2022 Medication Access Report: Oncology Edition

Oncology therapy innovation — and implications

Recent advancement in oncology therapies brings hope for longer survivorship, especially for cancers that previously had no medication options or rare cancers.

Convergence of biopharma and technology has advanced the research and development processes for novel therapies, bringing the first innovations since chemotherapy.^[4]Beyond AI: The recipe for success in merging tech and biology for drug discovery, STAT, 2022 Newly launched therapies are also reaching patients faster than in previous years. Of the 62 oncology drugs launched in the last five years, 57 received a form of expedited approval, a nod to their dramatic efficacy and the need for breakthrough or orphan drugs for patients who have no other treatment options.^[5]Global Oncology Trends 2021, Outlook to 2025, IQVIA Institute, 2021

Visual source: Analysis and derived values completed using Evaluate Pharma data, current as of March 2022 (www.evaluate.com)

Advancements in pharmacogenomics, genetically testing patients to determine the appropriate application of a drug, further allow care teams to not only better identify and treat specific processes to stop cancer progression, but also identify patients who stand to benefit most.^[6]Understanding Pharmacogenomics, American Society of Clinical Oncology, 2020 Sixty percent of newly launched medicines require or recommend pharmacogenomic biomarker testing prior to use.^[5]Global Oncology Trends 2021, Outlook to 2025, IQVIA Institute, 2021 This extra step can pay off in reducing trial-and-error treatment approaches for true precision medicine.

Innovation implications for patients and care teams

With greater options and innovations available for treating cancer comes more choices and complexity for patients and care teams. Cancer treatment no longer only looks like a patient sitting in an infusion center or hospital for hours. More often, patients can administer their treatments in their own homes. In fact, oral formulations represent over 60% of new oncology medicines introduced since 2015, a shift influenced by the COVID-19 pandemic, but also the nature of newer therapies.^[5]Global Oncology Trends 2021, Outlook to 2025, IQVIA Institute, 2021 Many targeted oncology therapies such as protein kinase inhibitors (PKI) are administered orally.^[5]Global Oncology Trends 2021, Outlook to 2025, IQVIA Institute, 2021

While these new options may give patients greater flexibility and fewer lifestyle disruptions, they also pose a challenge for adherence. With patient-administered medications, new variables come into play, including health literacy, side effect management and even forgetfulness. In fact, in a recent survey, forgetting to take their medication was the top reason patients did not take their medication as prescribed.^[7]CoverMyMeds Oncology Patient Survey, 2022

These choices present an opportunity to engage patients and caregivers as partners with care teams regarding their treatment decisions. Shared decision-making can help proactively address potential barriers so patients can receive the treatment that works best for their unique lifestyle and makeup. They also foster patient autonomy and empathy, which can be welcome anchors during a time often marked by vulnerability and emotion surrounding a diagnosis.

Access, affordability and adherence to oncology therapies are critical, and require support both human and technological in nature. Care teams need solutions that reduce unnecessary burdens so they can partner with patients to find the best and most efficient path forward for cancer treatment and holistic care.

Access

When finding the most effective treatment for a person living with cancer, providers walk a tightrope between judiciously evaluating all variables affecting the individual patient’s cancer and starting therapy quickly. After considering all pathways and guidelines and landing on a treatment, the access journey has only just begun. Next up are navigating a host of coverage verification and approval processes put in place to reduce unnecessary costs, which many stakeholders are hyperaware of in the oncology space. Costs of care for cancer are growing steadily each year. In 2015, total costs associated with cancer care and medications were $183 billion and, based only on population growth, are expected to increase 34% to $246 billion by 2030.^[8]National Cost of Cancer Care in the United States Expected to Rise to $246 Billion by 2030, The ASCO Post, 2020

Nearly all (99%) cancer medications are considered specialty medications, meaning they’re complex in makeup, distribution and/or payment models.^[9]2022 Economic Report on US Pharmacies and PBMs, Drug Channels, 2022 Patients and care teams could find a reprieve from managing a complex disease and medication regimen in simplified and expedited medication access.

A recent study showed time to therapy initiation (TTI) for cancer patients increased by 38% over the course of 9 years, with a correlation to an increasing number of prior authorization (PA) mandates, though the study did not track markers to determine direct impact to TTI.^[10]Time to initial cancer treatment in the United States and association with survival over time: An observational study, Khorana et. al., 2019 Notably, though, uninsured patients who did not go through a PA process had a shorter TTI.^[10]Time to initial cancer treatment in the United States and association with survival over time: An observational study, Khorana et. al., 2019 Patients who experienced a longer TTI had an increased risk of death in certain early-stage cancers.^[10]Time to initial cancer treatment in the United States and association with survival over time: An observational study, Khorana et. al., 2019 To this point, solutions that can automate and simplify medication access processes could help save lives.

The implications of utilization management in oncology

Utilization management methods, such as PA, step therapy and specialty tiering, can delay or prevent patients from accessing novel therapies that could more effectively treat their cancer, as a first line of treatment. This is especially concerning when treating cancer quickly is paramount to survival chances. A targeted medication’s effectiveness could be compromised, and symptoms could worsen, if patients are required to start with a less-preferred medication due to step therapy requirements.^[11]Impact of Pharmacy Benefit Managers on Oncology Practices and Patients, Royce et.al., 2020 In a recent survey of oncologists, 34% said their patients very or somewhat frequently are not able to receive all their necessary prescription medicines due to a decision by their health insurance plan.^[12]Experience and Impact of Utilization Management Techniques, Public Opinion Strategies & Hart Research Associates, 2019

In a separate survey of cancer patients, 34% said they had to wait for insurance approval of a treatment, resulting in treatment delays and increased stress for patients.^[11]Impact of Pharmacy Benefit Managers on Oncology Practices and Patients, Royce et.al., 2020

When asked to rank important factors about a chosen medication to treat cancer, patients most frequently rated treatment effectiveness and provider’s preferred medication as most important.^[7]CoverMyMeds Oncology Patient Survey, 2022 These were rated above even out-of-pocket cost and whether the medication was covered by their insurance.^[7]CoverMyMeds Oncology Patient Survey, 2022

Unfortunately, some insurance requirements can prevent patient access to their provider’s first choice of therapy and delay time to starting any treatment at all.

Prior authorization (PA)

The increasing use of oral and self-administered injectable treatments in oncology means more medications will be billed through pharmacy benefit, compared to traditional infused chemotherapies, which are billed through medical benefit. A recent study found nearly three-fourths of oral anticancer medications (72%) require PA.^[13]Association between insurance plan, prior authorization, and time to receipt of oral anticancer drugs, Lichtenstein et. al., 2021 Because of PA-associated delays, patients in the study waited a median of one week to start therapy and 25% waited two weeks.^[13]Association between insurance plan, prior authorization, and time to receipt of oral anticancer drugs, Lichtenstein et. al., 2021

For care teams, managing steps of the PA process takes time away from higher-value tasks such as patient communication and education. In one study of a breast cancer practice, prescriptions that required a PA involved five to 10 steps, completed by multiple team members, including a physician, pharmacist, program nurse and a resource specialist.^[14]Prior Authorization for Medications in a Breast Oncology Practice: Navigation of a Complex Process, Agarwal et. al., 2017 Some of these steps required repeated attempts, such as placing a phone call to an insurance company or specialty pharmacy.^[14]Prior Authorization for Medications in a Breast Oncology Practice: Navigation of a Complex Process, Agarwal et. al., 2017 Communicating with these entities typically took 80% of the total PA process time for care team members, with some spending up to five hours in communication for one prescription.^[14]Prior Authorization for Medications in a Breast Oncology Practice: Navigation of a Complex Process, Agarwal et. al., 2017

Finding efficient paths for care teams, patients and payers

Getting more people the therapy they need for their specific cancer in a timely manner requires transparency and efficiency for all stakeholders. Technology-enabled solutions can help automate benefit identification and verification, PA requests and patient support service enrollment. That way, care team members can spend time connecting with patients and dedicated process specialists can better advocate for more specialized cases.

Solutions for care teams

Access to patient-specific benefit information continuously in workflow can help clear medication access hurdles at each step on the way to starting therapy.

This can include hurdles such as location. For some eligible patients, medications come through clinical trials. It’s estimated fewer than 10% of adult cancer patients participate in clinical trials.^[15]The Role of Clinical Trial Participation in Cancer Research: Barriers, Evidence, and Strategies, Unger et. al., 2016 For about half of patients, a lack of nearby clinical trial availability was a barrier to participation.^[16]Why Do Only Eight Percent Of Cancer Patients In The U.S. Participate In Clinical Trials? Forbes, 2019

Centralized solutions leveraging both automation and human intervention may help patients access therapy more quickly and reduce cognitive burden for care teams. For specialty medications, inclusive of those prescribed in oncology, electronic solutions can help reduce benefits completion time by half a day compared to manual methods of benefit verification.^[17]CoverMyMeds data on file, full AMP portfolio analyzed from April 2019-Nov 2021 comparing phone and fax methods to electronic methods

In a recent survey 65% of oncology providers found turnaround time to be one of their most challenging pain point when it comes to PA.^[18]CoverMyMeds Oncology Provider Survey, 2022 A connected, in-workflow electronic prior authorization (ePA) solution can help reduce PA turnaround time by about six days compared to the traditional phone/fax processes.^[17]CoverMyMeds data on file, full AMP portfolio analyzed from April 2019-Nov 2021 comparing phone and fax methods to electronic methods Future healthcare systems that allow greater provider autonomy in medication decision-making can give care teams the confidence to better explain and engage patients in the treatment course of action.

Pharmacy and biopharma patient access support

Of the 49% of oncology patients who experienced a delay in receiving their medication, 26% self-reported worsening symptoms and 18% self-reported progression of their disease.^[7]CoverMyMeds Oncology Patient Survey, 2022 In partnership with pharmacies and technology expertise, biopharma companies can often help patients get on therapy faster while they wait to start their prescribed therapy due to pending approval. To get patients through the waiting period, bridge or quick start programs may be available to offer eligible patients a limited supply of their medication.^[19]What Makes a Good Call Center for Patient Assistance Program Success? Pharmacy Times, 2016 Integrated solutions may help connect patients and pharmacies to speed time to these therapies and increase awareness of these programs for better patient outcomes.

With more specialty pharmacies handling the increase in oral and self-administered cancer therapies, pharmacists have a greater role to play in helping patients gain access to their medications. In one study from 2018 to 2020, patients increasingly reported using specialty pharmacy services other than dispensing, such as help understanding insurance processes and filling out forms for financial assistance.^[20]The 2021 Economic Report on US Pharmaices and Pharmacy Benefit Managers, Drug Channels, 2021 Solutions that automate processes like PA, which is started at the pharmacy 75% of the time, can continue these higher-value tasks for patients.^[21]CoverMyMeds Provider Survey, 2021

Transparency for payers and PBMs

In turn, to best support and more quickly make determinations, payers and PBMs need greater transparency into clinical details and data. Partnerships with biopharma companies and greater real-world evidence in emerging therapies and for more treatment areas could help demonstrate the need and effectiveness of these advanced treatments. Alignment and real-world evidence are especially important as biopharma R&D teams continue to launch novel, often costly, therapies that will challenge standard coverage and reimbursement models for payers. Studies have shown payers value clinical outcomes most when considering relevant attributes for formulary decisions.^[22]Assessing Payers’ Preferences for Real-World Evidence in the United States: A Discrete Choice Experiment, Saldarriaga et. al., 2021 Improved partnership and communication among stakeholders could further reduce time on peer-to-peer reviews, clinical documentation and administrative burden for providers.

Affordability

Cancer doesn’t discriminate on those it strikes, yet out-of-pocket medication costs are often prohibitive, even for well-covered, financially secure patients. Most cancer patients report being unprepared for care costs and, as a result, often must make major changes to their lifestyle and finances. A recent survey of oncology patients and survivors found 73% are concerned about their ability to pay current or future costs of their care and 51% report incurring medical debt because of their cancer care costs.^[23]Survivor Views: Cancer & Medical Debt, American Cancer Society Cancer Action Network, 2022 Black Americans and those in states that haven’t yet or have only recently expanded Medicaid access had a greater likelihood of having medical debt associated with their cancer care.^[23]Survivor Views: Cancer & Medical Debt, American Cancer Society Cancer Action Network, 2022

Cancer’s unique affordability challenges

Due to treatment side effects, excessive missed days or logistical challenges, people find themselves leaving jobs to be full-time cancer patients. One in five patients surveyed said they had to quit their job due to cancer or cancer treatment.^[7]CoverMyMeds Oncology Patient Survey, 2022 Because of this, they lose not only a source of income, but possibly employee-sponsored health coverage. This could leave them exposed to the full cost of their treatments or at least a greater cost if they enroll in a high-deductible government-sponsored plan.

On the flip side of the coin, those who see improvements with cancer treatment may require lifelong maintenance therapy, either to maintain a state of health or for long-lasting symptoms and/or side effects. That also means medication and care costs continue.

Social determinants of health can predict or worsen the effect of financial toxicity, or affordability-related challenges people living with cancer experience. Cancer patients are more likely to experience financial hardships if they’re younger than 55, a person of color, didn’t finish high school or have lower income.^[23]Survivor Views: Cancer & Medical Debt, American Cancer Society Cancer Action Network, 2022 Indirect costs of care can create further toxicity, including transportation, long-term lodging if having to move closer to treatment centers, caregiving and secondary medical costs such as fertility treatments or high costs of special foods.^[24]The Costs of Cancer, American Cancer Society Cancer Action Network, 2020

Transparency: Part of the financial toxicity antidote

Patients need visibility into their expected out-of-pocket costs as well as their available affordability options — ideally at the point of prescribing. Knowing their affordability options, including available biopharma discounts and patient assistance programs, can help them create a financial game plan, which can alleviate stress down the line.

Care teams need these answers as soon as possible. While it’s not always the prescriber making the direct connection to these options for patients, the ability to surface patient-specific cost and available affordability options can help them make the warm handoff to care navigators and coordinators.

Electronic solutions can start patient hub enrollment at the point of prescribing to enable financial support access. Digital connections with payers and biopharma can help patients find possible financial support options through copay and patient assistance programs.

Reducing prescription abandonment through affordability connections

Specialty pharmacies are often finding affordability programs for patients and may harbor a deep knowledge of what’s available. A recent study showed 25% of patients relied on specialty pharmacists for help with filling out financial assistance forms and 19% for help finding social resources such as transportation, support groups and additional affordability assistance.^[25]The 2021 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers, Drug Channels, 2021 Pharmacists need role-specific integrated solutions that may easily allow them to find patient-specific affordability options either within or without benefit.

Integrated solutions can apply available biopharma company savings automatically for eligible patients, with no effort from the pharmacist or the patient, reducing costs and, potentially, prescription abandonment.

In a recent study of patients prescribed oral anticancer medications, patient abandonment increased with out-of-pocket medication costs. Nearly one-third of patients didn’t fill their prescription when costs were between $100 and $500.^[26]The Pharmacoeconomics of Oral and Self-Administered Cancer Treatments, Doshi et. al., 2018 One in 8 patients in the study had prescription out-of-pocket costs over $2,000, and 49% of them never filled their prescriptions.^[26]The Pharmacoeconomics of Oral and Self-Administered Cancer Treatments, Doshi et. al., 2018

Compounding prescription costs can also impact abandonment. Estimates find that cancer patients may take an average of 5 prescription medications, including those to help treat co-morbidities and manage side effects.^[27]Use of Prescription and Non-Prescription Medications and Supplements by Cancer Patients during Chemotherapy; Questionnaire Validation, Hanigan et. al., 2009

Electronically connected solutions in provider workflows can help surface available affordability programs at the point of prescribing. It can also help pharmacists apply savings for patients at the time of pickup, further helping make sure they can start therapy sooner. Solutions that help connect patients to affordability options can impact adherence and outcomes later in the treatment journey.

In one study of patients taking a particular type of oral anticancer medications, progress was significant. Patients with copay assistance had nearly $2,000 lower out of pocket costs, picked up their prescriptions 22 days sooner and had a 24% lower risk of discontinuing treatment compared to patients without copay assistance.^[28]The impact of copay assistance on patient out-of-pocket costs and treatment rates with ALK inhibitors, Seetasith et. al., 2019

Adherence

Oncology therapy complexities continue after the first medication fill, and these often fall to the patient to untangle.

Adherence challenges usually don’t surface by choice. Patients typically want to take their treatments as prescribed to feel and get better. However, they’re also juggling symptom management, understanding a complex disease, multiple medication regimens, mounting costs and social determinants of health barriers. People living with cancer are juggling more than they ever dreamed of and, at times, something is dropped. This can look like forgetting to take a pill, being unable to stomach chemotherapy or missing a prescription pickup due to work.

Forty-four percent of oncology patients surveyed said they’ve failed to take their medication as prescribed at some point. The most common reason was simply forgetting to take it (39%), followed by unpleasant side effects (20%).^[7]CoverMyMeds Oncology Patient Survey, 2022

Technology opportunities to improve patient adherence

Patient adherence concerns heighten with the increase in at-home cancer treatments. Recent estimates show 40% of chemotherapy is now given in oral form and, in larger studies, 30% of patients are nonadherent to oral chemotherapy.^[29]Utilizing patient reported outcomes for patients recieving oral chemotherapy, Mackler et.al., 2017 The oral oncology medication market is only expected to grow, which means adherence programs and strategies will become more crucial for the cancer patient community.

Challenges with oral chemotherapy can come with complex care regimens, undesirable side effects and delivery or pickup complications. Multiply these across an average of five of more prescriptions and patients and/or caregivers have a part-time job managing medications, on top of appointments, scans and other necessary procedures.^[27]Use of Prescription and Non-Prescription Medications and Supplements by Cancer Patients during Chemotherapy; Questionnaire Validation, Hanigan et. al., 2009

People living with cancer need a wide safety net of support that can not only help solve adherence challenges when they come up, but also prevent them in the first place.

Technology can best serve patient adherence by leveling the health literacy playing field and meeting patients where they are. A mix of high- and low-tech adherence support offerings can best serve a diverse patient population. Some may benefit from smart pills that can track adherence daily and others may need an encouraging call from a care team member. By automating the process-oriented parts of the medication access journey, care teams have greater opportunity to hold engaging patient conversations that can organically surface potential adherence barriers.

Empowered by integrated technology, care coordinators, navigators and providers can help create a patient-driven adherence support plan that avoids routes to failure. Tech-comfortable patients can sign up for text messaging reminders and alerts related to medication dosing, appointment reminders and insurance information. Others may prefer phone calls with clinical experts who can help answer questions related to their condition or medications. In one study, patients who received this support were 25% more adherent to therapy than a control group and increased length of time on therapy by nearly 31 days.^[30]Symphony Health Analytics, 2016

Greater patient education and health literacy can’t be overlooked when it comes to adherence. Specialty pharmacists can play a key role in helping patients access materials to better understand treatment plans, in the way they receive it best, especially when working in tandem with clinical teams.

In one study, clinical pharmacists spoke with patients directly after the provider and gave a full medication review as well as adherence strategies. Then, clinical pharmacists connected with the specialty pharmacists dispensing the drugs about any risk factors, social determinants of health or language barriers a patient might have. Patients’ therapy comprehension increased from 43% to 95% and adherence rates were as high as 95% in some patients.^[31]Increasing Patient Adherence to Oral Chemo, Clinical Oncology News, 2021

Conclusion

When it comes to oncology, medication access is crucial, and the powerful combination of technology and human intervention can be life-changing. During a time of diagnosis distress, accessing treatment should feel like gaining progress toward health rather than another burden to bear.

Integrated technology solutions can start medication access processes at the point of prescribing. With electronically enabled enrollment and 12% faster benefit checks, patients on specialty medications can receive therapy eight days sooner, on average, compared to manual methods.^[32]CoverMyMeds data on file, using a technology solution versus manual phone and fax methods, analysis of all AMP data on April 2019-Nov 2021

Many cancer survivors will remain on treatment for years to come, which necessitates an ongoing plan for affordability and adherence. Considering year-over-year fluctuations in drug formularies, life events and therapy switches, these plans should remain flexible — yet resilient. Open, honest communication and transparency can help with continuity of care between patients and care teams and among healthcare stakeholders.

To this end, care teams and healthcare stakeholders need visibility into each other’s processes to keep the individual patient’s needs at the center of decision-making and avoid duplicative work. In a recent survey, 10% of providers said they have no visibility into other care team members’ process or status when treating patients, while 66% said they had some visibility and 25% had high visibility.^[18]CoverMyMeds Oncology Provider Survey, 2022 As care continues in flexible locations and through multiple modalities, greater visibility and interoperability will be critical to deliver continuity of care for patients.

While cancer therapies become increasingly sophisticated to treat the complex set of diseases that make up the field of cancer, access should be simple. To achieve this simplicity, the healthcare industry can reroute burdensome, manual processes through technology to make more room for compassion that allows cancer patients to be people.