Chemotherapy Stewardship Offers Opportunities to Reduce Costs to Health Systems, Patients

As cancer care costs continue to increase in the United States, a focus on chemotherapy stewardship may result in cost savings for health systems and patients.

During a session of the Hematology/Oncology Pharmacy Association (HOPA) Practice Management 2020 Virtual Learning Event, presenter Ali McBride, PharmD, MS, BCOP, FAzPA, FASHP, said a 2011 projection by the National Cancer Institute (NCI) estimated there would be 18.1 million cancer survivors in the United States in 2020, which represents a 30% increase in the number of cancer survivors since 2010.

According to the NCI’s 2011 report, the cost of cancer care in the United States was projected to increase over the past decade, from nearly $125 billion in 2010 to an estimate of more than $158 billion (in 2010 dollars) this year. The primary reason cited for the increased cost of cancer care is growth and aging of the US population.

McBride, a clinical coordinator, hematology/oncology, at the University of Arizona Cancer Center and a member of the Directions in Oncology Pharmacy^TM advisory board, said pharmacists have opportunities to develop, implement, and participate in chemotherapy stewardship programs.

“We’ve been doing it for years, but we haven’t done a good job of earmarking this term,” McBride said.

Chemotherapy stewardship is used to determine whether clinical issues, such as dose reductions or modifications, may lead to inappropriate therapy or augmented toxicity. It can also identify safety issues with chemotherapy and supportive care medications; review off-label use and data to help improve the reimbursement process; and confirm that appropriate structures and processes are in place to ensure that treatment regimens can be provided safely in an outpatient setting.

Clinical assessment and cost assessment are both tools of chemotherapy stewardship.

Clinical assessment may include consideration of whether an agent is being used within established evidence-based guidelines, if there is a recognized benefit for use or published rationale supporting its use, as well as addressing supportive care and appropriate dosing.

Cost assessment may examine whether the agent is the most cost-effective drug to treat the patient’s indication while also maintaining prescriber authority and autonomy. It also determines whether the medication can be given in an ambulatory setting; if the dose can be rounded to the nearest vial size increment; whether there is documentation of insurance approval; whether the patient has a co-pay that is burdensome; and whether programs are available to help alleviate costs to the patient and the health system.

In an overview, McBride described the CMS Oncology Care Model (OCM), a 5-year model that runs through June 30, 2021. This multi-payer model is focused on providing oncology care with increased quality and coordination.

The goal is to pay providers based on the quality of care instead of a quantity of patients or services, and for reimbursement, to reduce overall costs. Currently, 200 diverse physician groups and 14 payers, including CMS, are participating in the OCM.

Under OCM, implementing biosimilars is key for cost savings, according to McBride. One example is pegfilgrastim, which has been shown to account for 5.3% of the total cost of cancer care for patients in the OCM. A cost-efficiency analysis using biosimilar pegfilgrastim versus reference pegfilgrastim found a cost savings potential per patient of $223 for 1 cycle to $1355 for 6 cycles.

“We’re looking at saving large amounts of money during that conversion [to biosimilars],” McBride said.

Implementation of a checklist for development may open up additional opportunities for reimbursement under OCM and other models, according to McBride.

Inpatient versus outpatient oncology care is another area that pharmacists can examine for chemotherapy stewardship by weighing the advantages and disadvantages of chemotherapy administration and reimbursement factors. The coronavirus disease 2019 pandemic has been a factor in moving more patients to an outpatient care setting, McBride said, and health systems are seeing the shift reflected in cost savings.

Other factors that play a role in chemotherapy stewardships are drug waste, intravenous drug optimization, and oral drug optimization.

“We’re looking at all these different pieces together,” McBride said.

Overall, changes made to models of care and pharmacy practice models may address outcome-based pathways in pharmacy to reduce total costs of oncology care.

REFERENCE

McBride A. Advancing the Role of the Oncology Pharmacists: New Opportunities in Next Decade for Ambulatory Oncology Pharmacists in Chemotherapy Stewardship. Presented at: Hematology/Oncology Pharmacy Association (HOPA) Practice Management 2020 Virtual Learning Event. September 11, 2020.