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Table of Contents
Introduction ................................................................................................................................................ 3
Unique Pressures Facing Oncology Practices ................................................................................................ 5
Impending Oncologist Shortage ......................................................................................................................... 5
Precarious Delivery, Reimbursement, and Pricing Environment ....................................................................... 6
Increased Use of Clinical Pathways .................................................................................................................... 9
Complexity of Care ........................................................................................................................................... 11
Increase in Availability and Use of Oral Agents .............................................................................................. 12
Shift Toward Hospital-owned Practices ........................................................................................................... 13
Restricted Access to Industry Resources .......................................................................................................... 14
Adjusting Communication Teams to Meet Oncologists Needs ................................................................... 15
The New Oncology Sales Representative ......................................................................................................... 15
Blended Communication Teams ....................................................................................................................... 17
Summary ................................................................................................................................................... 19
Resources .................................................................................................................................................. 20
[B]y 2018 the total oncology market will dwarf all other drug categories
with oncology product sales forecasted to be 12.2% of total drug sales,
nearly double that of the second-largest category (antidiabetics).
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In the United States, cancer care is largely provided and guided by medical oncologists. There are currently
about 13,000 oncologists practicing in the United States, the majority in private community practices. As a
group, oncologists are highly focused on patient care with more than 80% identifying direct patient care as
their primary professional activity. IMS Health estimates that 80% of US cancer care is carried out in
community-based oncology clinics, a well-respected care model.
But all is not well in the cancer-care arena. In 2013, the National Academy of Sciences published a 323-page
report entitled Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. The report
noted that cancer care is often not as patient-centered, accessible, coordinated, or evidence based as it could
be, detrimentally impacting patients. Indeed, as described below, US oncologists and oncology practices are
facing numerous stress points that are challenging their ability to provide high-quality care.
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In brown bagging, a patient purchases injectable oncology drugs from a specialty pharmacy, has them shipped
directly to his or her home, and then takes them to the oncologists office for administration. This model
includes multiple hazards. First, it eliminates the practices important buy-and-bill revenue stream. Further, it
raises an important safety concern. Although many injectable oncology products have strict storage and
handling requirements (eg, refrigeration), many patients comply poorly or not at all. Improper storage and
handling could lead to safety and/or efficacy issues.
Even in situations where products are purchased and administered via the buy-and-bill model, the
reimbursement environment is challenging. In the not-too-distant past, clinics were able to realize about a
20% markup on injectable drugs, providing profit to run the infusion operation and cover other costs.
However, more recently, Medicare and commercial insurers have been reducing the allowable markup
dramatically. Oncology drugs are now typically reimbursed at average sales price (ASP) plus 6%, and the rate
may be reduced even further in years to come.
One of the leading pricing issues pressing on privately owned oncology clinics is the US federal governments
340B Drug Pricing Plan, which allows specified hospitals (and their affiliated oncology clinics) to purchase
drugs at discounted prices. This preferential-pricing policy typically pertains to hospitals with a high population
of Medicare, Medicaid, and uninsured patients, because these institutions are seen as safety-net providers in
health care. The number of hospitals participating in 340B pricing has tripled in number since 2005, and the
program now includes roughly one-third of the nations hospitals. More hospitals are expected to enter the
340B program under the Affordable Care Act, as more hospitals become eligible for inclusion when they begin
to serve an increasing number of Medicaid patients.
The 340B discount is the average manufacturer price (AMP) reduced by a rebate of 20% to 50%. The ability to
buy drugs at this discount, but to charge private insurers and Medicare/Medicaid a market price, has turned
into an attractive revenue stream for hospital systems. Independent oncology practices are not eligible for
340B discounts.
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One final cost-related issue is worth noting. A number of recent FDA drug approvals especially in oncology
have been for targeted therapies (personalized medicine) that require the use of an associated diagnostic
test to determine which patients are appropriate/responsive to therapy (eg, EGFR mutation). Typically, these
tests are not produced and marketed by the same company that makes the therapy that will be administered
if the patient is found to be an appropriate candidate. Therefore, oncology-product sales representatives need
to be aware of any associated tests and their costs, processes, etc, including how testing can impact the
overall cost and prescribing of their drugs.
ASCO considers all these delivery, reimbursement, and pricing challenges to be of paramount importance. At
this writing, ASCOs Policy Priorities website page lists as its #1 priority the goal to achieve a fair, adequate
and stable payment environment for oncology practice.
10
Interestingly, cancer-specific clinical pathways can be presented to clinicians within their electronic health
record (EHR) systems. For example, The US Oncology Networks clinical pathways are built into the
organizations EHR system, iKnowMed. The EHR lists the on-pathway treatments for a given diagnosis and
the documentation to support their inclusion in the pathway.
All these pathways are aligned with the frequently updated Clinical Practice Guidelines in Oncology and
Compendia from the National Comprehensive Cancer Network (NCCN), a nonprofit organization composed of
the nations leading cancer institutions. The documentation of the evidence to support a pathway is
particularly helpful for oncologists caring for patients with less common cancers. As part of a continuing effort
to optimize clinical care, the NCCN is collaborating with The US Oncology Network and McKesson Specialty
Health to develop enhanced oncology pathways delivered through innovative technology.
Published reports demonstrate that when patients are treated according to pathways, their mortality and
survival are identical (compared to off-pathways treatment protocols), but with a decrease in overall cost.
However, pathway requirements add an additional level of administrative, clinical, and operational complexity
for any oncology practice especially when different payers require compliance with different pathways.
Furthermore, many oncologists dislike the loss of clinical autonomy that results when strict adherence to one
set of pathways or another is mandated by a hospital system or payers. In the end, oncologists are currently
split as to whether strict adherence to one set of clinical pathways or another will truly produce improved
clinical outcomes and/or reduced overall treatment costs.
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Complexity of Care
For many cancers, oncologists must navigate a growing wave of new therapeutic options. For example, in
2000, just one product was approved to treat renal cell carcinoma; by 2012, eight products were approved.
This explosion in the number of agents and myriad possible combinations and sequences of therapy represent
an enormous challenge to practicing physicians, as well as to patients and caregivers.
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Healthcare Passion: Perhaps more than in any other therapeutic arena, oncology sales representatives must
be passionate about health care and have empathy for patients and healthcare professionals (HCPs). This
passion for optimal health is a foundation that helps representatives initiate and maintain interactions with
physicians that can grow into mutually fulfilling, long-term relationships.
Consultative Sales Ability: Oncologists want sales representatives who listen, understand, and provide real
value to their practices. Todays best-practice sales representatives do not deliver standardized sales messages
to their physicians. Instead, they tailor their presentations to match each prescribers particular situation while
staying within compliance guidelines. Successful representatives initiate needs-based discussions with
physicians about their practices, patients, and prescribing and provide real value in better managing all of
these.
Absolute Compliance: Federal and state government scrutiny of drug promotion is at its highest levels ever
and shows no sign of abating. Not only must todays sales representatives be aware of company promotional
guidelines, they must be painstakingly compliant. To meet this need, many companies are ensuring that their
target representative profile includes regulatory compliance competency.
Superior Access Skills: As noted, oncology remains the most restrictive specialty for pharmaceutical sales
representative access. Still, in many offices, a few skilled representatives gain access while others do not.
Going forward, successful representatives will be those with the ability to reach the physician when others
cant.
Lifelong Development: In addition to learning the latest product and medical information such as changes
in labeling and practice guidelines oncology sales representatives must keep abreast of disease-state news
and developments. Now more than ever, top representatives have an intrinsic, continuing desire to learn, to
grow, and to become more-effective resources for their customers.
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Inside Sales and Service Teams:
Many life sciences companies are augmenting their field sales teams with an array of inside message delivery
teams. These inside teams can supplement field initiatives and be available to dialogue with HCPs on demand
and at times when traditional field representatives are not typically available (eg, early morning or after office
hours):
Live Video Detailing: Inside professional sales representatives (with field-level training) conduct live,
person-to-person details using the Web and phone. HCPs see and hear sales representatives via
webcam links, and the representatives hear HCPs on the phone. During video details, sales
representatives display appropriate client-approved content on healthcare providers computers. Most
live video details are initiated on demand by healthcare providers who click a brand-site Web link and
average over 10 minutes in length.
TeleDetailing: Experienced contact center sales representatives use their advanced training to deliver
key product messages to target prescribers accurately.
Inside Credentialed Sales Specialists: Phone-based HCPs (eg, PharmDs, RPhs, RNs, MDs) engage
oncologists and other high-level targets in complex, one-on-one clinical product discussions,
particularly in institutional settings.
Vacant Territory and White Space Management: Comprehensive vacant territory and white space
management can ensure coverage when a field sales representative is not available. Companies using a
variety of highly customizable vacancy management programs can use a combination of teleDetailing,
teleService, and live video detailing.
Flextime Representatives:
These sales professionals work a part-time schedule usually 20-24 hours per week. These are typically
highly experienced and accomplished life sciences professionals who choose flextime positions for quality-oflife issues. Flextime can be an effective scheduling model for all types of traditional and nontraditional
representatives.
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Summary
By 2018, the oncology-products market will account for more than 12% of total drug sales, dwarfing all other
drug categories. In the face of this rapid marketplace expansion, medical oncologists are facing a plethora of
daunting pressures that are challenging their ability to provide high-quality care:
Impending oncologist shortage
Precarious delivery, reimbursement, and pricing environment
Increased use of clinical pathways
Complexity of care
Increase in availability and use of oral agents
Shift toward hospital-owned practices
Restricted access to industry resources
Each of these challenges presents biopharmaceutical leaders with opportunities to provide appropriate
support to overworked oncologists. Biopharma companies can take a number of specific action steps that will
help fine-tune their communications teams and tactics in order to better meet the needs of oncologists. As
part of this process, many life sciences companies are making sure that their field sales representatives
possess several indispensable qualities and characteristics, including science-focused education and training,
consultative sales ability, and superior access skills. In addition to these sales force refinements, many
companies are also beginning to deploy blended teams consisting of a traditional field sales team, along with
some combination of nontraditional communication teams.
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Resources
American Society of Clinical Oncology. Key Trends in Tracking Supply of and Demand for Oncologists.
http://www.asco.org/sites/default/files/workforce_information_system_12.17.12. Accessed November 12,
2013.
American Society of Clinical Oncology. Policy Priorities. http://www.asco.org/advocacy/policy-priorities.
Accessed November 12, 2013.
American Society of Clinical Oncology. Workforce Studies. http://www.asco.org/advocacy/new-ascoworkforce-studies-oncology-practices-adapting-economic-political-demographic. Accessed November 12,
2013.
Community Oncology Alliance. http://www.communityoncology.org/site/blog/detail/2013/07/08/july-8-2013when-doctors-sell-out-hospitals-cash-in.html. Accessed November 12, 2013.
EvaluatePharma. World Preview 2013, Outlook to 2018. June 2013.
Health Strategies Group. The Oncology Market: Six Key Trends for the Next Three Years.
http://vitalcomgroup.com/wp-content/uploads/2013/07/EB_SixTrends_Hegwer. Accessed November 12,
2013.
Hughes D. Should you sell drugs to patients? http://www.medscape.com/viewarticle/803653. Accessed
November 12, 2013.
McKesson Specialty Health. Understanding the Oncology Market.
http://images2.advanstar.com/PixelMags/pharma-executive/pdf/2013-10. Page 18. Accessed November 12,
2013.
National Academy of Sciences Institute of Medicine. http://www.iom.edu/Reports/2013/Delivering-HighQuality-Cancer-Care-Charting-a-New-Course-for-a-System-in-Crisis.aspx. Accessed November 12, 2013.
Pines N. Oncology. http://www.mmm-online.com/therapeutic-focus-2013-oncology/article/304193/.
Accessed November 12, 2013.
Rao S. A patient centric commercial model for cancer care. J Commer Biotechnol. 2013;19(2).
Roffman J. http://www.zsassociates.com/about/news-and-events/oncology-remains-most-restrictivespecialty-for-second-year.aspx. Accessed November 12, 2013.
Shelley S. Industry confronts healthcares changing oncology practices.
http://pharmaceuticalcommerce.com/brand_communications?articleid=26844. Accessed November 12, 2013.
ZS Associates 2013 AccessMonitor press release: http://www.prnewswire.com/news-releases/oncologyremains-most-restrictive-specialty-for-second-year-217579141.html. Accessed November 12, 2013.
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