Oral Oncology Products
from Oncology Issues
Oral agents are easy to use and offer the promise of less frequent visits to the physician's office. This promise is not trivial, especially as we have come to realize that many forms of cancer may be managed with these drugs. Still, oral oncology therapies are encountering a number of obstacles, including concerns about patient compliance and reimbursement.
Will patients take all the medicine they should and take them on schedule? Will patients tell their doctors in a timely manner about the side effects they are having? Will insurance companies pay for oral medications so patients can afford them? As yet, these questions remain unanswered, and consequently the use of oral cancer agents has been limited.
The oncologists and nurses surveyed indicated little difference between oral and IV agents in terms of compliance, dose maintenance, and toxicity.
However, both nurses and physicians viewed oral drugs as being more easily administered, and nurses found it more difficult to obtain insurance approval for oral drugs. Nurses would typically be more aware of insurance issues than their physician counterparts because they are responsible, or work with the staff members responsible, for filing and following through on claims.
While scores on the availability of products were relatively neutral, many respondents commented on delays in obtaining oral agents because local pharmacies sometimes had a policy of not stocking them.
Barriers to Expanded Use
Perhaps the most interesting aspects of the study were the answers to the open-ended questions that asked respondents to describe their recent experiences prescribing oral chemotherapy. These responses highlighted a number of obstacles, which fall into one of three broad categories: financial, cultural, and practical.
Office-based oncology practices derive most of their revenues from treating patients with chemotherapy. The practices are compensated both for delivering the drugs and for the drugs themselves. Reimbursement of any kind is often lacking with oral agents. There are no administration fees and, unless the practice also dispenses the drugs, there is no involvement in their purchase. The oncologist simply writes a prescription, and the patient goes to a pharmacy and obtains the product.
Consequently, the practice will realize almost no revenue from those patients who are treated entirely with oral agents. While it is unlikely that any physician would base a treatment decision solely on financial considerations, it is also unrealistic to assume that financial considerations can be completely ignored, especially if IV drugs offer equivalent outcomes.
The one case in which oncology practices can realize revenue from patients treated with oral chemotherapy is when the practice also dispenses the product. Three of the 12 practices that participated in our study dispensed oral agents. As the availability of oral chemotherapeutic drugs increases, the number of dispensing practices is likely to increase as well.
Medical oncologists provide evaluation and management services, make referrals for diagnostic testing, radiation therapy, surgery, and other procedures as necessary, and offer any other support needed to reduce patient morbidity and extend patient survival. The core activity in medical oncology is, however, the provision of infusional chemotherapy. The entire structure of office-based practices revolves around this activity, and it is what distinguishes medical oncology from most other specialties.
This reality and the fact that physicians receive no reimbursement for providing oral therapy to Medicare patients are the principal barriers to the availability of oral agents. The advent of oral agents ultimately means that medical oncology will need to change its identity. Acknowledging this reality is difficult at a time when assaults on the profession are being mounted by public and private payers who are anxious to reduce compensation for the treatment of cancer patients.
If oral agents ultimately deliver on their promise of combining equally efficacious therapy with better adverse event profiles and easier administration, they will gradually gain their appropriate share of the marketplace. However, for the reasons noted above, the entry of these drugs into everyday care is slower than one would expect and may not come easily.
Mary Lou Bowers, M.B.A., is vice president, Consulting Division, at ELM Services, Inc., in Rockville, Md. George Silberman is senior consultant, and Lee E. Mortenson, D.P.A., is president and CEO of ELM Services, Inc., and executive director of the Association of Community Cancer Centers.
Oncology Issues 17(1):26-27, 2002. © 2002 Association of Community Cancer Centers
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