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In this episode, we will be discussing the role of health system specialty pharmacies in improving patient outcomes.

Our guest, Chelsey Lindner, is a clinical pharmacist who will share her insights on the unique combination of expertise and resources that these pharmacies offer to provide holistic support for cancer patients. She will also discuss the integrated care model, which has been proven to provide patients with the support they need to navigate their treatment journey.

Health system specialty pharmacies have been shown to help mitigate the access, safety, and follow-up issues that can lead to diminished health outcomes for cancer patients. By committing to integrated care, health systems can close the remaining loopholes in cancer treatment and improve patient outcomes.

Join us as we explore the important role of health system specialty pharmacies in cancer care.

Chelsey Lindner is a clinical pharmacist.

She shares her story and discusses her KevinMD article, “Integrated care is the key to optimizing cancer outcomes.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate, and subscribe at KevinMD.com/podcast. Today on the show we have Chelsey Lindner. She is a clinical pharmacist. Her KevinMD article, which we’ll talk about today, is titled “Integrated care is the key to optimizing cancer outcomes.” Chelsey, welcome to the show.

Chelsey Lindner: Thank you so much. Thank you for having me on today.

Kevin Pho: So we’ll get to the article in a little bit. First off, just briefly share your story and journey to where you are today.

Chelsey Lindner: Yeah, sure. After undergrad, I completed my doctorate in pharmacy. After pharmacy school, I did one year of residency in ambulatory care. During that experience, I rotated through various outpatient clinics and also worked with our health system specialty pharmacy.

For anybody who might not know, a specialty pharmacy really is just a pharmacy that fills high-cost or high-risk medications, and oftentimes insurance or the manufacturer might have specific contracting requirements that a specialty pharmacy can fulfill. Health systems can have their own specialty pharmacy, or you might think of some of our big-box corner retail stores; they might have their own specialty pharmacy service line as well, which we would consider a non-health system specialty pharmacy.

So after completing residency, I worked with our health system specialty pharmacy in an oncology-focused role. The benefit of that health system specialty pharmacy is that you can have a pharmacist or a pharmacy technician right in the clinic, meeting face to face with the patients, the providers, and the nurses. It really just helps streamline communication, and it improves patient safety and patient care as a whole.

After working for a health system specialty pharmacy, I transitioned to working for a cancer center pharmacy and helped to develop and manage an oral oncolytic management program. Some of the big things that I did in that role were to identify ways to optimize the patient experience when they’re undergoing cancer care, and I also helped to create treatment plans for oral cancer medications to enhance patient safety.

And then most recently, I came back to health system specialty pharmacy. I’m working remotely with Shields Health Solutions. For anybody who might not know, Shields is a specialty pharmacy integrator, and what that means is they partner with different health systems across the country to develop and operate health system specialty pharmacies. In this role, I work with on-site dispensing teams as well as clinic teams at NYU, actually, to manage oral cancer medications and other specialty medicines. I also serve as the oncology subject matter expert for our internal education and development program, so I host various educational webinars and provide professional development opportunities for our staff.

Kevin Pho: So in your background, when you’re embedded with the ambulatory team, tell us some stories or examples about your role as a clinical pharmacist and how that moved the needle when it came to patient safety and the patient experience.

Chelsey Lindner: Oh, yeah, definitely. I’m really passionate about patient care, especially when it comes to the oncology area of focus. These patients are going through a very hard time in their life, potentially facing a life-threatening illness, and I think it can be a very overwhelming time for those patients. There are a lot of pieces of the puzzle to navigate with their care. They might be on very complex regimens, meeting with various health care providers.

So I think having that opportunity to be in person, meet face to face, and be a point of contact and an advocate for them really helped to improve their patient journey as they went through their care. I have so many patients that would call me up and just ask questions or ask for updates on things. Having that really easy, open communication with the patient, and having been able to meet them face to face, I really think it improved the patient experience as a whole.

Kevin Pho: What are some examples of typical questions that you would be asked, either from patients or from the clinicians on the team?

Chelsey Lindner: Yeah, so I think probably the number one question I would get is when a patient was prescribed a new oral cancer medication. They would say to me, when I walked in the room to meet with them, “Can I just go pick this up at my local CVS? This is my local pharmacy; I’ll get it there.”

So the number one question I would get, or have to educate patients about, is that these medications, because they are oftentimes both high cost and high risk, are required to be filled through a specialty pharmacy. So I’d explain to them that process: This medication is not going to come from your corner retail store. We have a lot of pieces that we have to work through, as far as getting prior authorization from insurance. They’re very high-cost medicines, so we may need to see if we can acquire some type of financial assistance. And then eventually, we’ll be able to send this medication right to your home, or depending on the location, they may be able to pick it up in person, or we could even bring it right to their clinic appointment. But the number one question is, “Why can’t I get this from my corner retail store?”

Kevin Pho: So let’s talk about your KevinMD article, titled “Integrated care is the key to optimizing cancer outcomes.” Tell us, how did this article come together?

Chelsey Lindner: Point person for our company as a whole. So my marketing team did come to me and ask me to comment on the ACS annual report on cancer statistics, about why survival rates are improving, and then presented me with the opportunity to publish my thoughts, which led to the article.

So my initial thought is, I know we are seeing increased survival in part because we have better treatments. We have better screening capabilities; we’re screening patients earlier, so we’re detecting disease when we can still cure it. We have increased awareness of lifestyle factors that impact the risk for cancer. We have fewer people smoking.

But I think also the payer landscape has impacted patient outcomes, because a lot of reimbursement structures for doctors as well as pharmacies have been shifting from a quantity-focused payment scheme, like fee-for-service, where the more patients I see, the more money I get, and now are really trying to incentivize enhancing the quality of the care provided. So we’re seeing payment models shifting to performance-based, so providers and the whole health care team are incentivized to provide higher quality.

I think one of the big drivers for this is the Centers for Medicare and Medicaid Services. They created a payment model called the Oncology Care Model, and most recently now they’re switching to the Enhancing Oncology Model. This new model is really focused on improving care coordination in oncology care. So I think we’re going to continue to see improved outcomes as far as patient survival, but this is really where integrated care comes in. I think it’s really the key to being successful in this new model and continuing to optimize patient care as a whole.

So for my article, I really tried to focus on three main areas where I felt an integrated care model can impact positive outcomes. The first would be medication access. Difficulty accessing a medication is considered the first barrier to adherence. We have insurance approvals we have to go through, we have financial assistance, and we have potentially pharmacy restrictions. And so having a dedicated team or personnel to manage that step in the process really can help get patients on their therapy quicker.

We also can see enhanced patient safety. There’s more transparency between the pharmacy and the provider with this integrated model. The pharmacy may be able to directly communicate to the provider when the patient actually starts treatment, because again, remember, this is for oral cancer medications. The patient is just receiving it from the pharmacy, and so they may start taking it before their provider even knows about it. And then we also see that oftentimes the pharmacy or the pharmacist can sometimes be easier to reach than maybe the clinic staff, because they have a lot of different patients; they’re seeing patients in clinic and everything. So having that easier access to health care personnel can help patients and mitigate side effects.

And then lastly, the third area was long-term follow-up. A patient may be going for clinic visits initially on a regular basis, but as they’re more stable on therapy, they may see their provider less frequently. But the pharmacy is generally speaking with the patient every single month to schedule those refills, and so that’s a touch point with the patient between these visits where we can potentially identify adherence issues and side effect issues, and we can escalate or provide supportive care measures to really improve the entire patient journey. So those were the three main areas that I focused on in my article.

Kevin Pho: So you mentioned medication adherence, and as a primary care physician, certainly that’s one of the biggest issues that we need to deal with. What are some of the common reasons that you see that sometimes interfere with medication adherence?

Chelsey Lindner: Yeah, so a big one would be financial toxicity. Patients may be faced with a very high copay, especially if they potentially have Medicare; they might have a deductible to meet at the beginning of the year. And when I say expensive medicines, I mean one month of medication could cost almost about $20,000. So when we think about it, the patient might be responsible for a small percentage of that, and that is still a lot of money.

So I would say the copay cost is really the number one reason. But we’ve been doing a really great job with getting patients the financial assistance needed through different foundations, or getting them set up with the manufacturer patient assistance program. So for the majority of patients, we are able to get their copay down to less than $5, which is amazing and demonstrates the benefit of a health system specialty pharmacy and this integrated model.

But other than that, it could be that patients might not necessarily notice the benefit of taking their medicine, because it’s kind of like managing a chronic disease in some situations. So they don’t really understand, maybe, the importance of the medication.

And then I would say probably the other biggest one is side effects. I always reinforce to patients that we don’t want the treatment to be worse than the cancer itself. Especially when it comes to more palliative care, where we’re really just trying to improve survival and enhance their quality of life, that’s a big factor. But that’s where this integrated care model really is beneficial, because we can work with patients to minimize side effects and help teach them about what to expect with the therapy, and when to let somebody know when some type of intervention might be needed. So side effects are probably another big one.

Kevin Pho: So you mentioned the oncology care team as an example of integrated care. Specifically with that oncology care team, can you talk to us about the different roles and different members that would comprise that team?

Chelsey Lindner: Yeah, so as part of the health system specialty pharmacy, and the oncology care as a whole, usually with the health system specialty pharmacy you have clinical pharmacists, and you may have separate dispensing pharmacists. The clinical pharmacists are maybe doing more of the patient outreach, education, and counseling. The dispensing pharmacists are more so receiving those prescriptions and doing the actual dispensing of the medication.

And then you’ll usually see a level of certified pharmacy technicians, where, depending on the institution, they may have more structure to that role. At Shields, we have liaisons, who are pharmacy technicians, and then we also have patient support advocates, so we’re able to divide some of the responsibilities. Essentially, the liaisons are the ones that are calling patients every month to schedule refills and set up new deliveries for new patients, whereas the patient support advocates might be working toward getting that insurance approval, doing appeals, and helping patients get financial assistance. So through that, we can be able to touch more patients, because we’re dividing up some of that workflow.

But then in clinic, we have our providers, our advanced practice practitioners, and our nurses that are right there in clinic meeting with patients, and we can easily communicate with them through our electronic health record or email. And then some institutions may have a financial advisor who may be able to do some of the financial assistance piece, as well as social workers, dietitians, and palliative care specialists. With oncology care, there are really a lot of people involved, and I think that team approach really enhances the patient’s outcomes and just their experience as a whole.

Kevin Pho: Now tell us what kind of medical institutions have these integrated health specialty pharmacies. Are they typically large academic medical centers? Are they smaller community hospitals? What are some typical medical institutions that we’re talking about here?

Chelsey Lindner: So a lot of them are academic medical centers, just typically because they have more resources and more personnel to be able to get a health system specialty pharmacy started. All that means is that that particular institution, like NYU, which is the team I work for, has an actual specialty pharmacy on site operated by NYU. And so essentially, we can keep those patients in-house, so we have more transparency over their care and their treatment.

Kevin Pho: We’re talking to Chelsey Lindner. She’s a clinical pharmacist. Her KevinMD article is titled “Integrated care is the key to optimizing cancer outcomes.” Chelsey, what are some of the take-home messages that you want to leave with the KevinMD audience?

Chelsey Lindner: Yeah, I would say that integrated care is really the key to being successful in the new Enhancing Oncology Model, and using a health system specialty pharmacy is usually going to be the best choice for your patient. We see improved coordination of care for both new starts as well as patients continuing on therapy when they use a health system specialty pharmacy. It streamlines communication between the patient, the pharmacy, and the provider. We have that enhanced transparency regarding the medication dispensing. We do see enhanced patient satisfaction as well as provider satisfaction when they use these health system specialty pharmacies, and we see enhanced patient safety and follow-up. So that’s the main thing: If you have a health system specialty pharmacy, and we can work with this integrated care model, we’re going to see better care for the patient.

Kevin Pho: Chelsey, thank you so much for sharing your time and insight, and thanks again for being on the show.