The Group Room sits down with Mary Kruczynski, Director of Policy at the Community Oncology Alliance at the 2012 Community Oncology Alliance (COA) Annual Meeting. Mary talks about the three main issues COA is fighting on capitol hill — oral drug parity, drug shortages and physician reimbursements — and of course, their overarching mission to keep community oncology practices open and viable in this ever changing health care market.

The Group Room interviews at the Community Oncology Alliance (COA) 2012 annual meeting in Las Vegas was made possible by the generous support of our members.

VIDEO TRANSCRIPT

This is Selma Schimmel in Las Vegas at the Community Oncology Alliance meeting.  And now I am joined by Mary Kruczynski, who is the Director of Policy Analysis for COA, which is the Community Oncology Alliance.  Hello, Mary.

Mary Kruczynski, Director of Policy, Community Oncology Alliance

Hello, how are you?

Selma Schimmel, Founder & CEO, Vital Options International

I’m okay, how are you?

Mary Kruczynski, Director of Policy, Community Oncology Alliance

I’m pretty busy today.

Selma Schimmel, Founder & CEO, Vital Options International

I have a feeling you have your hands full with policy issues for 2012 and beyond.

Mary Kruczynski, Director of Policy, Community Oncology Alliance

Yes, we do.

Selma Schimmel, Founder & CEO, Vital Options International

Where do we begin?

Mary Kruczynski, Director of Policy, Community Oncology Alliance

A lot of issues.  Well, the areas that I have been focusing on most recently are oral drug parity; there is a lot of legislation at the state level.  The state legislations are very active in many of the 50 states.  A lot of movement from the folks in the various advocacy groups up on the capital steps in the various states.  We’re hoping to get oral parity passed, even though the legislation affects only a part of the population.  It would not effect the Medicare population, but it will help those who are privately insured to be able to afford their oral cancer drugs.

You see, as it stands right now, if a patient is prescribed a medication and it is in injectable form it is covered under the medical benefit.  If the cancer drug they need is an oral formulation it is covered under their pharmacy benefit, assuming they have one.  And the out of pocket for the patient for an oral drug is far greater than any cost from an injectable, so it is very important that we get patients access to these drugs that are affordable.

Selma Schimmel, Founder & CEO, Vital Options International

Why, I mean I understand this, and they have specialty pharmacies, and you can’t fill some of these drugs at some of your regular pharmacy, you’ve got to get it done through the insurance carrier’s specialty outlet.  Why is it… Logically, it would seem that it is cheaper to be able to take it orally, go home and do it, less personnel involved, you don’t go to the doctor’s office.  Where is that gap?  Why is it more costly?

Mary Kruczynski, Director of Policy, Community Oncology Alliance

It is more costly because it is an oral drug and it goes through a pharmacy benefit, and typically, any medication that you get under a pharmacy benefit has a co-pay or a deductible, as opposed to the medical benefit.  And the fallacy is that an oral drug is simple, that you just go home and take a pill and it’s all good, but it’s not true at all.  Actually, patients, cancer patients, taking oral medications are even more difficult to manage than those on an infusible or injectable therapy.

Selma Schimmel, Founder & CEO, Vital Options International

And I would imagine that is because you’ve got the compliance and adherence issues.  When you go to the doctor’s office, the doctor can monitor, he or she is aware that the patient has taken the meds, patient goes home…  So, on the flip side, the ease of doing it at home is one thing if the patient is totally compliant, but I believe then it would make sense that it’s more challenging within the practice because you never really know what is going on with your patient until you evaluate your patient.

Mary Kruczynski, Director of Policy, Community Oncology Alliance

Until you see that patient face to face, you don’t really know – correct – until you do blood work, until you look at them, until you ask them questions.  Many times we’d say, ‘are you taking your medication appropriately? [Shaking head ‘no’] Yes, I am.’  You know, until you actually have that eye contact with the patient you really don’t know the whole story and that is the fallacy.

And there is a standard operating procedure that has to be set up for orals because 35% of the drugs in the cancer pipeline are in an oral formulation so it will be very, very important moving forward that we do have coverage parity because if we don’t, patients won’t be able to receive the treatments as appropriately and you’re going to find them in the ER.

Selma Schimmel, Founder & CEO, Vital Options International

And, with more and more generics coming in to place, so if there is a drug that, let’s just say, two weeks ago as an example, was not available generically and the patient had been taking it in its original format and now it is available generically and the insurance company says well now you take it generically.  Are there issues with the, when drugs go generic for cancer patients?

Mary Kruczynski, Director of Policy, Community Oncology Alliance

In the oral formulation, no; because the orals are very new to market, so you won’t see too many generics in the near future.  But the injectables and the infusibles, yes; the problem continues to grow.

We look at generics and the problems that we have with access moving forward, as a problem of price and cost of supply and demand.  When a brand drug goes generic the price is lower- that’s good for you and me because that means it’s more affordable for us to achieve that drug, and you’ve got maybe five or six manufacturers manufacturing that drug.  As time goes on, that price continues to get lower and lower, and the manufacturing facilities still have the same cost associated with the actual making of that product.  And cancer drugs have to be made very differently, they’re not like popping out a Bayer aspirin.  They are in a very sterile environment and a lot of quality metrics have to be met.  So they’re still continuing to spend the same amount of money to manufacture a drug that becomes less and less profitable for them.  And we hate to say that they choose not to manufacture because they’re not making money, but like anything else, if your costs aren’t covered you’re going to have to close your doors.  And so you have gone from somebody that had six manufacturers making a new generic drug to a sole source, one manufacturer.  So, it is simple economics- supply and demand.

And if something happens on that line and it shuts down, then you have nothing, as is the case with one of the brand drugs that we are now going to India to get.

Selma Schimmel, Founder & CEO, Vital Options International

I think that it is a real wake up call for us when the United States drugs are unavailable.  And some of these drugs are drugs that have been in use for quite a while as stable drugs for serious cancers, like ovarian.

Mary Kruczynski, Director of Policy, Community Oncology Alliance

And childhood cancers, leukemia…  You’ve got children right now who cannot get Cytarabine to basically cure them; it’s a curable disease.  And it’s… if I were a parent of a child I guarantee you I’d be on the hill every day until the problem gets solved.  But it’s not a quick solution.

Selma Schimmel, Founder & CEO, Vital Options International

But the policy issues that you’re navigating your way through right now, obviously, the drug shortage is at the top.  What is next?

Mary Kruczynski, Director of Policy, Community Oncology Alliance

So, besides oral parity and drug shortages we are very, very concerned about physician reimbursement because physicians are closing their doors because they can’t pay their bills and keep their staff.

We see a lot of movement toward the hospital environment from the community practices because they are between a rock and a hard place financially.  And they’re being wooed to the hospitals saying, ‘come work for us, you can be an employee, you won’t have any of these headaches, you won’t have to worry about electronic medical records, you won’t have to worry about e-prescribing, you won’t have to worry about a formula of drugs that you can or cannot afford, and life will be good.’  So, we see this movement back to the hospital when, back in the 80’s the government said to us, ‘you know, every patient that gets cancer gets admitted as an inpatient and they’re there for weeks on end receiving their cancer treatment.  We cannot afford to keep that going.  Oncologists, you need to figure out a way to get the patients out of the hospital and administer that care at a different site of service.’

Now, back then we had about eight cancer drugs, but oncologists managed to set up a protocol to deliver that chemotherapy outside of the hospital setting.  And as time grew and more drugs came to market they perfected that into where we now have, probably, the greatest cancer care delivery system in the country.  We’re seeing it revert back, kind of like miniskirts, to the hospital.  And so COA said, ‘this is wrong.  Why are we dismantling the system?’

We recently completed a study comparing the cost of delivering cancer care, total care, to a patient diagnosed with cancer.  Whether that care was delivered in the hospital outpatient setting or whether that care was delivered in the community freestanding practice setting.  I can tell you that we went through rounds and rounds of claims, claims that were furnished to us by private payers, which has never been done before.  Paid claims with actual dollars expended both by the payer and also by the patient out of pocket co-payer deductible.  Why did they do that?  Because payers, insurance companies know that they’re paying up to five times the cost for care, cancer care in the hospital setting versus the office setting.  They don’t want to see their patients, their insured lives rather, our patients, being treated in the hospital setting.  So they gave us their paid claims so that we could do an analysis via Avalare.  And the analysis revealed what we suspected and that was the cost of delivering cancer care in the hospital outpatient setting far outweighs the cost of delivering care in the freestanding community setting.  We hope to use this information as we move back to Washington in the payer’s space talking about reimbursement and bridging it to the care model that we’re pushing forward, which is the oncology medical home.

Selma Schimmel, Founder & CEO, Vital Options International

Obviously this is a work in progress and this is a lengthy process.  How do you emotionally keep your energy going through so many real difficulties?  You face a lot of uphill struggles?

Mary Kruczynski, Director of Policy, Community Oncology Alliance

They’re all uphill struggles.  You have to be passionate, you have to love what you do, you have to remember who you’re doing it for.  You know, when I got into the business of cancer no one in my family had ever had cancer.  So I didn’t get into this because I had a previous history.  Coincidentally, during the course of my time in this business, I lost both my parents to cancer.  And they did get excellent care and I would like to see that for those that come after them.  And certainly, one in two men and one in three women will have cancer in their lifetime.  I believe in what I do.  I feel fulfilled in what I do.  And I have a passion.  And everyone involved in cancer, you have to have a passion.  How could you treat people every day and look into their eyes if you didn’t passionately care about them.

Selma Schimmel, Founder & CEO, Vital Options International

Oncology is one of the most unique areas of medicine and one of the most rapidly changing areas with the advancements in molecular therapies and understanding the human genome.

Mary Kruczynski, Director of Policy, Community Oncology Alliance

Yes, it is.  And there is great hope for a cure for cancer someday.  Our concern is, will the physicians be here to deliver a cure?

Selma Schimmel, Founder & CEO, Vital Options International

I look forward to meeting with you again to see what is not only happening the remainder of this year, but what is beyond this.

Mary Kruczynski, Director of Policy, Community Oncology Alliance

Well, I appreciate you taking the time.

Selma Schimmel, Founder & CEO, Vital Options International

Thank you, Mary Kruczynski, Director of Policy Analysis for the Community Oncology Alliance.

Mary Kruczynski, Director of Policy, Community Oncology Alliance

Thank you.

END OF VIDEO