Access to Care: A Pharmacist’s Perspective

When I joined the faculty of the McWhorter School of Pharmacy (MSOP) at Samford University in Birmingham, Alabama, in July of 2008, I was excited to discover a corporate spirit and passion for involvement with underserved populations that were similar to that of my own. In Alabama, one does not have to travel far from a major city to find people in need; nowhere is this more true than in the university’s original home in Perry County, which ranks as one of the poorest counties in the United States.¹ With Perry County located about an hour’s drive from Birmingham, MSOP students and faculty routinely conduct health screenings, and operate full-time diabetes and hypertension clinics through the local department of health, thus promoting the health and wellness of this at-risk population and supplementing the severely stressed healthcare resources available there. Not surprisingly, with a shortage of primary care physicians, access to care in this region is significantly below both Alabama and United States medians, whereas cancer incidence and deaths from lung, colon, and prostate cancer are far above the national norms.² In this regard, Alabama is not unique. Underserved populations are found in every town, city, county, and state in this country, yet solutions for improving access to quality healthcare for all patients are difficult to implement.

Recognizing that poor access to high-quality medical care is associated with a relative lack of cancer screening and early diagnosis, thus leading to the cancer trends observed in Perry County, the Institute of Medicine (IOM) and the Oncology Nursing Society (ONS) have authored recommendations and white papers to assist those of us “in the field” in making advances in our own backyards. The ONS advocates for “comprehensive healthcare coverage with respect to cancer prevention, early detection, risk assessment, risk reduction services, genetic counseling, and genetic predisposition testing,” to ensure that cancer incidence is reduced and survivorship is maximized.³ This is, unfortunately, much easier said than done, although some existing programs have had a significant effect on these underserved populations. One needs to look no farther than the success of the Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program for evidence of the impact on this population. This program assists low-income, uninsured, or underinsured women’s access to breast and cervical cancer screening programs.⁴ Early data published in 1998 suggested that among women who had received a prior mammogram, the rates of breast cancer detection declined and the size of invasive tumors was smaller than among those who had never previously been screened.⁵ More recent data demonstrate that as a result of this program, 5904 breast cancers (of 340,038 women screened) and 261 cervical cancers (of 251,637 women screened) were detected in 2012 alone.⁴ Although programs such as this certainly do not reach all women or all patients in need, they are a step in the right direction of meeting the goals of the ONS and the IOM.

What about the role played by pharmacy and by oncology pharmacy, in particular? Screening and early detection programs are making huge strides in improving access to care, and in reducing morbidity and mortality from cancer, but the financial burdens faced by a patient and his or her family increase exponentially once a cancer diagnosis has been made. In 2010, the National Cancer Institute estimated that the average cost of managing a single patient with newly diagnosed lung cancer was ~$60,000 for the initial therapy and $7000 to $8000 for continuing treatment.⁶ Far too often, the greatest financial burden is the cost of the drug therapy that is indicated by best practices and clinical practice guidelines. Certainly, county and state safety net hospitals and their indigent care programs, Medicaid and Medicare programs, and access to insurance via provisions of the Affordable Care Act ensure that many patients receive, at a minimum, standard of care therapy. However, these same programs may balk at the costs associated with the latest cutting-edge medications that could offer some patients improved outcomes.

As an oncology pharmacist, I am often called upon to leverage contacts within the pharmaceutical industry in order to (1) provide samples of oral medications (which virtually never occurs with high-cost oral oncolytics, but is occasionally successful with other supportive care medications or even several hormonal therapies); (2) offer access and counseling for patients with respect to financial assistance programs available from drug manufacturers or cancer organizations; or (3) find clinical trials in which the costs associated with access to a drug may be provided by the sponsor (which is often rare in the case of oncology trials, where the expectation is that standard of care medications are still billed to insurance companies). Even with the best intentions, financial coverage gaps often leave families with massive debt or, even worse, having to consider not pursuing additional treatments due to cost-related factors.

These barriers to quality cancer care are unfortunately not limited to the indigent. Recently, a retired patient with lung cancer who had exhausted all standard of care options underwent foundation medical screening, where a driver mutation in the BRAF gene was identified. It was determined that she was ineligible for a clinical trial with an investigational BRAF inhibitor, and her insurance company refused payment for commercially available BRAF inhibitors solely because they were not approved by the US Food and Drug Administration for her particular disease state. As a practitioner, I lament the inability to successfully persuade an insurance provider that this type of therapy may be better than conventional cytotoxic chemotherapy for a patient such as this. Ultimately, the cost of several thousand dollars per month of these newer generation drugs prevented the patient from receiving a potentially active and beneficial treatment.

In our healthcare system, we must follow the lead established by the ONS and the IOM, and evaluate methods for improving access to quality healthcare, so that patients such as those in Perry County and those with insurance who have exorbitant copays or out-of-pocket expenses are permitted access to therapies that may prolong survivorship and quality of life. Although the boundaries for costs absorbed by insurance plans or taxpayers are far too often a politicized issue rather than one borne of empathy and compassion for our fellow man, we clearly still have a long way to go to ensure that all patients are provided with access to high-quality healthcare. The answer likely lies not with the newest, most expensive treatment option or the oldest, least expensive standard of care option, but with improved access to screening and early detection. Keeping our population engaged and informed, while promoting and incentivizing provider involvement in underserved populations, may be the best method for reducing healthcare disparities in cancer care.

References

1. Census Bureau Releases Poverty Rate Estimates for State; Shelby Is Most Affluent, Black Belt Counties Poorest. http://cber.cba.ua.edu/rbriefs/news112200.html. Accessed September 8, 2014.
   
2. The Office of Primary Care and Rural Health, Alabama Department of Public Health and the Alabama Rural Health Association. Selected Health Status Indicators: Perry County. www.adph.org/ruralhealth/assets/Perry13.pdf. Accessed September 8, 2014.
   
3. Oncology Nursing Society. Access to Quality Cancer Care. www2.ons.org/Publications/Positions/QualityCare. Accessed September 8, 2014.
   
4. Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program (NBCCEDP). About the Program. www.cdc.gov/cancer/nbccedp/about.htm. Accessed September 8, 2014.
   
5. May DS, Lee NC, Nadel MR, Henson RM, Miller DS. The National Breast and Cervical Cancer Early Detection Program: report on the first 4 years of mammography provided to medically underserved women. AJR Am J Roentgenol. 1998;170:97-104.
   
6. National Cancer Institute. Cancer Prevalence and Cost of Care Projections. costprojections.cancer.gov/annual.costs.html. Accessed September 8, 2014.