Hollywood, FL—In response to mandates for more efficient and lower-cost cancer drug utilization, CVS Caremark is developing innovative strategies, said Kirby J. Eng, RPh, Director of Oncology Medical Pharmacy Management, CVS Caremark, at the Third Annual Conference of the Association for Value-Based Cancer Care.
“While society, business, and government try to determine how to address the unsustainable costs in cancer care, we in the pharmacy care management business are going to be fixated on drug therapy, aiming to be good stewards so that the right drugs are used for the right reason at the right cost,” he said.
This will become more challenging, considering that 25 new oncology drugs have been approved in just the past 2 years, and that more than 300 oncology compounds are in development, Mr Eng said.
Most of the cancer drug costs can be attributed to a handful of the 200-plus cancer compounds that are now on the market. Approximately 30% of these drugs are used off label (Conti RM, et al. J Clin Oncol. 2013;31:1134-1139), although not necessarily inappropriately, according to the compendia, society guidelines, and Centers for Medicare & Medicaid Services–recognized peer- reviewed journals.
“Look at the complexity of trying to manage cancer drug spending. We have more than 100 diseases included within cancer. We have over 200 drugs.” With this broad reference base, “it obviously becomes very challenging and daunting for employers, as well as health plans, to manage cancer drug spending,” Mr Eng observed.
Managing Cancer Drug Spending
Although specialty pharmacy and pharmacy benefit managers (PBMs) primarily focus on drugs that are covered under the pharmacy benefit, 75% of drug spending still falls under the medical benefit.
“This is where we run into some challenges,” he noted. “To meet that challenge, we’ve created a fully dedicated business unit just to focus on drugs that are covered under the medical benefit. Oncology is about 50% of that drug spending. Our value proposition to our clients includes the ability not only to manage drugs under the pharmacy benefit, but to migrate and integrate drugs into the medical benefit.”
Several research groups have identified key trends in oncology drug management (Table). The trend toward more rigorous approval criteria goes beyond assuring the appropriateness of drug use in general to the appropriate line of therapy, Mr Eng elaborated. Another trend is to require physicians to submit claims for drugs administered in the office and billed under the medical benefit with a corresponding National Drug Code. The trend toward the integration of the medical and the pharmacy benefits refers to (1) the clinical criteria that are universally applied to drug therapy, regardless of benefit design, and (2) the systems that help to support this.
Among the various approaches within the specialty pharmacy and PBM business, the ultimate winners will probably be the approaches that can integrate technology into a health plan’s existing infrastructure and approaches that can allow for “visibility” of drugs “before they’re actually used, either being filled at a pharmacy or being administered in the office. We’re clearly making a concerted effort in that area,” he said.
This pertains to site-of-care management. CVS Caremark would like to provide its clients with utilization management regardless of where the drug is administered, Mr Eng noted.
Integration of Oncology Pharmacy Care Management
The integration of pharmacy care management is a key focus for CVS Caremark, Mr Eng said. “We are thinking about the different ways we can engage with patients, beginning with our retail pharmacy, then PBM, our specialty pharmacy (our mail order model), and our retail clinics,” he noted. “There will be a high degree of focus on ‘high-touch’ patient engagement.”
Taking telephonic clinical pharmacy support further, CVS Caremark is designing face-to-face interventions at retail pharmacies and home visits from pharmacists where necessary. Pilot programs are showing improvements in drug adherence and reductions in healthcare costs.
“We were so pleased with the results that we are introducing 5 more chronic care management initiatives, one of which is for breast cancer,” he pointed out.
More convenient drug fills also fall under the “patient engagement” umbrella. “We want to give patients the ability to receive their drugs in whatever form is most convenient for them,” Mr Eng emphasized.
For example, patients can receive their drugs in retail pharmacies at the same rates as if they were mailed. He expects this to be expanded into the oncology area. “Cancer drugs are high on the radar in terms of allowing member or patient flexibility,” Mr Eng said.
CVS Caremark is also considering formulary management strategies for several tumor types (at the request of many of its clients); is involved in clinical pathway programs; and is enhancing collaboration between oncologists and clinical pharmacists.
“We are clearly committed to managing trends across benefit design, regardless of the side of service,” Mr Eng concluded.