Paula Bickley, vice president of market access for biologics at McKesson and one of the featured speakers at the 4th Annual PBMI Specialty Rx Forum, spoke with Managed Healthcare Executive® Senior Editor Peter Wehrwein.

Peter Wehrwein, Managed Healthcare Executive® Senior Editor

Well good morning everybody, my name is Peter Wehrwein and I am senior editor at managed healthcare executive, and today I have the pleasure of speaking to Paula Bickley, who is vice president market access for Biologics at McKesson. She’s speaking to us from beautiful Raleigh, North Carolina. And we’re speaking to Paula today in advance of the meeting tomorrow the fourth annual PBMI Specialty Drug Forum where Paula is one of the featured speakers. So, good morning!

Paula Bickley, Vice President Market Access for Biologics at McKesson

Good morning, a pleasure to talk with you, Peter.

P.W.

So tomorrow you’re going to be talking about putting the patient first, but I took a look at your slide deck, which you kindly sent in advance, and near the end of the deck, you point out that this putting patients first should not be or is not simply a tagline, a cliche or a marketing device–that it has some real meaning if we take it seriously. So why did you feel you needed to remind us that this isn’t or shouldn’t be just a tagline?

P.B.

Yeah, a great question and I know that can feel pretty provocative when I say that. Two things: One, it’s fairly pervasive in healthcare that a lot of healthcare providers feel that the patient needs to be first and use that to really talk about their essence. You know, how they treat patients.

I want to take it a little bit of a step further, because I think the evidence will say, and a lot of what I’d like to present to the audience tomorrow, is real, factual information that really shows if you do the right thing for the patient and put the first–give them the health care they need, take exquisite care of them while they’re under your care and custody–it really accrues a benefit chiefly and primarily to the patient. But every stakeholder in health care tangibly benefits when the patient is put first. Biopharma benefits, payers benefit, providers benefit ultimately, and all in the service of patients.

So, that’s a bit of a tease obviously, as to what I’m going to talk about tomorrow. But if you can get the right drug from a specialty pharmacy perspective, the right drug to the right patient at the right time–and again, that sounds a bit like a marketing tagline as well–but really doing that is a formidable challenge. It requires the subject matter expertise of as many as 13 different experts for every patient that face and manage and coordinate care across a variety of stakeholders.

So, again, I hope that what I can present Friday during the conference is compelling, solid, and really allows people to take away that it’s okay to put the patient first. It’s okay to provide them the care they need, even if it means pushing through a lot of administrative barriers, financial barriers, clinical barriers, because at the end of the day there is a direct correlation obviously into their optimized outcome, but there are clear indications that it helps support the strategy of each of these unique stakeholders, and often stakeholders who are really kind of locked in inherent conflict–provider payers, biopharma payers, biopharma patients. So, again, I’m happy to go into as much detail as you think would be effective today, but really, that’s what I hope people take away from the conversation we have on Friday.

P.W.

It’s quite a challenge to get 13 different sorts of experts, and I think you list them. As you know, there’s business intelligence, there’s patient court, care coordinators […] to get them to work together, do you have some notions about how you get such disparate people working in different parts of the healthcare system to combine in this effort?

P.B.

From a specialty pharmacy perspective, it starts really long before a new therapy is approved and becomes available, and it’s working directly with that biopharma company to help them understand the therapeutic landscape that their new therapy is going to emerge into and how payers are likely to respond to their new therapy.

[…] What are the administrative and financial and clinical barriers that are going to meet patients when they’re prescribed these therapies? For providers, who wants to prescribe and needs to treat patients with these new therapies? It’s teaching them how to originate a prescription completely. What does it take? What does a complete specialty pharmacy prescription look like? What has to come with that prescription so the specialty pharmacy provider can advocate for their treatment decision and keep that prescription moving one directionally from referral to dispense? [They need to] understand the underlying diagnosis, understand the goal of treatment, and help communicate that and convey that to the patient.

It takes all of the tactical kind of mechanical things that happen inside a pharmacy dispensing workflow. Specialists who only work on getting prior authorization approval. A whole different group of specialists that, all they do is secure financial grants, whatever financial grants are available, to patients. And then, obviously, once the patient initiates treatment, it requires the exquisite care coordination between our clinical pharmacists, our nurses, and the providers that are out there in the provider offices or hospitals. You know, I’m speaking more to the expertise of everyone, but there is a complex and well choreographed dance that happens to get that patient to initiate treatment.

P.W.

So there’s a lot of discussion and debate, and you know it’s part of our politics now about the high cost of drugs. So, is patient-centeredness or putting the patient first or right-drug-right-patient-right-time, is it a way of addressing the problem and the challenge of the expense of these medications?

P.B

Indubitably, yes, if the patient needs the therapy and there’s evidence to suggest that this is the right drug for the right patient at the right time. If we are not as a caregiving circle, a caregiving echo system, committed to helping them adhere to that, there is clear evidence studied over a long period of time that suggests the cost of non-adherence is pervasive, and in recent study that we socialize at Biologics, can easily cost our health care economy $290 billion dollars annually.

[…] If you do all the work to get a patient on therapy, but then you really leave them to their own devices for these complex and often toxic and very costly therapies to your point, one study suggests that as much as two-thirds of hospitalizations today are driven by medication non-adherence. A hundred billion dollars alone spent at a hospital site of service for patients who are there because they did not properly take and manage their oral course of treatment.

P.W.

Right, right. And you make a point in your slide deck, which you will use for tomorrow’s presentation, that although adherence is a complicated problem there’s many ways that one can influence adherence. One tried and true and proven way, a big lever on the problem, is building a strong nurse-patient relationship. […] If you had only one thing to do, what would it be, in terms of adherence? It seemed that you might pick building that nurse-patient relationship as highly influential on having a great deal of effect on adherence.

P.B.

Again, studied often, studied broadly, in many different therapeutic areas. And so, I think the jury is not out. I think the jury has spoken very clearly that there is something pretty special about a very trusting and effective collaboration partnership between a nurse and his or her patient. […]

As a specialty pharmacy, I want to make sure–and I think most people accept this intellectually–but I’m not sure until I worked and have had now 12 years working inside a specialty pharmacy provider organization, I’m not sure I saw specialty pharmacy as a specialized health care provider. I think it’s easy to see specialty pharmacy as a put-through organization–lick it, stick it, ship it. We’re good at getting those refills out, you know. It’s a production-based kind of environment, and certainly good specialty pharmacies have to be really good at that kind of cycle management. But at its core, specialty pharmacy is a specialized healthcare provider uniquely qualified to handle the very unique and complex challenges that come with oral specialty treatment.

And I’ll use cancer, which we all know well at Biologics, I’ll use that therapeutic area as an example. So, it does take the pharmacist–and this may be different at a different specialty pharmacy, so I can speak really to a data point of one–but our patients go through a 35 to 45-minute onboarding session with a pharmacist on day zero. We’ve shipped the product to them and they have it in hand. They’re able to open the packaging and all that comes with the packaging and look at the pills and verify the color and verify the size and verify the count. And our pharmacists go through again, and easily a 30 to 45-minute conversation that goes through… helps them understand the diagnosis, the goals of their treatment, the providers’ clinical thinking. Um, certainly talks about dosing, what to look out for, how to dose, how to dose effectively with or without food, what times of day, how many times a day, etc. So, that’s obviously very unique to those kinds of clinical pharmacists that really get those first two inches right.

The other thing that pharmacists do, and this is really where I think we set our nurses up for success, they go through a multi-dimensional risk assessment to really understand down to a numerical score what is the likelihood that this patient is going to have a challenge to comply with your therapy. […] It covers financial, stress, depression, previous treatment–you know, not to be too granular, but it’s based on that assessment that the pharmacist completes on day zero that really drives the frequency and the goals of the ongoing nursing care.

So, a long time ago, in 2013, a first-in-class product came to market that was prescribed and indicated for women who had metastatic ovarian cancer. And it was an amazing opportunity for women who had already gone through multiple lines of treatment, different modalities of treatment. They were tired, and this particular therapy had a high pill count–16 pills a day, big pills. Our nurses, again based on this sense and real risk assessment that the pharmacist did, were really able to meet the patient–again, tired; long challenge with therapy; many, many prior treatments–and help them learn some tricks on how to take this therapy appropriately. I mean, that’s a high pill burden for a tired patient. Take it with milk, head position.

[…] And again, I’m really trying to help this whole concept of nursing and how strongly we feel at Biologics that we really need to do everything we can to promote that nurse-patient relationship. That’s the kind of things that happen in those calls. Really practicing head position, chin position. […] Those nurse calls really connect goals and achievement from one call to the next. Anyway, obviously I get excited talking about it. I’m sorry if I went into a thematic, uh, sidebar.

P.W.

Whenever I talk to somebody who’s had an encounter with the health care system hospitalization, or I guess typically hospitalization, they often say the nurses were great and I think it often comes down to those very specific, practical, granular bits of advice or care that help people take their medications, make them more comfortable. That makes a huge difference in terms of the experience of health care and its effectiveness. And in this case we’re talking–

P.B.

Peter, and I’m so sorry to interrupt, but […] I really want to emphasize that you bring up a very good point, because there’s actually studies–some in particular from out of the University of North Carolina, the Lineberger Comprehensive Cancer Center–that provides a space for patients to report their symptoms. So, this simple act of patient-driven reporting’s side effect is connected to better compliance, longer time on treatment–longer by two months or more–progression-free disease.

So, the fact that the patient has a forum with a trusted partner like the nurse that they establish a relationship with and stay with throughout their course of oral treatment, the fact that they get to talk about their side effects and work with the coach that can help them mitigate those side effects leads to more progression free treatment, more time on therapy, better compliance, optimal outcomes.

P.W.

Um, yeah, we started this conversation talking about tag lines and making sure that, you know, we don’t just leave it at a tag line. I’ll propose another tagline that a caring health care system is a listening one. I think this has been a great introduction to your talk tomorrow about patient-centeredness ant the 4th annual PBMI specialty drug forum, and I’m looking forward to hearing more tomorrow. So, thanks for the time today.

P.B.

I appreciate it, Peter. I’m honored to have the opportunity. I look forward to it as well. Thank you.