Oncology benefit management

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Due to the multiple components of health care management—claims (data processing), treatment, diagnoses, drug administration, etc. — it[clarification needed] requires sophisticated technology and coverage to be effective. As seen by the various sections included in delivering health care, it is necessary to have an integrated system that allows a seamless flow of information to prevent lag time and consequential complications because of the lack a standardized system. If the a doctor uses a paper claims system (with a much longer lag time), but the pharmacy dispensing medication uses an electronic claims system (with a much shorter processing period), then complications are bound to rise especially if the doctor discovered crucial information on the diagnosis of the patient that affected the type(s) of medication the patient needed for treatment.

Pharmacy Benefit Management[edit]

In order to clear any inconsistencies, it is also essential to understand the terms “pharmacy benefit management” versus “oncology benefit management”. Pharmacy benefit management PBM companies “…use sophisticated electronic systems to manage retail and mail-order drugs covered under the pharmacy benefit”.[1] These electronic processing systems ensure that the “…right patient, right drug, right dose, right route, [and] right time”[2] are met in a timely fashion—a feat difficult to achieve with manual claims systems.[3]

One of the nation’s largest pharmacy benefit managers, Express Scripts, identifies the core duties of a pharmacy benefit manager as:

  • Finding the most effective mixture of brand-name and generic drugs to deliver the same quality of care/treatment at a more affordable price[4]
  • An integrated technological platform that allows the prompt and correct delivery of drugs[4]

In short, a Pharmacy Benefit Manager (PBM) is a third party administrator of prescription drug programs (or benefits).[5]

Ambulatory oncology[edit]

Ambulatory oncology is the ambulatory care of cancer patients on an out-of-hospital basis.[6] At an ambulatory oncology facility, patients are typically those who do not need hospitalization and come to these facilities just for treatment.[7]

Pediatric oncology[edit]

Pediatric oncology—the treatment of children with cancer—is typically managed on an inpatient (or an “in-hospital”) basis. Thus, pediatric OBM are typically managed through the children hospitals like CHOC that specialize in pediatric oncology services, and not separate OBM companies.[8]

Surgical oncology[edit]

As for surgical oncology surgical oncology, the majority of the time the resection (or “the removal”[9]) of a tumor is done on an inpatient basis, and then the actual treatments are done at out-of-hospital ambulatory sites.[10]

Adult oncology[edit]

Adult oncology is an illness that can most cost-effectively be managed as outpatient (or “ambulatory”) treatments.[11] Therefore, adult oncology is most often managed on an ambulatory setting (i.e. physicians’ private practices).[12] Due to the complexity of adult ambulatory oncology, it requires a multidisciplinary approach for its treatment.

Scope of an Oncology Benefit Manager[edit]