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"The larger groups have made the move to work with pharmacists," said Mary Lou Bowers, a health care consultant in oncology at The Pritchard Group LLC in Rockville, Maryland. Before joining Pritchard, she held a similar position for eight years at ELM Services Inc., also in Rockville.

Signs of a trend.

Bowers estimated that 70–80% of large oncology practices, having at least eight oncologists on staff, employ pharmacists and pharmacy technicians.

Although large oncology practices constitute less than 40% of the oncologist work force, they conduct about 40% of the oncology business in the country, she said.

Congress’s Medicare Payment Advisory Commission, during visits to five metropolitan areas and states in 2004 and 2005, found several community-based oncology practices with pharmacist employees.

The commission had conducted the visits as part of its assignment to examine the effect that congressionally mandated changes to the payment system were having on Medicare beneficiaries’ access to chemotherapy services. Those changes included paying 85%, instead of the longtime 95%, of the average wholesale price for physician-administered medications in 2004. The next year, payments changed to 106% of the average sales price—reportedly a value just a little higher than the actual price paid by physicians.

Hiring a pharmacist to buy and prepare medications for the practice and recommend drug products on the basis of price and clinical effectiveness was one action that the commission said oncologists had undertaken to reduce costs or improve efficiency, according to a report released in January 2006.

"It used to be relatively easy to make money in community practice," said Susan B. Goodin, director of pharmaceutical sciences at The Cancer Institute of New Jersey in New Brunswick. The facility is 1 of 39 National Cancer Institute (NCI)-designated comprehensive cancer centers in the country. "Reimbursement was good; let the good times roll."

"With the changes that have occurred in the last two years," she continued, "I think they’re all starting to see that there’s certainly more challenges and in order to make it, you’re going to have to ... learn how to optimize therapy but not give up [good] outcomes. And certainly it’s what pharmacists have been doing for years."

One group’s rationale.

Oncologist Michael J. Nissenblatt of Central Jersey Oncology Center, P.A., said he recently hired a local hospital’s oncology pharmacist for the practice’s two sites.

"She does absolutely everything," Nissenblatt said of Eileen Peng, who now works full-time with the six oncologists.

In just the first week, he said, Peng suggested that the practice start buying lyophilized i.v. immune globulin (IVIG) so that patients could resume receiving the treatment in the office. The oncologists had been sending patients to a hospital outpatient department because the practice lost about $1000 with each infusion of a ready-to-administer IVIG product, he said. Now a pharmacy technician prepares the doses for office use.

What Nissenblatt said he gained foremost by hiring a pharmacist was an employee who was "as familiar with the protocols as we were but was at a heightened level of awareness about the interactions of the drugs with patients’ other comorbidities and medications."

The oncologists, he said, wanted someone on whom they could rely to recommend dosage adjustments for patients with renal dysfunction and help ensure the relatively safe administration of cancer treatments known to have toxic effects on the heart or lungs.

In addition to advising the oncologists about drug regimens, Peng was hired to oversee the preparation of injectable cancer treatments by a pharmacy technician, thus freeing up the oncology nurses from drug preparation and administration, Nissenblatt said.

"We felt there would be a win–win–win situation for everybody if we had a pharmacist," he said. "That is, we would improve the accuracy of treatment for our patients, we would improve the quality of our nursing for our patients, and at the same time we would improve our level of knowledge by the doctors about each of the protocols and make sure that they were absolutely perfect."

Economics pushes strategy.

Goodin, at The Cancer Institute, said she knew of community-based oncology practices in addition to Nissenblatt’s that had hired pharmacists to do more than prepare medications. Some of those practices hired their pharmacists to focus on therapies and continued to have the nurses prepare the drug infusions.

"But I think the bigger issue," she said, "is really this reimbursement [challenge] and using pharmacists to help them optimize product selection for reimbursement."

Goodin said she had recently spoken with a Philadelphia oncology practice that had hired a pharmacist to oversee drug purchases and therapies and help optimize the billing.

"The upsurge has certainly been in the last five years," she said, and more so in the past year.

Many of these oncologists, Goodin said, have joined forces rather than continue in solo practice and, in building a larger practice, remember the positive interaction they had with pharmacists during a medical fellowship or in a health system.

"They realize ... the value that a pharmacist has brought to them from a clinical standpoint but also from an economic standpoint," she said.

Good for patients.

Bowers, the health care consultant, said some of the large community-based oncology practices have added "retail pharmacies," with the office pharmacist filling prescriptions for oral oncology and oncology-related medications, as well as mixing the drugs for infusion in the office.

This arrangement, she said, is a convenience to patients who may have trouble obtaining these specialty medications at regular community pharmacies, and it is a recognition of the movement in cancer treatment from injectable to oral medications.

Goodin said that 85% of all cancer care now occurs at facilities other than NCI-designated comprehensive cancer centers and academic medical centers. "It occurs out in the community," she said.

With more pharmacists working in community-based oncology practices, Goodin said, "This is a continued opportunity for pharmacists to have a positive impact on patient care."

— Cheryl A. Thompson

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				Clinical Pharmacists in Oncology Practice J. Oncol. Pract, July 1, 2008; 4(4): 172 - 174. [Full Text] [PDF]

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