Implementation of ipilimumab therapy in a private practice oncology group: Overcoming start-up and reimbursement issues related to expensive new cancer drugs

Abstract

The monoclonal antibody ipilimumab was the first treatment in more than 30 years to improve long-term survival in metastatic melanoma patients. Offering expensive ipilimumab treatment presented significant business challenges and potential financial risks for our private oncology practice and for patients because of the high acquisition cost of this agent. There was initial uncertainty about the willingness of insurance companies to reimburse for this new drug based on previous experiences in our practice with other expensive new drugs. Here we describe how our multiphysician practice methodically introduced ipilimumab treatment into the practice. Structured communication between the clinical, pharmacy, and business components of the practice proved to be critical. The financial counselor, pharmacist, primary nurse, and physician coordinated each patient's financial and medical information. Efficient drug ordering practices were devised. Our practice made an initial calculation of how much debt was reasonable as a test of reimbursement mechanisms and set an initial limit of 3 patients to be treated with ipilimumab. The billing specialists and pharmacist closely monitored pending claims on a weekly basis to stay aware of potential problems in claims processing. Due to the initial success of this approach, the number of patients being treated has steadily increased. Our experience allowed us to establish a model for how the use of new and expensive cancer therapies can be implemented in a private practice clinic without causing excessive financial risk. Our practice was able to analyze the financial viability of a new treatment that offered significant benefit for patients within 6 months of starting the first pilot patient.