What's on the Horizon for Community Oncology Pharmacy in 2025

Pharmacy Times^® interviewed Judith Alberto, MHA, RPh, BCOP, director of clinical initiatives at Community Oncology Alliance (COA), about the importance of integrating pharmacists into oncology clinics, as well as key policy issues affecting community oncology pharmacists in 2025. She emphasizes how embedded pharmacists contribute to better patient outcomes, reduced costs, and higher patient satisfaction by offering expertise in medication management, patient education, and therapy counseling.

Alberto highlights the need for standardized data collection to demonstrate the value pharmacists bring, especially in improving adherence and measuring patient satisfaction. She notes that measuring adherence and compliance can be challenging, particularly with oral oncology medications due to varying dosing schedules.

Regarding policy issues for 2025, Alberto identifies major challenges for community oncology pharmacies, including low reimbursement rates, pharmacy benefit manager (PBM) practices limiting patient choice, and restrictions on mail delivery of oral medications following the end of the public health emergency. She expresses concern over the Inflation Reduction Act (IRA), noting both positive aspects, such as the $2000 cap on patient out-of-pocket expenses, and negative impacts, such as inequitable reimbursement structures that could financially strain community pharmacies.

Alberto also discusses the emerging role of AI in community oncology pharmacy, including its potential for clinical decision support, drug interaction management, and operational efficiencies, while cautioning about its reliability.

She concludes with a call for increased advocacy and policy engagement to address key issues such as hospital consolidation and PBM reforms, expressing optimism for positive policy changes in 2025 through collaborative efforts with COA and its members.

Alana Hippensteele: Hi, I'm Alana Hippensteele with Pharmacy Times. Joining me is Judith Alberto, MHA, RPh, BCOP, of Community Oncology Alliance. Judy, would you mind introducing yourself and tell us a little bit about your role at COA?

Judith Alberto, MHA, RPh, BCOP: Yes, absolutely. Thank you for having me, Alana, it's very much an honor to be here. My name is Judy Alberto, and I'm with Community Oncology Alliance, or COA, as director of clinical initiatives. I've been with COA for about 2 years. We are the only nonprofit organization that supports community oncology practices and, most importantly, the patients that they serve.

Hippensteele: Great, thank you. So, we have in past discussions discussed the topic of better integrating pharmacists into the oncology clinic. Could you tell me a little bit about how that can benefit patient care, having pharmacists more embedded in the clinic? What is the value of that, and where is the impact going to be seen in patient care?

Alberto: Yep, absolutely. And this is a passion of mine, Alana, just to have pharmacists at a point where they are seeing patients, and they are making that impact. I think it’s on every single aspect of the care team. So, when you can have a pharmacist that's in the clinic, they're with the physician, they're with the [advanced practice providers], and they're seeing patients. They're helping with decision support tools. They're helping with the medication that they're choosing, whether it's oral or infusion for oncology patients, it really makes a difference, because that's where their expertise is. Their expertise is in drug management, medication management, therapy, and counseling and educating, not only of patients and their families, but also the care team. And so, they bring that dimension, and it really allows everyone to work to the scope of their license. Where you see the greatest impact is definitely on outcomes. And so, there's the ability to improve outcomes and decrease cost as well as increase patient satisfaction. Patients love to see their pharmacist.

Hippensteele: Yeah, and so on that point, I think in terms of the very clear value add that pharmacists can bring to patient care, I think one of the challenges can be making that value very clear to other stakeholders. How do you think data can be better utilized to showcase the value that pharmacy and pharmacists can bring when embedded in the clinic?

Alberto: You bring up a really good point—that's where the weakness lies. What data do you use to put a pharmacist on your team? I've heard physicians say before that they can't afford to put a pharmacist on their team. I say to that you can't afford not to put a pharmacist on your team.

So, what we really need to is eventually see pharmacists as providers and as clinicians, and be able to get reimbursement for that, so your practice has the resources to be able to sustain that. The way to do that is to gather data to standardize the practice of pharmacy and the practice of patient care, so you can really get those metrics and monitor the impact that the pharmacist makes. And so that's sometimes very difficult to quantify. How are you improving outcomes by additional pharmacists on your team? That's something that we're working towards. We're trying to look at standardizing those quality measures, create them, standardize them, and then really monitor and measure them. So, that's what we're working on. And then we know that that impact can be financial, can be clinical, operational, to put that pharmacist on that team in the clinic, seeing patients and allowing everybody, again, to work to the top of their license.

Hippensteele: Yeah, absolutely. I know that in terms of the very clear pharmacy—the monetary opportunities that pharmacies bring is very clear, but sometimes the services of pharmacists and what they provide can be some somewhat unclear to other stakeholders. What are some of those very clear, very obvious data points that you think could be used. Or I know that this is something that's growing and emerging, but are there any specific areas where you think that it could be further focused on?

Alberto: Yes, so I think the oral space is really where we're seeing the biggest challenges right now. So, when you look at that turnaround time for your prescription fill, you look at adherence. What does adherence look like, and how do we measure that compliance for patients? That's not standardized. It differs per pharmacy, even per individual. How are you measuring that? Is it when the prescription is called in, or is it when the patient picks up the prescription? And so that varies, and so it's hard to measure what that looks like. I think because oncology medicine, especially in the oral space, is so complex, and it's not like other medications that we see. They might be 3 weeks on, 1 week off, their dosing might change frequently. So, how are you measuring that that patient is compliant and adherent and taking their medication? So, what may look like noncompliance is really compliance. And so, it's hard to measure and standardize that.

We also see in the infusion space that can be hard to measure also, because so many factors are—there's so many departments in different facets that come in that could impact what the pharmacist is doing. Yeah, it’s a little easier to measure there than the oral, but if you take it up another notch to the clinic, and I say up as in a building, if you're going up to where the patients are seen—but if you look into the clinic, that's a little bit easier. I think measuring patient satisfaction in that stage might be the easiest way to start to look at, how are we impacting outcomes? The patient is coming in, they're being kind of triaged through. They're seeing everybody they need to see. When the pharmacist is part of that, then that patient satisfaction can go up. So, that might be a good place to start.

Hippensteele: Yeah, patient surveys.

Alberto: Yes, patient surveys, exactly. That we can bring into the oral space, as well as the clinic and infusion. So, a lot of pharmacists, I know, are starting to give their patients [surveys on] satisfaction. Can they come in to pick up their prescription? Did you get it in a timely manner? Were there any delays? Were you counseled appropriately? Were you satisfied with that? So that's something that we are looking at to see how we can measure that.

Hippensteele: That's fantastic. So additionally, I'm curious about your thoughts on the greatest challenges facing community oncology pharmacists in terms of policy changes and updates in 2025. What are your thoughts?

Alberto: Yes, so we do have a few challenges coming up for 2025. I think the first one is the low reimbursements that the community oncology pharmacies have been seeing, and so unfortunately, they're underwater on a lot of their medication. Coupled with that is some of the utilization management tools payer mandates that also impact that, and so you may not have a choice but to use either a biosimilar, a brand, or generic that is underwater. And so, you're forced to choose that, and it's causing a lot of problems for our pharmacies to the point that they may not be able to keep the lights on because they're so underwater for the reimbursements. That's the biggest thing. The biggest challenge, I would say, that we're seeing.

Next to that is PBM reform. And so, a lot of our PBMs, the top 3 PBMs make up 80% of PBMs. So, there's not a lot of choices there either. And we're seeing that a lot of prescriptions are not being retained in the community oncology space. They're being taken by the PBMs, whether it's steering [as in] they're telling patients that they need to go to their pharmacy to get them filled, and that's a problem. Again, they're losing revenue. They're losing that profit margin, and that's a problem.

I think next in line would be the Stark delivery law. So, when the public health emergency ended and our community oncology pharmacies were told that they could not mail deliver their oral medications any longer, again, forced it over to the PBMs, and that's causing problems for patients [because] they want that choice. They want to stay with their community oncology pharmacy, and they can't, and again, the pharmacy is losing that profit margin and that revenue, and that's causing a lot of problems.

Hippensteele: Yeah. How about specifically the IRA? Could you tell me about the impact of the IRA on community oncology pharmacy?

Alberto: Yes, so one of the good things for the IRA is that our patients now have a $2000 cap for the year, and so we're very excited about that. Unfortunately, on the flip side, again, some of what the IRA is doing on the reimbursement side is not very equitable to our community pharmacy practices. And so, they're looking at this manufacturing fair pricing, this MFP pricing, that's taking the place of [average sales price] plus 6% for our Medicare patients. And so not only now is that going to even more affect your profit margin, but now it's a resource burden, because you have to split that inventory. So, what you're purchasing at acquisition price and what you're getting reimbursed [for] will be different for Medicare patients and non-Medicare patients. So, it's really going to cause a burden on that as well.

We're also a little bit concerned about when the patients come in, who's likely to benefit from this new IRA Medicare prescription payment plan that we know with the capping and with them being able to spread their $2000 over 12 months. So again, a very good thing for the patient, and we're very excited for that, but we're nervous that, you know, what will that actually look like when patients start to come in. Who will be eligible for that? Who's likely to benefit? So that information should be coming from the payers, PBMs, and we have to educate the patients. And so, we're waiting to see now at the beginning of 2025 what that will look like for the pharmacies, resource intensive again, and trying to help the patients through this. Also, if they don't make a payment, then they're no longer allowed in the program, and so we have to deal with that [as] the pharmacist again. We're not sure how the patient will be notified if they'll come in expecting their medication. So, we know that that's going to be a problem as well.

Community pharmacists are very concerned, and physician-owned pharmacies are very concerned about the IRA, that that could be kind of the last punch that may turn the lights off again, may put them completely underwater, and then we may see that they're bought out by hospitals and consolidation, and that's not something that we want to see. We want our patients to have a choice. Patients want to stay in their community and with everything that we've discussed that may not be possible.

Hippensteele: Right. How about some of the trends that you're observing related to AI and machine learning models. So, I know we've been discussing some of the challenges, but that does seem to be somewhat of a—with some caveats—bit of a bright spot on the horizon. What do you think? How is that currently being used in community oncology pharmacies, and what might be the future of that?

Alberto: So, we definitely have a future in AI. There's no doubt. It's here to stay, and that is a good thing. I think we have to be careful, because we don't know yet how reliable, how accurate [AI is]. So, a lot of our practices are starting to pilot different AI practices. So, [we’re] cautiously optimistic.

So sometimes what we're seeing pilots in a scribe in clinical decision making within the clinic. And that's very helpful, very helpful to the whole team that these notes are planned out, and every visit they're updated appropriately. And that's very encouraging. It will help the pharmacist and the nursing team to be able to see what the patient will be on, what their therapy is, and then they can accurately check that. I think that there's also a lot of AI in drug interactions and what are the dose modifications. A lot helping the pharmacist kind of free them up now. They can see patients, they can see their families, and do education, and we talked a little bit about educating the team. I think this will help free them up to do education in that way as well. They're already using some data analytics and AI to do infusion and on the oral side pill counting, and they have machines that can help with that. Again, freeing up the pharmacist. But at this point, we're cautiously optimistic and looking to the future to see what else could come out to help us. But encouraged by it.

Hippensteele: Yeah. Any closing thoughts? Anything that you are optimistic about on the horizon for community oncology pharmacy?

Alberto: I think overall, we're very optimistic about what 2025 will hold for policy changes. Not everything we wanted in the end of year packages did come through. But we're confident that with enough of our community practice members getting involved on the hill, helping us to look at those policy changes, look at what the benefits can be, educating themselves on their state level and at a federal level, what the pain points are and how we can make it better, and working with COA, then we are optimistic that we can really educate our representatives in Washington and get some of these policy changes that we've been talking about with the hospital consolidation, 340B, vertical integration, a lot of that needs to change, and we know that our oncology practices are passionate about it, as COA is passionate about it. So, if there's anything that we want them to take home with, it's that please get involved. Let us work with you. Let us educate you on this, and let's work together to get these changes done in 2025.

Hippensteele: Absolutely. Thank you.

Alberto: Great. Thanks, Alana.