Sarah Wheeler, PharmD, BCOP, clinical pharmacy specialist in Hematology/Oncology at UF Health Shands Cancer Hospital, discusses how oncology pharmacists can help their patients overcome some of the barriers patients with cancer may encounter during treatment.
Pharmacy Times interviewed Sarah Wheeler, PharmD, BCOP, clinical pharmacy specialist in Hematology/Oncology at UF Health Shands Cancer Hospital, on her session at the Hematology/Oncology Pharmacy Association 2022 annual conference session titled ‘And The Title We Didn’t Train for: Navigating the Balance Between Being a Caregiver AND an Oncology Pharmacist.’
During this discussion, Wheeler addresses what the oncology pharmacist’s responsibility is to their patient in helping them overcome some of the barriers patients with cancer might encounter, and whether methods to address these responsibilities are discussed during oncology pharmacists’ training and education.
Sarah Wheeler: So, I think there's one thing when you're asking about responsibility of oncology pharmacists, and then the training for oncology pharmacists—do we get trained to do half of the responsibilities that end up on our plate? And the answer is no, we don't.
A lot of it is something that we figure out as we go along. So pharmacists, in general, in my opinion, are problem solvers. That's partly why we became a pharmacist, we like to be able to solve problems. We're okay with not always getting all the accolades, as you think about the pharmacy profession in general, kind of starting behind the counter and helping and doing things. We've kind of been that way of always being there, always kind of behind the scenes, fixing things, solving problems—that's our go to.
So when people need a fire put out, it's usually the pharmacist they go to. So we have a lot of responsibility, and a lot of it is outside of our job description, in some ways—and school doesn't prepare you for it.
So school does a good job of preparing you for the black and white, normal kind of things like, ‘Hey, this medication is used for this, if they're creatinine clearance is this, dose reduce,’ like they do a good job on that like drug-drug, you match those things up—absolutely. But the real-world logistics is something that I don't think any school prepares you for. We talked a lot about even the medical teams that I work with, with the physicians, even with our social workers, even with our case managers—that some of the logistics, social issues, day to day that we're dealing with, and really take our most time stuff that we've learned being in practice and it’s not anything that we've been taught about.
So, for me, I think one of my responsibilities, to the patient is making sure they can get their medication. So often, when I'm in rounds with providers, I'm like, ‘Hey, did you do a test claim on this? Do we know how much money this medication is going to cost? This is usually expensive medicine, they probably need a prior authorization, let me do this, let me do this.’
I know other teams where they don't have a pharmacist will just send the prescription to the pharmacy, and the patient will just show up and won't be ready. I think this is one of my roles being a pharmacist is to make sure that patient is leaving here either with the medication in their hand, or I know darn well that when we get to the pharmacy, it's affordable and the pharmacy’s going to be able to fill it. So that's one of my personal responsibilities that I take on is I want to make sure that every patient has what they're supposed to have to be able to treat them—that's one burden I can take off them. I can worry about getting all the medication stuff taken care of for them.
So, right now, we have a patient that is really taking a lot of time to try to get these medications for them and navigating through the insurance because that's one thing they don't teach you is how do you do a prior authorization, what are the kinds of things the insurance company is going to need, how do you write a letter of medical necessity, who do you write a letter of medical necessity to, [and] how do you get it to them? In the appeal process, sometimes it's very easy to know who to send these things to, but if you're trying to do it up front […] to get things approved to try and speed it up, that can be a little bit harder.
Some insurance companies are very easy to work with, and some of them aren't. From a medication standpoint, there's some that can be filled at your local neighborhood, corner pharmacy, whereas others have to come from a specialty pharmacy, and there's other medications that are limited distribution, so only certain pharmacies can.
The limited distribution ones can be a pain because, for example, there's a medication that can only come from Walgreens Alliance Rx. So anybody who has insurance that's contracted with like CVS or CVS Specialty, the insurance blocks it and says no, you have to fill out CVS. Well, CVS doesn't carry that medication, [so] we had to call the insurance and get an override to allow for this one of the distribution medication to be filled at a Walgreens, when ordinarily they want CVS. So that's a whole other timeframe that we have to do. So you have to get that approval, and then you have to get approval for the drug, and so there's all these different steps. In school, they make things so much easier, kind of like this is the medication you need for this, it's going to be approved—when it’s really not.
Then the cost of medications is a whole other barrier. Even for people who have insurance, I have a patient who—the one that I was just talking about—medications are super expensive. So having to work through those, getting insurance to pay for them, number 1, and then figuring out a way to get the co-pays down is a whole other thing.
I have another patient who owes $2300 a month for his medication that's going to be like a lifelong medication. So figuring out how do you make that to where they can get that every month is frustrating. Some of the companies have great patient assistance programs where you're able to do that, other ones don't depending on if you have government funding, depending on if you have commercial funding, [or] if you don't have any funding.
So there's a lot of different channels and ways to navigate through this but you really learn a lot of it on the fly. It's not something that I feel like school does a great job preparing me for, but to schools’ defense, I don't know how they could because when we're all in pharmacy school, we're all going through different branches, and we all have different responsibilities.
So, being a community pharmacist, you have one set of responsibilities; a hospital pharmacist, and you have another; in clinic, another; a specialty pharmacist, another; a nuclear pharmacist, another. A critical care pharmacist is going to do something different than me as an oncology pharmacist. So, I do think that's going to be hard for schools, but maybe occasionally having a couple of cases about how you can potentially navigate through some of these things, or at least a little bit more awareness on some of the social issues I do think would be beneficial.