirprescriptionsfilled,butalsotobeabletoassesspatientsandactasaresourceforpatientsonaregularbasis.
Q. What if a physician decides to switch therapy and the drug was ordered ahead of time?
D’Amato. Ourpracticegenerallywaitsforpayerapprovalfortheexpensiveoncolytics.Oncethemedi-cationisapproved,weorderitfornext-daydelivery.IwouldworkwithmywholesalerifitwasamedicationthatIwasnevergoingtouseagain.Inotherwords,ifthepatientwasunabletoreceivethemedicationandaslongasthemedicationhadnotbeenopened,wewouldtrytoreturnittothewholesalerandgetcompensation.
Kovach.Ifourphysicianschangethetherapywhenthepatientcomesinandwehavethemedicationonourshelf,Iwouldtryandreturnittothewholesaler.Wealsotakealookatourscheduleandseeifanotherpatientwhoisonthesamemedicationiscomingin.
Gerards-Benage. Ourpracticewillrestockmedicationsforfutureuseifthemedicationisnotusedandhasnotbeenopened.
Hennessy. Itisrareforourpracticetorunintothissituation.Ourpharmacydoesnotstockthehigh-costoncolytics.Werunthroughourinventoryfairlyquickly,sowewillhaveaprettygoodchanceofgettingitofftheshelfinamonthorso.
ThisprojectwasmadepossiblethroughaneducationalgrantfromMillennium:TheTakedaOncologyCompany.AvalereHealth,LLC,providedstrategicadvisoryservicesandanalysisforthisproject.
