The Role of Payers in the Dispensing Process

Peter Salgo, MD: Well, let me answer the last part first. Of course the patient is paying for the drug. Because the benefit is in lieu of income; that benefit is in lieu of salary. That’s that patient’s money. Yes, it’s being stewarded by an organization, but it’s ultimately the employee’s money. But are you really implying—let’s be clear about this—that it’s because of the way we divided up the health care side silos, the health care payers as a consequence of private industry paying for it? And that if only we had a single-payer health care system, this would all be solved? Is that what you’re really implying?

Cheryl Allen, BPharm, MBA: I’m implying that that’s where a lot of the paperwork nightmare comes from.

Peter Salgo, MD: Because I can hear rotten fruit hearing the screams right now.

Cheryl Allen, BPharm, MBA: I mean if we’re talking about why we have the system that we have today, that’s why we have a system that we have today.

Peter Salgo, MD: Yes, agree.

Cheryl Allen, BPharm, MBA: But think about universal-payer systems that we could proxy again. Did we not just say that here that prescribers have the ability to put doublet and triplet therapies together?

Peter Salgo, MD: Sure.

Cheryl Allen, BPharm, MBA: And here in the United States, payers are paying for it when it’s an appropriate utilization of therapy. So I think at the end of the day we can.

Noa Biran, MD: But who decides that? That’s the question.

Cheryl Allen, BPharm, MBA: Well I think NCCN [the National Comprehensive Cancer Network] is defining it for oncology.

Peter Salgo, MD: Or maybe physicians should define it?

Noa Biran, MD: Maybe experts in the field should define it, you know?

Peter Salgo, MD: But at the end of the day, is it the money people who define it or the doctors who define it?

Noa Biran, MD: Why does NCCN define it? Right, exactly, that’s the question.

Peter Salgo, MD: Is that what you’re asking?

Noa Biran, MD: Right.

Peter Salgo, MD: Good question.

Cheryl Allen, BPharm, MBA: Why don’t prescribers in the field?

Peter Salgo, MD: Yeah.

Cheryl Allen, BPharm, MBA: Well, I think there are collaborations with payer communities and the prescriber community, particularly in oncology, where they’re looking at pathways. So certainly there’s a lot of that going on.

Peter Salgo, MD: But at the end of the day, have physicians in some very real way ceded control of their practices to the money people? That it’s the fiduciary-responsibility people who are making the call? You have a clinical decision that you’ve made, but the money people say no. Very frustrating.

Noa Biran, MD: All the time. All the time. Every single decision.

Peter Salgo, MD: She says, “If I do everything you want, and I do everything that every oncologist wants every time, we’re broke in 2 years.” Can’t do that either, can you?

Cheryl Allen, BPharm, MBA: Right, right. Well, when you think about the changing trends in oncology, I mean, you know the community oncologist has gone by the wayside, right? We don’t have too many individual practices anymore.

Peter Salgo, MD: She says there are a lot of them. She says there are tons of them.

Cheryl Allen, BPharm, MBA: Yeah, you know, we have group.

Noa Biran, MD: I think it’s hard to be a solo practitioner, I agree. But there are certainly a lot of, you know, mom-and-pop oncologists that are local, and they’re good. They’re excellent. I work with a lot of them. They’re very, very good. But they’re not specializing in 1 cancer. And today, it’s very difficult to keep on top of every single cancer. I don’t know how that’s possible.

Cheryl Allen, BPharm, MBA: But where we do see oncology practices being bought up by hospitals and health systems—and then incorporating into these big self-dispensing-type situations—yeah, we see situations where the decision of the drug product may or may not lie with the prescriber. And whether that’s in oncology or whether that’s in MS, you know, we may ultimately see that part of the appropriate determination of therapy going to, “What is within the patient’s benefit?” and then they’ll figure out the drug from there.

Peter Salgo, MD: But what you’re describing, isn’t that just what we tried to put together, or I tried to put together, a few minutes ago? Concentrate oncologists, concentrate specialists, concentrate pharmacies—we keep an eye on the money, we make it as efficient as possible. And the mom-and-pop oncologists, they go by the wayside. Is that the future? Is that what you want to see?

Cheryl Allen, BPharm, MBA: Oh, no. That’s not what I want to see. I mean, I think that there’s enough patient need out there that we need community oncologists. We certainly need the large centers with the specialization. So I certainly don’t want to see the community folks go away. But what I’m saying is that from an economic perspective, we find that many of the community sites can’t seem to survive with the increasing pressures.

Peter Salgo, MD: Are you buying this?

Noa Biran, MD: Yeah. I mean, I think that a lot of the big academic centers are now branching out into the community, and I think that honestly, the trend is going to be that the community practice—type scenario fades. I think even The University of Texas MD Anderson Cancer Center and Memorial Sloan Kettering Cancer Center are putting out satellites all over the place. And so are the Mount Sinai Health System and Columbia NewYork-Presbyterian Hospital, you know? They’re putting out satellites in Basking Ridge, in Monmouth—in all areas of New Jersey—and they’re putting subspecialists in the community. And I think that the local doctors are certainly feeling the pressure. And I worry that 10 years from now, they will exist less and less. And even when I was first looking for a job 5 or 6 years ago, and I interviewed at a community practice, they said, “We can’t guarantee this practice will exist in 5 years.” They told me that straight up. So I think it’s becoming more challenging. And patients are now more and more educated, and they’re seeking out subspecialists.

Peter Salgo, MD: I know what patients ask me in civilian life because I have an ICU [intensive care unit]. They generally don’t ask me a lot, which is our ventilator space. But people come to me and they say, “My mom has a tumor. My mom has cancer. Where would you go?” And the answer they want to hear is, 1 of the big cancer centers or 1 of the big specialists where they see a ton of this. They don’t want to hear “Dr. Cancer Specialist,” who sees that and a whole host of other kinds of tumors, and maybe sore throats, and maybe an occasional endocarditis. They want to hear that they’re going to get the laser-like focus on this disease. It makes sense to them. And is this the way we’re all going? Do you think 10 years from now? You seem to think so. What do you think, as a payer?

Cheryl Allen, BPharm, MBA: I don’t think the payers can afford that, quite honestly.

Peter Salgo, MD: Can they afford not to?

Cheryl Allen, BPharm, MBA: Well, you know.

Noa Biran, MD: But why is it not more expensive for them to. I mean, it should be better care.

Cheryl Allen, BPharm, MBA: Well, if the insinuation is that everyone wants the best of the best.

Peter Salgo, MD: Right.

Cheryl Allen, BPharm, MBA: And we all want this then. I think that there are trends toward larger practices, group settings, hospitals’ health systems buying up community practices for other economic incentives—and not necessarily around the billing of the drug product, right? There are other categories there. But I think ultimately with consolidation in the space around the payers and the PBMs [pharmacy benefit managers], what it will all get down to is pushing to the lowest-cost resource. So we’re going to begin to look at, just like in an infusion, what is the less costly site of care? What is the least costly drug regimen product? That’s where the patient will ultimately go. Are we into that right now? No, because we allow for selection of health insurance benefits. So patients are choosing, and then that benefit then tells the patient where they’ll go.