The Patient Prescription Pipeline: Enhancing Health Equity With Medically Integrated Pharmacies

Health equity remains a persistent challenge in health care, affecting access to timely medications and ongoing treatment across disease states, socioeconomic backgrounds, ethnicities, and races. Patients with cancer and their providers often face a complex web of barriers, including prior authorizations, high treatment costs, and fragmented communication between health care providers, all of which undermine both effective care and patient outcomes. These barriers, coupled with the growing influence of PBM-owned specialty pharmacies (SPs), create a challenging landscape for both patients and providers. However, one potential solution gaining attention is the use of medically integrated pharmacies (MIPs), which was discussed by a panel of experts at the sixth annual National Community Oncology Dispensing Association (NCODA) Oncology Institute in Boston.¹ They explored how MIPs and independent pharmacy networks can play a vital role in improving health equity, ensuring that patients with cancer receive the care they need.

Limited distribution models offer a pathway for practices to maintain control over their prescriptions to protect patient health outcomes. Image Credit: © Andy Dean - stock.adobe.com

Medically integrated care teams, including MIPs, have emerged as a vital solution for improving care coordination and access to treatment for patients. These teams, consisting of oncologists, pharmacists, advanced practice providers, nurses, and pharmacy technicians, work collaboratively throughout the patient’s cancer journey. Within this model, MIPs play a key role by managing the distribution of medications directly within the clinic where patients receive care, ensuring more cohesive treatment, reducing financial toxicity, and promoting better adherence to therapy, ultimately enhancing patient outcomes.

Shifting from a vertical, isolated care model into a collaborative approach can improve the clinician and patient experience, thereby increasing the quality of care and creating opportunities to navigate inefficiencies more effectively. For patients with cancer who require consistent treatment monitoring or experience sudden shifts in disease progression, the integration of an MIP allows clinicians to provide more effective treatment education, dispense medications directly to patients, get ahead of waste during dose adjustments, and help minimize out-of-pocket costs. Additionally, practices can more effectively maintain control over the distribution network to protect patient access, quality of care, and financial viability for practices.

The panel moderator Sharita Howe, PharmD, associate director of partner development and strategy at NCODA, emphasized the importance of deconstructing isolated care models and shared what some of the benefits of an MIP may look like.

“If you move away from siloed care into a more collaborative approach, you can increase those patient outcomes,” she said. “You have mitigation of costs, avoidance of [medication] waste and things like that…A lot of the practices have financial counselors and navigators that'll assist patients with anything that they may need from a financial toxicity perspective, and then a lot of practices now are doing health disparity analyses.”

Limited distribution networks involve manufacturers partnering with a select group of pharmacies to dispense limited distribution drugs, such as zanubrutinib (Brukinsa, Beigene), under specific contractual agreements.² Limited distribution networks can include independent pharmacies and independent SPs such as Onco360 and Biologics, as well as PBM-owned SPs, including CVS Caremark. However, patients receiving treatments through these mediums often run into significant care obstacles. PBM-owned SPs are vertically integrated, allowing PBMs to direct patients toward external pharmacies for specialty prescriptions and forcing them to navigate the drug distribution system without resources that can be provided by MIPs. Additionally, coordination and communication of care between institutions is often fragmented, resulting in incomplete medical records and poorly managed treatment changes.

The process of getting prescriptions to patients involves several stages with multiple opportunities to either minimize or exacerbate barriers to care. After treatments are prescribed by providers, the prescriptions must go through an insurance verification and approval, preparation, education, delivery, and ongoing treatment monitoring. In SP settings, clinical information may be based off pharmacy and insurance records, which can exacerbate socioeconomic and sociocultural barriers, and they may only provide medication counseling upon request, abandoning opportunities to educate patients to ensure optimal treatment outcomes. Further, many SPs do not offer local pickup options, forcing patients to rely on mail order delivery, which may delay delivery of treatments.

“[SPs] may send that prescription out, or they send out a 60- or 90-day supply, and we all hear of these stories,” said Kathy Oubre, MS, chief executive officer of the Pontchartrain Cancer Center in Louisiana. “But then there’s a dose reduction or a progression in the disease, and therapy needs to change. There are out-of-pocket costs associated with these changes. When we talk about equity and financial toxicity, these are not just buzzwords—they are real challenges we face in caring for our patients.”

The presence of PBM-owned SPs significantly impacts a practice’s ability to retain prescriptions. Without PBM involvement, practices can capture 98% of prescriptions across all insurance types, but this rate drops to 79% when PBMs are involved—and plummets to just 15% if three or more PBM-owned SPs participate. This decline jeopardizes the ability of practices to provide consistent, high-quality care.

Despite the many benefits of limited distribution models, there is ongoing tension between payer relationships, PBMs, and pharmaceutical manufacturers, and the evolving role of independent pharmacy networks in oncology care is increasingly critical as practices seek to maintain autonomy. Practices face challenges with PBMs poaching patients by trying to redirect prescriptions, either through refill requests or direct contact with the patient, making it difficult to keep patients within the MIP network. Additionally, pressure from payers threatens limited distribution models, forcing manufacturers and practices to navigate the fine line of maintaining control over drug access meeting the demands of larger payer systems. These dynamics force practices to continuously find new ways to protect revenue streams and ensure patient access to high-quality, integrated care.

Third-party associations are critical resources for practices navigating the complex relationships between payers, PBMs, and pharmaceutical manufacturers. Bill Karnes, national director, physician networks and strategic partners at BeiGene, shared how these organizations and stakeholders can come together to overcome the challenges posed by PBMs.

“Third party associations, whether they be NCODA or COA, both are very important, because it's where the stakeholders are really coming together and sharing honest information about what they're thinking,” he said. “So, it helps us form our internal decisions on stakes that we're taking. [It could be] a payer pressuring you to contract more with them and take the decision away from the practices to give them more authority. But it's coming to meetings like this and keeping your finger on the pulse of what's going on from an industry standpoint [that’s important].”

Limited distribution models supporting MIPs offer a pathway for practices to maintain control over their prescriptions to protect patient health outcomes. Through ensuring that more prescriptions are filled within their own networks, practices can avoid the obstacles of PBM interference and enhance the overall care experience for patients. As independent pharmacy networks and MIPs continue to grow in prominence, the future of oncology care depends on collaboration between payers, manufacturers, and providers to maintain equitable, patient-centered care in an evolving health care landscape.

REFERENCES

1. Howe S, Karnes B, Noto J, et al. Deep dive 2: distribution. National Community Oncology Dispensing Association Oncology Institute. August 21, 2024. Boston, MA.

2. Limited distribution drugs: a guide to networks and specialty pharmacies. GoodRx. September 13, 2023. Accessed September 20, 2024. https://www.goodrx.com/drugs/medication-basics/limited-distribution-drugs