2020 Vision:

An Examination of the Oncology Marketplace and Oncologists Practices

A Publicis Touchpoint Solutions White Paper

2014 Publicis Touchpoint Solutions, Inc.

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

2020 Vision: Focus on Oncologists

Introduction
Cancer was responsible for 577,000 deaths in the United States in 2012, and 1.6 million new US cases were
diagnosed. By 2030, new US cases are expected to total 2.3 million per year. For any biopharmaceutical
industry observer with lingering doubt about the size, growth rate, and importance of the oncology market,
the graphic below should settle the issue. In their June 2013 report, World Preview 2013, Outlook to 2018,
EvaluatePharma predicted that the growth rate for oncology products will eclipse that of all other categories
between 2012 and 2018. Moreover, by 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 secondlargest category (antidiabetics). Indeed, the dramatic expansion has begun already; IMS reports that the
oncology market grew by 7.3% in 2012 to $25.6 billion.

[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.

Unique Pressures Facing Oncology Practices

Oncologists are facing unprecedented pressures as both clinicians and business managers. Seven of the
leading pressure points are described below. Following each description is a list of related action steps that
leaders in the life sciences industry can take to support oncologists. These action steps are drawn from recent
ZS Associates and Health Strategies Group publications, as well as from our own Publicis Touchpoint Solutions
team.

Impending Oncologist Shortage

A recent study commissioned by the American Society of Clinical Oncology (ASCO) predicts that the demand
for medical oncologists will increase dramatically between now and 2020 as a result of a 48% increase in
cancer incidence and an 81% increase in people living with or surviving cancer. During this same time period,
the supply of oncologists is predicted to increase by only 14%. The study found that more than half of
currently practicing medical oncologists are age 50 or older and will reach retirement age by 2020. Medical
oncologists younger than 45 are also working fewer hours on average than those ages 45 to 64, exacerbating
the problem of an aging workforce. Based on these trends, the study concluded that there will be a shortage
of 2,500 to 4,080 medical oncologists by 2020.

Industry Action Steps:

1. Develop resources for use by the entire patient care staff, including NPs/PAs and infusion nurses.
Resources should include clinical information, pathway management, and patient management tools.
2. Provide support staff to help relieve over-worked HCPs. For example, consider deploying clinical health
educators (CHEs), credentialed life sciences professionals who provide nonpromotional education to
patients and caregivers, as well as adherence and persistency support.
3. Build tools and messages that are specific to oncologists needs. Younger oncologists tend to prefer
information on reimbursement and practice management, as well as how to engage with patients.
Older oncologists are more inclined to value clinical information and educational meetings.

A recent study commissioned by the American Society of Clinical Oncology

(ASCO) predicts that the demand for medical oncologists will increase
dramatically between now and 2020 as a result of a 48% increase in cancer
incidence and an 81% increase in people living with or surviving cancer.

Precarious Delivery, Reimbursement, and Pricing Environment

The practice of oncology relies on the so-called buy-and-bill model. Oncology practices typically purchase
the majority of the infusion-based or injectable therapies they will administer directly from drug wholesalers
or group purchasing organizations. They store the pre-purchased drug inventory onsite, dispense it to patients
via in-office infusion/injection, and seek reimbursement from private and government payers and from
patient co-pays or co-insurance. This is a crucial revenue stream; in many oncology practices, up to 80% of
revenue currently comes from the buying and billing of drugs. Yet the buy-and-bill model faces multiple
threats, including white bagging and brown bagging.
In a white-bagging scenario, injectable drugs for a specific patient are shipped to and administered by the
oncologists office, but the practice never takes legal ownership of the product. Instead, it simply becomes a
drop-ship location to which the drug is sent on behalf of the patient. The oncology office is not buying and
billing the product, and receives no revenue. Whats more, the physician office is tasked with storing the
product for the patient, requiring time, effort, and space, which are not reimbursed.

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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.

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.

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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.

Industry Action Steps:

1. Guide field-based teams to start developing meaningful relationships with their clinics billing and
reimbursement personnel in order to help them make informed reimbursement decisions.
2. Provide more support and information on product reimbursement to patient financial counselors and
office managers.
3. Ensure that oncology specialty sales representatives have a thorough knowledge of product
reimbursement issues.

Increased Use of Clinical Pathways

Clinical pathways are decision-support tools that use established clinical guidelines and other resources to
determine the most efficient, least toxic, and least costly treatment pathway for a particular cancer. Clinical
pathways are published by independent, third-party organizations and aim to standardize cancer care across
the spectrum of care settings and disease states.
Kantar Healths 2012 survey of managed care organizations showed that 24% of payers already had a pathway
program in place, with an additional 45% considering implementing a program in the next three years. More
than a half-dozen companies including The US Oncology Networks Level I Pathways, Via Oncology, Eviti,
New Century Health, Cardinal Health Specialty Solutions/P4, ICORE, and AmerisourceBergen/ION Solutions
currently publish competing clinical pathways.

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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.

Industry Action Steps:

1. Ensure that the sales team understands which pathways are most utilized in their market.
2. Engage regional opinion leaders and other points of influence for pathway developers.
3. Deliver carefully honed messages that include pathway alignment or use.
4. Deploy specialized team members to provide key advocacy groups with information about the

product(s) and comparative use.

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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.

Industry Action Steps:

1. Train representatives on all aspects of the product, its formulary status and reimbursement, the
competition, adherence challenges, etc.
2. Arm the customer-facing team with decision-making tools and other resources that can help
oncologists navigate complex regimens.
3. Develop specific educational tools for the office staff on how to manage patients during therapy and
how to address treatment complications.
4. Take greater care to learn which factors influence patients acceptance and adherence to therapy.
5. Provide more tools, such as contact centers, social networking sites, and other resources to help
support caregivers and patients.

[I]n 2000, just one product was approved to treat renal

cell carcinoma; by 2012, eight products were approved.

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Increase in Availability and Use of Oral Agents

Oral cancer treatments have flooded the market since 2000, and are forecasted by EvaluatePharma to account
for as much as 43% of the oncology market by 2018. The availability of oral agents can vex an oncology
practice in at least two important ways. First, they complicate the therapeutic mix, especially for leukemias
and lymphomas. Second, they can wreak havoc on a practices cash flow and profit by reducing the volume of
in-office, buy-and-bill infusions and injections. However, some clinics have begun offering in-office dispensing
of oral agents, a practice that can be profitable financially and can offer profound benefits with regard to
patient/staff communication, patient/caregiver education, and medication adherence rates.

Industry Action Steps:

1. Provide robust adherence programming that oncologists can recommend to their oral-agent patients.
These programs can range from typical dosing and refill reminders to online and phone support to inhome clinical health educators.
2. Consider offering support to community clinics that are considering in-office dispensing.

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Shift Toward Hospital-owned Practices

While as many as 85% of US cancer patients have been treated historically in their own communities in private
clinics and small hospitals, future cancer care will increasingly be provided in hospital-owned clinics. In its
2012 Trends Report, the Community Oncology Alliance noted that 50% of reporting community oncology
practices have closed or have been acquired/managed by hospitals. This has important implications for the
industry, since hospital-owned medical practices tend to be more restrictive than those owned by physicians.

Industry Action Steps:

1. Rethink the approach to academic institutions and large practices. Some companies are piloting new
account management models that increase the customization and relevance to large customers.
2. Provide representatives with enhanced training, well-developed institutional strategies, appropriate
messaging, and expert resources. Prove to decision makers that your sales team offers real value to
the clinical team.
3. Develop new methods of communicating with customers, such as eDetailing, live video detailing, and
mobile applications.
4. Take a more holistic approach to account-level planning; explore the structure of hospital-owned
practices/groups to learn where decisions are actually made.

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Restricted Access to Industry Resources

All types of oncology practices including physician-owned practices are increasingly restricting access to
life sciences sales representatives, a choice that can deprive oncologists of valuable educational and practicesupport resources. According to the 2013 AccessMonitor from ZS Associates, oncology remains the most
restrictive specialty for pharmaceutical sales representative access. Moreover, the trend is toward further
restriction. The 2013 ZS survey reported that about 65% of US oncologists placed moderate-to-severe
restrictions on visits from pharmaceutical sales representatives, more than any other specialty. This is
compared to 17% of oncologists restricting access in 2008. The access issue is paramount in many minds. In
a national survey of industry experts, oncologists, and payers, inability by a sales representative to see an
oncologist was cited as one of the most concerning trends in commercial oncology.

Industry Action Steps:

1. Customize the portfolio of products that each sales representative carries to become more customer-focused.
For example, some companies have evolved their product-focused sales teams to become more tumor-focused.
This enables them to tailor their offerings to particular treatment areas of interest to each oncologist.
2. Develop new, innovative customer engagement models designed from the perspective of the customer.
3. Expand marketing to mid-level practitioners, who may play a more significant role in caring for oncology
patients.
4. Monitor face-to-face interactions with office staff and oncologists for value.
5. Maximize high access opportunities (eg, Phase III trials, product launch, new indication, major reimbursement
changes) to develop relationships with oncologists.
6. Enhance sales representatives value by increasing the number of patient support tools they can leverage. Help
representatives become partners with oncology practices to support improved patient outcomes.

According to 2013 data from ZS Associates, oncology remains

the most restrictive specialty for pharmaceutical sales representative
access. ZS found that about 65% of US oncologists placed
moderate-to-severe restrictions on visits from pharmaceutical sales
representatives, more than any other specialty.

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Adjusting Communication Teams to Meet Oncologists Needs

As part of their ongoing process improvement efforts, many life sciences companies are beginning to adjust
their communications teams to better meet the needs of oncologists. Those adjustments typically begin with
improvements to the sales force.

The New Oncology Sales Representative

The new oncology sales representative must be equipped to navigate a multitude of challenges. In order to be
successful, the following qualities and characteristics are indispensable:
Science-focused Education/Training: Oncologists respond well to sales representatives with:
Science and/or medical training, such as advanced degrees in health sciences
Recognized credentials, including former nurses and pharmacists
Significant experience in pharmaceutical sales
Companies need high-level, exceedingly well-trained sales representatives who can analyze and interpret
complex cancer-related information and then educate physicians on the practical relevance of the latest
clinical research. Sales representatives must be able to understand and communicate easily the intricacies of a
high-science product, market, and disease state.

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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.

The new oncology sales representative must be equipped

to navigate a multitude of challenges.

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Blended Communication Teams

In addition to fielding high-quality oncology sales teams, many life sciences companies are beginning to
implement blended communication teams; we believe these teams will be the norm by 2020. Blended teams
typically consist of a traditional field sales team plus some combination of the following nontraditional
communication teams:
Clinical Health Education Teams:
Clinical health education teams are staffed with credentialed healthcare professionals (frequently nurses, but
could include other professionals as needed). Clinical health educators can work with physicians and their
staffs and/or directly with patients (with the agreement of both the HCP and patient). The objective of any
clinical health education team is always to improve health outcomes through improved education.
Hybrid Sales Representatives:
A newer representative type includes hybrid sales representatives, who have defined geographic territories
but can reach HCPs through each HCPs preferred channel (face-to-face in field, live video, and/or phone) and
at the HCPs preferred time (including after hours and weekends). The hybrid representative concept blends
the best of both worlds a consistent, personal representative combined with the flexibility to time shift and
communicate through both tangible and virtual channels.

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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.

In addition to fielding high-quality oncology sales teams, many life

sciences companies are beginning to implement blended communication
teams; we believe these teams will be the norm by 2020.

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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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2014 Publicis Touchpoint Solutions, Inc.

00108292014