Bryan A. Mehlhaff, MD
With the emergence of the novel treatments abiraterone acetate (Zytiga) and enzalutamide (Xtandi), urology groups are beginning to offer in-office dispensing to their metastatic castration-resistant prostate cancer (mCRPC) patients. Couple this with the financial challenge of diminished reimbursement faced by urology practices and the appeal of this service becomes apparent.
In-office dispensing can meet patient needs by enhancing patient care and outcomes and provides the practice with an additional service line and revenue stream, said Karen K. Kellogg, PharmD, director business solutions, VitalSource GPO, Specialty Solutions, during a breakout session at the 2015 LUGPA Annual Meeting. Kellogg, along with David J. Coury, CEO of UroGPO, and Bryan A. Mehlhaff, MD, of Oregon Urology, served as panelists during the session titled, “In-office Dispensing With Urologists.”
In-office dispensing is not a new idea. Oncology practices have been doing it for quite some time and were successful with the buy-and-bill model. But as more urologists prescribe abiraterone and enzalutamide, and provide the safety counseling, the financial counseling, the follow-up, and patient support that the medication requires, it has become apparent that the only thing urologists were not doing was dispensing the drugs.
“There’s a lot of interest in urology groups to get involved in in-office dispensing. It’s only been in the last year that we’ve incorporated it in our practice,” said Mehlhaff. “It has now become an integral part of how we take care of our patients.”
The benefits of physician dispensing are both clinical and financial. From a clinical perspective, it enables greater continuity of care and improves patient adherence to therapy. It reduces the barriers and abandonment rates by providing an easier path to treatment. From a financial perspective, in-office dispensing distinguishes a practice from its competitors and can minimize the time-consuming task of correcting misunderstood prescriptions.
“How many times does a prescription go unfilled because the patient did not know about the high out-of-pocket cost or because the prescription was not available at the local retail pharmacy?” asked Kellogg.
There are a number of start-up questions and considerations to make if a practice is interested in going the in-office dispensing route. Questions about the practice’s current and potential dispensing volume, the use of e-prescription services, the current payer mix, and if the physician leaders and managers in the practice are engaged should all be considered before making the business decision.
Specific requirements to set up an in-office dispensary include researching physician dispensing state regulations, equipment (computer, dispensing software, and printer), acquisition of an NCPDP/NABP number, third-party payer direct contracts, staff training on dispensing software and workflow, and inventory procurement (selection of a drug wholesaler).
“If your group has many offices, I would recommend creating one dispensing site,” said Coury. “Then have all of your offices e-prescribe into that one site.”
One of the largest hurdles once the dispensary is established is dealing with insurers and prior authorization, said Coury. All Medicare Part D plans will require a prior authorization in 2015 on oral oncolytics. Although it sounds difficult because staff training is required, training is usually straightforward.
“The advantage is your office will be dealing with prescription benefit managers, not insurers,” said Coury. “You’re not billing medical plans, you’re billing prescription plans, and so it’s a whole new set of payers. Luckily, PBMs are used to dealing with prior authorization and they turn around orders within a day.”
Insurers also use specialty pharmacy to deliver expensive medications. But there are disadvantages with using that service, said Mehlhaff.
“I’ve had problems with specialty pharmacy in the past, especially when it comes to shipping the drug,” said Mehlhaff. “The specialty pharmacy ships the drug automatically, no matter what—whether it’s snowing, whether the office is closed, on the weekend, even when the patient is no longer living. That’s just a waste of money and resources.”