The Impact of a Changing Health Care Delivery System on the Quality of Oncology Care - Administrative Supplement

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Project Summary This application is being submitted in response to the Notice of Special Interest (NOSI) identified as NOT-CA-23-044. The cancer care delivery system that frequently provides care that is not patient-centered, evidence-based, or accessible to vulnerable populations. In recent years, there has also been increasing consolidation among providers, which could have important implications for the quality of cancer care. Under the parent R01, we are studying the implications of growing integration across providers for patients with cancer. One key outcome we have considered is the impact of integration on the delivery of oral oncolytics. Oral oncolytics are an increasingly important treatment modality, accounting for nearly half of chemotherapy spending among patients enrolled in Medicare Fee-for-Service and Part D in 2019. Nonetheless, patients face significant challenges in accessing these medicines including high rates of prescription abandonment, non-adherence, and early discontinuation. Integration between health plans and specialty pharmacies may also impact patients using oral oncolytics. Indeed, many health plans have acquired a specialty pharmacy. This includes Centene and AcariaHealth (2013), CVS and Aetna (2018), Cigna and Accredo Pharmacy (2018), and Anthem and Bioplus (2022). Similarly, UnitedHealthcare has long been integrated with Optum Specialty Pharmacy, but has also recently acquired Avella (2018) and Diplomat (2019). Humana has long been integrated with Humana Specialty Pharmacy. Yet, the implications for patients are unclear. On the one hand, plan-pharmacy integration may allow plans to better assure patients receive and are adhering to medications, especially when it may reduce other forms of avoidable costs. On the other hand, plan-pharmacy integration may harm patients if it reduces the pharmacy’s incentive to assure access, as utilization poses a direct cost to the parent company. We propose describing and studying the effects of health plan and specialty pharmacy integration in cancer care. We will first build a unique longitudinal dataset identifying the pharmacies owned by each health insurer carrier in each year between 2010 and 2021. We will then seek to accomplish the following aims: 1. Describe trends in the degree to which oral oncolytics are filled through health plan-integrated pharmacies 2. Evaluate the association between health plan-pharmacy integration and patient outcomes including time- to-fill and medication adherence for oral oncolytics This proposal is closely related to the parent R01 and policy in two ways. First, this project studies a novel form of integration that has gone understudied: integration between health plans and pharmacies. This form of integration is also highly relevant for anti-trust policy, as the Federal Trade Commission is interested in crafting policy related to integration between plans, pharmacy benefit managers, and pharmacies. Second, the project focuses on a key policy lever, namely health plan policy, that influences quality and access to care.