Dr. Chino welcomes Dr. Emily Mackler, PharmD, BCOP, the Co-founder and Chief Medical Officer of the YesRx program and an Adjunct Clinical Associate Professor at the University of Michigan. The YesRx program has saved patients in Michigan more than 17 million dollars in the past 2 years. Dr. Mackler's article, "Transforming Cancer Drug Access: Insights Into Utilization and Clinician Satisfaction in a Statewide Cancer Drug Repository Network," presented at the ASCO Quality Care Symposium. TRANSCRIPT Dr. Fumiko Chino: Hello and welcome to Put into Practice, the podcast for the JCO Oncology Practice. I'm Dr. Fumiko Chino, an Associate Professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. Our listeners know that financial toxicity is a growing issue which limits access to high quality cancer care. Cancer drug repository programs offer a unique solution to the affordability crisis, connecting patients to free medications while reducing medical waste. Cancer drug repositories collect unused, unexpired, manufacturer sealed cancer medications and redistribute them to those in need. I'm happy to welcome a guest today to discuss the YesRx program that has saved patients in Michigan over 17 million dollars in the past 2 years. Dr. Emily Mackler, PharmD, BCOP, is the Co-founder and Chief Medical Officer of the YesRx and an Adjunct Clinical Associate Professor at the University of Michigan. Go Blue! She has led the development and implementation of quality improvement programs across the state of Michigan to improve the care of patients with cancer. She is the first author of the JCOP manuscript "Transforming Cancer Drug Access: Insights on Utilization and Clinician Satisfaction in a Statewide Cancer Drug Repository Network," which was simultaneously published with her oral presentation at the 2025 ASCO Quality Care Symposium. Our full disclosures are available in the transcript of this episode, and we have already agreed to go by our first names for the podcast today. Emily, it's wonderful to speak to you. Dr. Emily Mackler: Thank you. It's an honor to be here, and I appreciate the "Go Blue." Dr. Fumiko Chino: I spent some time in Ann Arbor and have some great love of Michigan. So, and the Mitten State in general. Dr. Emily Mackler: Wonderful. Dr. Fumiko Chino: Absolutely. I'm a Midwesterner at heart, so there's deep love. I love the YesRx program. I think it just makes sense. Do you mind outlining for me just how the program started, what you found in the last two years helping lead it? Dr. Emily Mackler: I actually love our initiation story to this program in that our legislation in Michigan took effect actually in 2006, and our program, the first repository went live in 2021 in a small community practice in Michigan where the community oncologist came into the pharmacist's office, put a bottle of medication on her desk and said, "This is a Honda Civic. Can you do something with it?" That was really our impetus or kind of the starting point. We started the network in 2023 because the first three sites in the state that developed their own internal cancer drug repository programs were done as most things are because a need was identified and there was passion about providing this care and resource to patients. And it became more and more evident that the sustainability for those sites was becoming challenged as there was growth. And I think the most important component that brought us together as a network was that not every practice had the resources to house their own repository, therefore further limiting access to those who probably already had it limited. Dr. Fumiko Chino: I got you. Do you mind just running through some numbers? Because I know, for example, you've had really incredible growth over the last 2 years, starting at 9 participating sites, going to over 100 now, and I know you've helped over 1000 people in Michigan. Dr. Emily Mackler: We did start with 9 sites, and those were part of three practices across the state. We are now at over 105 sites across Michigan, including tribal health clinics, small community practices. We cover 90% of the counties in the state as far as those counties having leveraged resources to donate medications or having have received medications from the repository. We have received over 28 million dollars worth of eligible cancer medication within the repository and have been able to get out over 18 million dollars to Michigan residents. So over 1500 Michigan residents have received medication at no cost from the cancer drug repository. Dr. Fumiko Chino: And I know that as part of this manuscript, there were some surveys for the providers who had participated in the network, and it sounds like they were really just overwhelmingly positive. They thought it was easy to participate, they felt like it helped their patients. So just an incredible service. Dr. Emily Mackler: And I think from that component with the survey, the approach we've taken is a little bit different than perhaps other large drug repository programs in that our goal was really to serve the clinician in the practice, be the physician, the pharmacist helping with access, the nurse. There are many systems in place that cause some fragmentation of care in oncology practice, and they seem to continue. And we really wanted this to be a very easy, quick resource for clinics that filled gaps for them. And so our response rate to the clinic where, if we have a request come in for a medication, we get that back in the hands of the clinic within 1 to 2 days, and they can provide it to their patient at no cost. We really try to make it as easy as possible for them, no paperwork required for them to fill out related to patient need. We just need the patient to say that they do have need or the patient's advocate, be the financial counselor or navigator in the clinic or someone else. So satisfaction for us was really key to measure and make sure we were following through on what our ultimate goal was, which was really to, again, keep that agency in the clinic, have the information at the ready for the clinicians to not delay treatment any further. Dr. Fumiko Chino: You mentioned something that led into my next question, which is that we know that sort of, in general, the drug repository programs require medications to be unexpired, in manufacturer sealed packaging, they must be inspected by a pharmacist, and they must be received by patients in financial need. And so my next question was just going to be about, you know, the quality control aspects of it, what type of medications aren't accepted, and then the specific qualifications that patients must meet to kind of demonstrate need. It sounds like at least from that respect, you're really relying on the treating physician and their team to say, "Hey, this person has need," and you don't require additional documentation, which obviously makes it much easier for the clinician. But for some of those other aspects, you know, in terms of what are you accepting, what can you not accept, and what do you do with the things that people send in anyway? Dr. Emily Mackler: We really follow the legislation within Michigan, which we are so grateful because it was so forward thinking at the time it was approved. We can accept any medications again that are sealed in manufacturer packaging, except for controlled products, so controlled substances are not acceptable. We cannot accept manufacturer enrollment program medications, so things like lenalidomide that require REMS programming are not allowed to be accepted in the repository at this time. And we do need to ensure that the medications are stored at room temperature for us to accept them. Other than that, it's quite open, and the legislation allows us to collect any medications used for the treatment of cancer or to support the cancer patient. So, in addition to cancer medications, we've also collected and been able to distribute to patients antiemetics, DOACs for instance, or other medications may be used to help support the patient during their cancer treatment. So really somewhat broad. As far as eligibility, our mission is to prioritize patients who are the most vulnerable or in need of therapy. We have not had to develop a tiered system as of yet because we've really been able to keep the inventory to a place where at any point that it's been requested, we've been able to fill the need. There are some scenarios where maybe those medications are difficult to come by, but really nothing where we've had to tier availability. As far as what we do with medications that are not eligible, if they've come to us and they've been inspected and don't meet our criteria for safety, we have a partnership with a research lab at the University of Michigan called the Sexton Lab, and they study currently approved, FDA approved medications for other indications. That lab looks at those medications to see what else they might be useful for, uses some AI technology, and they actually accept the majority of the medications that we're not able to use for that research purpose. Dr. Fumiko Chino: That's fantastic. So you're saying that if someone turns in their ondansetron but it's not in a blister pack, or they turn in their oxycodone in the pharmacy bottle, you're still able to upcycle that medication? Dr. Emily Mackler: Yes, as much as possible. We really try to eliminate any unnecessary medication waste. Dr. Fumiko Chino: Wonderful. Dr. Emily Mackler: We really try to eliminate any unnecessary medication waste.   Dr. Fumiko Chino: I was actually really impressed about the rollout of the YesRx program. I know that you had mentioned in the manuscript that it was specifically designed to focus first on supporting the clinics in the communities with the least amount of resources serving the most vulnerable population, and then sort of later phased out to the larger, more resourced areas. And this strategy was done to create an explicitly stated more equitable, effective, and sustainable statewide program. Can you comment on how kind of this worked in practice and what the resources required by the program to keep up the quality as it's grown? Because it sounds like from what you had said initially just like, it became unsustainable with just the three groups doing it initially and had to sort of- had to get more infrastructure. Dr. Emily Mackler: Yeah, this approach was really important to us, and I think in part from the feedback, again, of these first three sites of what, we spent about 6 months really learning from them: “What if you could wave a magic wand, what would you do with just this kind of programming in general?” The most important component was sharing inventory. And as you can imagine, if you think across an entire state, perhaps what's donated in one area is maybe not needed as much in that area but needed in a different area of the state. And that sharing of inventory really couldn't exist in those first models. So that was a big priority. The second one was this recognition that the sites that could develop the program had the resources to develop them. And so we really took time and effort in contacting and working with some of the more rural oncology practices with leveraging the physician oncology organizations in the state, the Michigan Society of Hematology Oncology and the Michigan Oncology Quality Consortium, to learn from the members of those organizations how could they take part and how could we serve them best. The most integral part of us launching that way was an incredibly invested health care partner who donated storage space and pharmacist resource to YesRx, to our statewide network, and with that, we were able to engage sites that couldn't store, couldn't dispense, didn't have pharmacists at their site, but where we could engage them by having the medication sent to the central storage area and that we could have them e-prescribe to that site and we could get the prescriptions right to them. And so that was really our effort and then engaging some of the larger, more resourced practices after that point. One of the reasons that we provide to the clinic is that we want to make sure that the clinic knows when the patient has their medication in hand. We also are really with the regulatory components of the cancer drug repository program, the patient or whoever collects the medication is required to sign a recipient form. So we want to make sure that they're educated on this medication has been donated and is part of a repository. So that clinic is getting the form signed and sending it back to our central storage site. Dr. Fumiko Chino: That totally makes sense because the feasibility of doing that remotely is very challenging. Dr. Emily Mackler: Yes. Dr. Fumiko Chino: So just moving to talk about the oral anticancer drug specific drug repository programs, I know as of 2024, there are five states that have these oral anticancer drug repository programs, but there's a larger number, 28, who have just the generalized drug repository program. And I actually read a Health Affairs Scholar review, which we'll link to in the notes for this podcast, which I thought was a super helpful guide. And I know you mentioned earlier that Michigan, although the legislation took effect in 2006, the state approved CDR wasn't really implemented until 15 years later. So it sounds like there was a gap there, and I would assume that there was some advocacy required to help kind of fight for the programs. I would love to know if you were involved in any lobbying at the state level to move the program forward because it seemed like there was like a pause there where it just wasn't moved forward. Dr. Emily Mackler: Not as much on the advocacy component at that point in time, so post-approval, and I really think the delay in our state was related to the effort to get them running and have it be sustainable. I continue to feel that kind of the closed door repositories can be challenging in the long run because the population served is more limited and isn't encompassing necessarily all the residents that could benefit from it. We have definitely been heavily involved in advocacy since our launch, however, and there are so many different components of this. One is a keen effort for us to be partially funded by the state of Michigan given the care that is provided and the resource for Michiganders across the state. Those efforts are underway. The other aspects are we have been using the program, the legislation now for the last two years, and we have some ideas on optimizing it. There are some components that if revised, we think we could serve more Michigan residents and that the program could perhaps be run smoother in different aspects. And so those efforts will be underway as well. More so advocacy wise and educating, letting legislators know that this has been in law in essence since 2006, and we're really acting on it now and serving their constituents and then how are ways that we can really optimize the programming. Dr. Fumiko Chino: I know you said in the manuscript that the program was designed to be a short term gap for a one month supply, and really only a handful of people got more than a one month supply if alternative resources weren't in place at that time. So it's clear that the programs like YesRx are a supplement but are not a replacement for the existing financial access programs. And I was just wondering if you thought that there were lessons learned from this program that can make other programs more efficient? Dr. Emily Mackler: I think without a doubt, the financial access resources could be streamlined. I think anyone you talk to in a clinic and the knowledge of the financial navigators or social workers or pharmacy staff that are working on these programs is so immense, and the amount they have to keep up is incredible. It would be phenomenal if there were a shared application or some component that would really help streamline some of the processes or even identify what is the best option for this patient. Is it perhaps changing their insurance plan versus co-pay assistance or something else? And so I do wish and think that those things could be streamlined. I think coming together and sharing resources for us has been phenomenal. If you think about waste reduction already on the end of reducing waste of medications, that's part of our goal, but we're also reducing waste or redundancies in workforce burden as far as developing policies and procedures, putting together information, networking and making sure communities know about the programming. Those are all resources that would have had to be replicated at each one of these sites that we've been able to streamline. So I do think that could benefit patients and the practices immensely. I also think on the financial toxicity for patients with cancer, it continues to be a growing problem. When I started practice, I didn't know the term financial toxicity. I don't recall it being used 20 plus years ago. And it's now such a burden. Even delays in starting treatment is something that we've been able to fill gaps for patients, and it has done an immense amount to decrease their anxiety during this journey that they're on. And so it would be nice if other programs could replicate that ease so that patient's emotional burden could be decreased in the process. Dr. Fumiko Chino: Absolutely. I personally do a lot of research on prior authorization, and even though the patient might ultimately get the medication, that wait for approval can be excruciating, outside of just the fact of not having the medication and therefore not having effective treatment of symptoms or anticancer therapy, but it's the, "I don't know when it's going to be approved. It increases my anxiety.” So being able to have that stop gap, one month prescription, I think is such an incredible resource. Dr. Emily Mackler: We help a lot of patients up front. We also do mid therapy, and the clinical implications of that are, I think, important. If you think about being on treatment and then having a break of 2 weeks or a month that's not intended, not great or not great for outcomes or adherence for sure. And the amount that that happens due to financial reasons is so much more than I even appreciated: changing an insurance plan and waiting for the new one to take effect, foundation support running up, utilizing or using up all the co-pay assistance that was available to them, so many different scenarios. And you really run a risk of some of the clinical outcomes in those situations or hearing patients split their chemotherapy dosing to try to get through those time periods. So those gaps are also gaps that we're able to fill that we feel really grateful for. Dr. Fumiko Chino: I'm so impressed by this program. We are wrapping up the podcast, so I just want to leave a little bit of time at the end if there's anything that we missed talking about, if you wanted to talk about, you know, what the future for YesRx is. I know you already mentioned sort of your ongoing advocacy at the state level to bolster support and funding for the program. Dr. Emily Mackler: I think the only thing that I would like to add is how much we've really had support from partners across the state. And for groups or states or individuals who really want to do something similar or replicate a model, we would love to have those conversations with you and see where legislation is at your point or what kind of resources could you get set up. But we really are grateful for the supports that we've had that have really been mission-aligned with us to try to reach as many patients as we can with these medications and, again, reduce the unnecessary waste. Dr. Fumiko Chino: Well, on that positive note, and I love the idea that this is the siren call for our fellow oncologists and pharmacists across the United States to sort of replicate this program, I want to thank you so much for this amazing conversation today. Many thanks to both Dr. Mackler as well as our listeners. You will find the links to the papers that we discussed in the transcript of this episode. If you value the insights that you hear on the JCO OP Put into Practice podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts. I hope you'll join us next month for Put into Practice's next episode. Until then, you can catch up on all of the amazing research being presented at the ASCO Quality Care Symposium at www.asco.org/quality. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

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