Transcript David Thomson

Patient Access Scheme –
Clinical Pharmacist View
David Thomson,
Lead Pharmacist, YCN
Chair, BOPA
Improving access to costeffective medicines
Appraisals outcomes since Jan
09
Drug
Title
EoL
applied?
Access
scheme ?
Approved?
Feb 10
Trabectidin
Soft tissue sarcoma
Yes
Yes
Yes
Nov 09
Topotecan
Lung cancer (small-cell)
Yes
No
Yes
Oct 09
Topotecan
Cervical cancer (recurrent)
No
No
Yes
Sept 09
Sunitinib
GIST
Yes
Yes
Yes
Sept 09
Pemetrexed
Lung cancer (non-small cell,
1st line)
No
No
Yes
Aug 09
Cetuximab
Colorectal cancer (1st line)
No
Yes
Limited
Jul 09
Rituximab
Leukaemia (chronic
lymphocytic, 1st line)
No
No
Yes
Jun 09
Cetuximab
Head and neck cancer
(squamous cell carcinoma
No
No
No
Jun 09
Lenalidomide
Multiple myeloma
Yes
Yes
Yes
Mar 09
Suntinib
Renal cell carcinoma
Yes
Yes
Yes
Appraisals outcomes since Jan
09
Drug
Title
EoL
applied?
Access
scheme ?
Approved?
Feb 10
Trabectidin
Soft tissue sarcoma
Yes
Yes
Yes
Nov 09
Topotecan
Lung cancer (small-cell)
Yes
No
Yes
Oct 09
Topotecan
Cervical cancer (recurrent)
No
No
Yes
Sept 09
Sunitinib
GIST
Yes
Yes
Yes
Sept 09
Pemetrexed
Lung cancer (non-small cell,
1st line)
No
No
Yes
Aug 09
Cetuximab
Colorectal cancer (1st line)
No
Yes
Limited
Jul 09
Rituximab
Leukaemia (chronic
lymphocytic, 1st line)
No
No
Yes
Jun 09
Cetuximab
Head and neck cancer
(squamous cell carcinoma
No
No
No
Jun 09
Lenalidomide
Multiple myeloma
Yes
Yes
Yes
Mar 09
Suntinib
Renal cell carcinoma
Yes
Yes
Yes
In the beginning........
What is the evidence?
CNPF Report - Research
question?
What has been the
impact of
implementing risk
sharing schemes to
improve access to
cancer medicines in
the NHS?
Aims and objectives
• To define reality – who is doing what?
• To obtain a general rating and estimate
of administration time for 4 schemes.
• To assess the impact on pharmacy
departments.
• To obtain comments and suggestions
for improvement from scheme users.
Study design
Methods
Initial Findings
• Questionnaire using online
tool Survey Monkey during
summer 2009.
• Open to all BOPA
membership
• More than one reply per
trust allowed
• 4 schemes - Sunitinib,
Bortezomib, Cetuximab,
Erlotinib
• All schemes in operation at
least 12 months between
2007 and 2009
• 37/131 trusts responded –
28%
• Covered 756 patients
3
180
295
Erlotinib (pre-NICE) for
NSCLC
Sunitinib for Renal Cell
or GIST
Bortezomib for Multiple
Myeloma
278
Cetuximab for
advanced Colorectal
Limitations
• Low response rate
• People with issues are more likely to
respond
• Not all respondents answered all the
questions.
• Only views of Pharmacy Staff represented
– not clinicians, finance, PCT views.
• From this talks perspective – views of
pharmacy staff weren’t seperated into
clinical, procurement etc
Who is impacted by schemes?
minutes to administer
Reported time for scheme
administration
50
45
40
35
30
25
20
15
10
5
0
Series1
Erlotinib (pre- Sunitinib for Bortezomib for Cetuximab for
NICE) for
Renal Cell or
Multiple
advanced
NSCLC
GIST
Myeloma
Colorectal
How would you rate this type of scheme
Consultants were initially very good at
completing form. Enthusiasm wore off
70.0%
after about 6 months. It isn't in
anyone's job 60.0%
description to chase the
clinician to complete
the form so it
50.0%
rarely gets done.
Easy to apply. Free stock invoices
easier to manage. Cost per drug
evens out. OK provided all drug
used by one speciality so see
benefit of free stock
40.0%
30.0%
20.0%
10.0%
0.0%
Very Good
(preferred type
of scheme)
Suntinib
Good
(manageable)
scheme.
Average (causesUnworkable
Bad (causes lots
Very BadCannot
(to be
true cost peravoidedpatient as free
problems but show
of problems)
nothing
unworkable)
stock supplied retrospectively.
insurmountable)Also free stock is supplied in the
form of a credit note against a
previous invoice. Cannot
separate out free stock from
normal supplies.
This scheme has the first cycle free and then a 5% discount on list
price. The scheme required each patient to be registered with a form
sent to manufacturers and free stock supplied for the first cycle.
Relies on good communication.
Pharmacists are in clinic and
have access to patient letters. If
a patient hasn't responded, the
refund is claimed
60.0%
50.0%
There is a lack of continuity
40.0%
in the clinic making it a
challenge to identify 30.0%
nonresponding patients as a
result, the pharmacy20.0%
team
now remind the MDT at the
start of cycle 4 of the10.0%
need to
assess response etc. 0.0%
This is
a step in the right direction Very Good
but still potentially misses (preferred type
patients who do not get as of scheme)
far as 4 cycles treatment (for
whatever reason)
Bortezomib
Requires huge investment of
time to monitor patients and
ensure refund timescales met.
As with sunitinib issues
How would you rate this type of scheme
around assigning the rebate
to patients and adjusting the
drug budget/ expenditure
reports is a nightmare
When the consultants want to initiate the treatment,
we need to request them filling in the PBR (audit)
form forward to PCT for approval. Then, we wait for
confirmation
from PCT to go ahead. When the
Good
Average (causes Bad (causes lots Very Bad (to be
started
e.g.
Velcade, you have
(manageable)patient
problems
but the
of treatment,
problems)
avoidedto keep
track of the number of unworkable)
cycles, if they have
nothing
stopped
and does it entitled for VRS scheme. Then,
insurmountable)
asking for Serum M protein to be done, chasing up
the consultant the claim form. It is a time wasting
process.
Response measured by (serum M protein) after 4 cycles. If patient hasn’t
responded a ‘refund’ can be claimed, but all claims must be made within 60
days. Refund can be cash, credit note, or stock replacement
Bortezomib – Pharmacy time
Bortezomib – Refund findings
Which options for ‘refund’ have been chosen for velcade
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Replacement drug
stock
Credit note
Cash refund to Trust Cash refund to PCT
What is a good scheme?
CNPF - Conclusions
• Pharmacy bears brunt of burden BUT
– Rely on patient level data which isn’t collected as
standard in the NHS
– Retrospective rebates can conflict with NHS
financial flows (which are different locally)
• Outcome based schemes take longer to
administer, are preferred less BUT have less
reported problems refunding payers.
• Schemes with upfront discount preferred BUT
payers still not getting refunded (<50%)
• 73% of services can’t take any more schemes
• Dedicated post needed to administer
schemes
Conclusions
• Is PASLU actually set up to solve the problem?
• Can anyone else?
– NHS issues – can we be more consistent in terms
of local requirements?
– Commercial issues - Can Pharmaceutical
companies work together?
• Are politicians willing to accept that there is a
problem without headlines?
• These issues won’t go away and will impact on
the success or failure of:
– The proposed £200m drug fund
– The delivery of value based pricing