Philadelphia, PA—An expanding role for oncology pharmacy in the optimization of cancer care is likely to emerge over the next 3 to 5 years, as payers seek better outcomes for their money, said Jeff Ulanet, MBA, Vice President, Oncology, Medco, at a roundtable payers’ discussion. Oncology pharmacy is a specialty that will likely progress to mimic a medical specialty that a physician can use to optimize treatment more than in the past. “In fact, we can make the case that specialization matters more in oncology than in almost any other disease,” Mr Ulanet said, as the roles of pharmacogenomics and molecular testing expand, along with symptom mitigation and the management of nutrition, drug–food interactions, and side effects. An expected shortage of oncologists in the coming years will mean that physicians will look to pharmacists as an extension of their practice, he predicted, in an attempt to obtain better outcomes for all the drugs and treatments they render. The management of the cancer benefit will be an ongoing challenge, as payers try to find the right balance between cost and efficacy. “If payers are going to spend $100,000 on a patient, they would like to see a better outcome,” said Mr Ulanet. “It’s not all about cost, but it is about outcomes for that cost. Pharmacy management and therapy management is the way in which you can assure a better and greater use of the dollars you’re spending.” As precision therapies emerge, a combination of technologies and activities performed within the pharmacy will advance to optimize those therapies, he said. Expect the use of advanced electronic prescribing to support decision tools for diagnostic tests and response monitoring that aid the pharmacy in the selection of patients for particular drug therapies, said Mr Ulanet. Molecular testing will eventually be incorporated into the pharmacy as a more efficient way to ensure optimal drug delivery. Electronic medical records and third-party payers will play a role in automating the integration of molecular testing and drug delivery. Tools for enhancing patient selfmanagement may also emerge, as the average patient with cancer is receiving a complex drug regimen that includes 10 oral drugs daily, he said. Cost-Effective Delivery of Cancer Care In today’s market, keeping the buyand- bill option in the physician’s office is the best strategy for a commercial payer to deliver cancer care, said Alan M. Lotvin, MD, President and Chief Executive Officer, ICORE Healthcare. It provides physicians a purchasing advantage of about 17%, on a weighted average basis, over any pharmacy. The logistics of oncology drug dispensing is also in favor of the physician distributing the drug, because of waste in oncology drug delivery. “There’s no way around that problem unless you have a compounding pharmacy close to the doctor’s office that will deliver on demand…it’s not necessarily an easily scalable approach,” he said. The second challenge to removing buy-and-bill from the physician is economics. When a vial of an oncology drug is shipped to the physician’s office, “the plan is going to be billed for an entire vial,” said Dr Lotvin. Most physicians still want to be in the buy-and-bill business, because it is a revenue generator that inflates at 7% to 8% annually. “The biggest challenge with taking these drugs out of the physician’s office is not just that the physician has a lot of cost built into it, but that the waste goes up dramatically and the amount that gets billed goes up dramatically,” he said. “If you want to get rid of incentives, change the pricing to eliminate incentives; don’t worry about the distribution model, and if you want to think about the distribution model and where the drugs are coming from, the doctors pulling them off the shelves is often the least costly and least wasteful.” About 70% of a community oncologist’s top-line revenue flows through the dispensing of drugs, said Kimberly Bergstrom, PharmD, Chief Clinical Officer, McKesson Specialty Care Solutions. Traditionally, “we have focused on fixing the reimbursement issue, but the real issue is appropriate utilization,” she said. One method for managing drug distribution is to pay physicians more for choosing a generic when appropriate, providing them with an incentive to act in the plan’s best interest while ensuring that they’re never “under water” in their drug purchases, said Dr Lotvin. Dr Bergstrom agrees that a differentiated reimbursement for the use of generics would allow community oncologists to administer them without losing money. But the way reimbursement is currently designed, providers stand to lose money by choosing generics. As more equivalent oncologic drugs (eg, more vascular endothelial growth factors) make their way through the pipeline, Dr Lotvin sees some of the decision-making in their use shifting from provider to payer. “We’re still a few years away from having enough competition; part of that is the pipeline rate coming out of the FDA, and part is due to every drug having a unique indication, so it is hard to call them clinically equivalent,” he said. “We’ll see it more with the common therapies, but we’re not there yet.”
