According to a recent report, the number of oral oncolytics is increasing and has been estimated to account for a quarter to a third of all anticancer agents in the pipeline.1,2
Oral agents are poised to provide advantages for patients, such as convenient administration requiring fewer office visits. However, these drugs are expensive, are not stocked by many retail pharmacies, and because they can cause side effects as serious as those caused by parenteral agents, require patient education. Additionally, patient adherence and persistence, which are difficult for prescribing physicians to measure, have been shown to be suboptimal for oral agents even as part of uncomplicated regimens in clinical trials, and in presumably highly motivated patients.3
Prescriptions for oral chemotherapy agents can be filled in retail pharmacies (if the agents are stocked), hospital pharmacies, specialty pharmacies, mail order pharmacies, or through the doctor’s office either via a competitive acquisition program or in an office-based pharmacy.4
In-office drug dispensing by doctors, particularly those treating injured workers covered by workers’ compensation, has recently been vilified in the press as immoral and corrupt for the marked-up fees being charged, which are said to be contributing to significant healthcare costs.5
Nevertheless, doctors are increasingly filling the prescriptions they write,6
and in-house dispensing has paradoxically been suggested by the American Academy of Urgent Care Medicine as a way to reduce healthcare costs by increasing the number of patients who fill their prescriptions and take their medications appropriately, and by providing the opportunity for patient education to reduce side effects that would require additional management.7
Therefore, in-house dispensing of oral agents in the community oncology setting may provide a safer and more reliable and convenient way for patients to receive their medications.3,7
Barbara L. McAneny, MD
In-house dispensing by physicians is allowed in some form in nearly all states7
except New York, Massachusetts, and Texas.6
In Utah, legislation has recently been passed to allow in-house dispensing despite opposition from pharmacists at large hospital-based cancer centers who have been responsible for the dispensing of oral anticancer agents.1
Furthermore, some states may require a physician or practice to either be licensed or to pay fees to dispense, or, in a few instances, to register as a retail pharmacy with pharmacists doing the actual dispensing.7
About half of states have “any willing provider” laws that specify that if an in-house pharmacy meets the requirements for a specialty pharmacy in that state, payers cannot prevent the in-house pharmacy from filling prescriptions.8 Although in-house dispensing could reduce the costs to a practice associated with the time involved in dealing with outside pharmacies that fill their prescriptions,3
there are other potential costs and barriers to be considered. For instance, Barbara L. McAneny, MD, chief executive officer of New Mexico Oncology Hematology Consultants, thinks that oral medications may disrupt the traditional method of financing community practices.
The IV vs Oral Model
The historic model of IV chemotherapy delivery in the office, McAneny points out, resulted from Medicare paying a markup on the drug margin and letting the practices figure out how to administer and manage therapy. Although practices, including hers, still depend on the IV drug margin, the increasing prominence of oral therapies instead of IV infusions has contributed to the instability of community oncology practices. As more oncologists have chosen to work in hospital-based centers to take advantage of the higher payments received by hospitals for their services, McAneny believes that payers will eventually come to realize that it makes more sense to pay community practices enough to manage cancer in the lower-cost community setting.