Riding the Wave of Progress

Staying on top of the evolution in oncology & biologics treatments

New developments in medicine sometimes surge forward so quickly that it can be hard to keep up, even for the healthcare professionals who need to use or acquire the innovations. With this rapid development in mind, HealthTrust subject matter experts Mohammed Elayan, PharmD, Director, Oncology Pharmacy Clinical Operations, and Jason Braithwaite, PharmD, MS, BCPS, AVP, Clinical Pharmacy Services, discussed the changing world of oncology and biologics with attendees at the 2023 HealthTrust University Conference.

The team explains the challenges facing the industry and the HealthTrust solutions available to help.

Innovations in therapies

“The oncology and biologic landscape is rapidly evolving and incredibly complex, both clinically and operationally,” explains Elayan. “From a business perspective, health systems are dealing with these incredibly high-cost drugs. Ensuring they’re giving them in a safe, effective and financially sustainable manner is a challenge in today’s market.”

Several factors, such as payor restrictions, operational considerations, rising drug costs and technology fragmentation lead to complexity in the healthcare landscape. This is especially evident in the outpatient infusion area where market forces are driving innovation in patient treatment.

“Innovation is good, but the pace of innovation is so rapid that providers are having a hard time adapting and evolving quickly enough to utilize drugs appropriately. By the time you’ve figured out how to administer one, there is a new one on the market, and the guidelines have changed,” says Braithwaite.

For example, with the demand for life-saving treatments, many oncology agents are being approved early in the approval pathway, with several occurring immediately following phase two clinical trials.

“With many novel cancer therapies, it’s deemed that the benefit of a new treatment is likely higher than the risk of side effects of a new therapy, leading to a more rapid approval,” Braithwaite explains. But this also means less data and evidence is available to determine safety and clinical protocols. There can also be a rush to implement policies when drugs are approved earlier than expected.

Payor & reimbursement challenges

Historically, healthcare systems have been focused on inpatient care, with clinical and financial services developed accordingly. Billing models are based on one-time encounters, such as emergency room visits or diagnostic-related group (DRG) payments.

But oncology and biologic treatments are generally part of a longer-term care plan involving multiple encounters and multiple payment authorizations. “It’s a lot more complicated. You’re managing these patients not just clinically for an extended period of time, but financially too. If your processes are set up to only handle a one-time encounter, and now you’re handling multiple, it becomes challenging, especially when the reimbursement model is different on the outpatient side,” says Elayan.

And while providers want to prescribe treatments with minimal side effects and the best outcomes, the reality is that there are a number of other factors that need to be considered, such as monitoring requirements, 340B eligibility and payor restrictions. “Payors often try to dictate what should be used, as well as when and where it should be used. While there are many variables, I think the payor dynamic is the most difficult one to deal with at this time,” explains Braithwaite.

HealthTrust solutions

Recognizing the industry’s increasing challenges, HealthTrust has developed new offerings to support its members.

Some of the ways HealthTrust helps members tackle these challenges include:

Sharing up-to-date information on commercial payors and Medicare policies as well as reimbursement models
Tracking drugs from early phase clinical trials to market launch
Offering a drug information service with drug comparison documents
Providing operational expertise to help members implement or enhance outpatient services

“HealthTrust Pharmacy Services can come into a health system and help the team operationalize its approach with many of these oncology and outpatient drugs. We have expertise in this field—from revenue cycle management and formulary selection to all of the operational components of putting an outpatient pharmacy program in place,” says Braithwaite.

“It’s challenging for members to balance all of the things thrown at them daily when their focus needs to be on patient care,” adds Elayan. “There’s tremendous value in having a team that knows our members inside and out. Our services have evolved to help drive value in this ever-changing landscape.”

Enhance your outpatient pharmacy program with solutions from HealthTrust. Contact your HealthTrust Account Manager for more information.