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Our institution has transitioned to utilizing a radiology authorization team. This is a team of non clinicians interpreting and providing clinical information can sometimes trigger a delay in a review or result in a peer to peer. Overall the team is pretty good and this service has been helpful to alleviate some work load from our secretaries. The only pitfall is when they have multiple auths to that require peer to peer and we as the clinicians are only provided with a short window of time to obtain this.
Most of the pvt payor companies we deal with have transitioned to a scheduled peer to peer appointment call. The negatives are that at times when an urgent auth is needed and no MD is available this can delay care rendered to the pt.
Positives: you can (most of the time) choose the time when you would like to conduct the call, you can plan and prepare for it rather than having a reactive call with a scheduler/ secty calling asking you to get on the phone with the doctor who is on the line at that moment. I find the docotor is prepared for the call and that has contributed to a quicker and more often pleasant call.
At times when I really need an auth before the next day, I have been successful with speaking to an MD within a short time frame or scheduled for later in the day/ just after clinic hours.Indeed though this is just one example of the numerous areas of a patients care that requires review and authorization.
So sorry to hear this outcome, Lisa, thank you for letting us know.
We have had this issue over the last several years. Medicare changed their policy to allow only 4 PETCT scans for a lifetime for a diagnosis. Many of the private payers have followed and only are allowing PETCT scans at initial diagnosis and/or if something it seen with what they determine as conventional imaging. We have found this most difficult in our patients who have subcutaneous or intransit disease for standard imaging doesn’t give us a good representation of their disease status.
We have not seen this either,yes, please keep us apprised of how your patient is doing. Hoping that they’ve already improved.
I am hoping that OncoEndocrinology will become a specialty such as oncodermatology has in response to the oncology patient community needs. I suspect the development of a specialty will take some time, but the long term endocrine effects are across the cancer spectrum now.
Fertility preservation and long term planning as noted above can vary state to state and insurance plan to plan, sometimes at great personal cost. We will only find out more by doing research and following this population of patients.Has anyone heard an update on when the FDA will be approving these medications? We have a few patients whose Pyrexia on danrafenib and tramatenib is really signicant and even with various interventions we are not able to keep them consistently on drugs.
We are currently moving most of our patients on both adjuvant and maintained Nivolumab to 4 weeks. It is easier on the patient from a time and financial perspective. They don’t have to take time off of work, find childcare, or have to pay Travel expenses as often. We are keeping patients on he 2 week schedule only if they are complicated or may need a little more frequent visits/monitoring.
Thank you, Lisa for sharing the issue with medicare & the 480mg dosing of Opdivo. I will need to bring this to the attention of my financial folks as they have been clearing a bunch of our patients during the past week-mostly medicare pts.
Regarding the time extension, for the majority of our pateints, they were prepared & looking forward to the change in schedule. During trials we did not (are not seeing) any more appreciable side effects (anecdotal).
We really push alot of education up front with the empahasis on pts “calling at the onset of any changes”.
We empahsize that this is the most important job that they are responsible for and we are in the best position to help when we are aprised of any symptomatic changes.
I think this topical issue directly relates to health literacy (current hot topic), and our assessement of each individual patients understanding and potential needs. Our own health literacy proficiency as nurses comes into play with identifying the patient who may not be as adherent vs the one who may be very nervous and need more support have different needs and we as nurses are pretty great at identifying the pt who may need that interim follow up.Suzanne, you make a good point that infliximab should not be administered for immune hepatitis, in the literature, this is noted as a contraindication due to it’s own potential for hepatotoxicity.
What are some of the barriers that you have encountered with creating these required survivorship care plans? How have you addressed these barriers?
I know in my practice, time is a number one barrier is time both meeting with patients and then entering the required information is the greatest issue. We try to identify patients before they come in for their appointment and will often mail them thier completed care plan.
Additionally, we are working with our IT team to upgrade some of the integration features in our EMR to help make the templating process more fluid, currently the most applicable information is input by hand.Patients often greet this with appreciation but I often question how helpful this actually is for our patients in the current context to their care and how can we make this more meaningful for them? A work in progress…
NEW DOSING OF OPDIVO APPROVED 3/6/18
Opdivo (nivolumab) PI was updated for melanoma to reflectUNRESECTABLE OR METASTATIC:
-Opdivo 240mg q 2 weeks or 480mg q 4 weeks
– Yervoy+ Opdivo 1mg/kg q 3 weeks x 4 infusions, followed by either 240mg q 2w or 480mg q 4w- maintenanceADJUVANT:
-240mg q 2 w or 480mg q 4
INFUSION TIMES:
all are approved for Opdivo over 30minNo, Krista, we have been fortunate enough that even our most severe cases of pneumonitis have responded to high dose steroids, but I could see how the thought consideration could come up.
I suppose that we may in that instance consider temsirolimus or another anti-rejection med, which would be utilized with a patient who had a lung transplant- like we do with mycophenalate & irAE related hepatitis.-Kathy
We are now required under the OCM rules to meet a certain percentage of survivorship care plans per year. What I find interesting is that Medicare does not recognize stage IV patients as part of the OCM bundle for survivorship.
There is minimal information currently available about immunotherapy survivors in any of the cancers. Studies are needed to look at the finciancial, psychological, spirtitual and emotional long term side effects immunotherapy patients face along with residual physiological side effects.
Well said ladies, I certainly echo your points on the clinical decsision making. It is going to be great to have another option to enable continuation of therapy. Somtimes this can be confusing for patients, in justifying a switch of therapy, I usually use the analogy of changing blood pressure medications such as a betablocker, within the same category, that usually helps as that analaogy tends to be relatable.
Additionally, I think the role of pt support programs can play a role of initial choice of therapy.
We too have been following approval indications, and have been fielding questions from patients. This patient population we have typically been promoting clinical trial options, typically adjuvant vaccines, however some of the adjuvant ICI trials are starting to expanding to include early stage III patients.
On another note, I know that serum marker research is well into development but not ready for release yet. My hope is that advancement with lab markers will assist in evaluating risk for recurrence and help with questions such as this in weighing risks / benefits and lead to other immunologic tests evaluating potentential for irAE’s for all pts but especially early stage adjuvant patients.
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