Dr Colby Evans: The Managed Care Perspective on Biosimilars in Immunology

Colby Evans, MD, a dermatologist at Evans Dermatology Partners and a co-author of an The American Journal of Managed Care® supplement “Biosimilars for Immune-Mediated Inflammatory Diseases: 2022 Update,” highlighted the managed care perspective on using bioismilars in the immunology space. This written Q&A is part of a series and references the article titled "Biosimilars for Immune-Mediated Inflammatory Diseases – A Managed Care Perspective"

How can managed care organizations (MCOs) play a role in overcoming the barriers to the adoption of biosimilars in the US healthcare system and promoting their utilization?

Evans: Aligning incentives with what is best for the patient is how medical professionals and managed care organizations can best utilize biosimilars. Since biosimilars are, by definition, not new or superior treatments, other strategies are required to interest the patient and provider to utilize them.

Lower co-pays, less extensive (or eliminating) prior authorization, or easier access will give patients and their doctors a reason to pursue these treatments which can then lower cost for the system and improve access overall. Without these incentives, patients are simply being offered a similar drug at the same (out-of-pocket) price, why would anyone want to switch in that setting?

What are the potential cost savings associated with the use of biosimilars in immune-mediated inflammatory diseases, and how can MCOs optimize cost-effective strategies while maintaining patient safety and quality of care?

Evans: Although the retail price of biosimilars are not enormously less expensive than reference drugs (as is often the reverse for tablets and generics), the potential for costs savings is still quite large. Not only do biologics represent a disproportionate portion of the overall pharmaceutical expense compared to traditional drugs, their use is growing rapidly across every specialty in medicine. As biologics become the standard of care for new diseases of every sort, in the long-term biosimilars will be a key component to maintaining patient access to the best care.

What are the best practices for MCOs in managing the introduction and utilization of biosimilars in immune-mediated inflammatory diseases, including strategies for formulary design, utilization management, and patient engagement?

Evans: Best practices for biosimilar introduction and use are still evolving, especially in the United States where uptake lags compared to European health systems. A careful review of the authorizing studies is a good place to start, followed by patient support systems and tiering that offer patients and providers a reason to choose the biosimilar. Simply getting FDA approval and putting it on the market at a lower retail price, which might work with a generic, has not proved successful so far in the United States.

Consider what motivates the patient, often their biologic is the first thing that has ever dramatically helped a life-altering medical problem. Understand their reluctance to change from a reference drug in that setting and offer education and incentives to help them see the benefits to each choice.

How can MCOs collaborate with healthcare providers, patients, and other stakeholders to ensure the successful integration of biosimilars into the management of immune-mediated inflammatory diseases, including strategies for education, communication, and shared decision-making?

Evans: Although some education of health care providers has been done, more is needed to help front-line prescribers understand the safety and efficacy of biosimilars. Education, while needed, will not alone move the needle on biologic uptake. Providers need incentives to utilize biologics, if the efficacy and cost to the patient are the same either way, there is no motivation to consider switching. Decreasing red tape (like prior authorizations or step therapy) for biosimilars and making sure that the patient out-of-pocket cost is low are excellent first steps.

How are MCOs preparing for the stocking and management challenges are expected to arise with have so many biosimilars referencing the same drugs, such as what is likely to happen in the adalimumab space?

Evans: The most successful reference drugs are naturally likely to have many biosimilars eventually available. Although every plan is unlikely to offer every variation of a biosimilar, having a robust and reliable distribution network—or partner—is critical to maintain patient access and good care. It certainly may be reasonable to offer more than 1biosimilar of the same reference drug during their initial availability until the market dynamics settle.

What lessons can be learned from other countries or regions that have successfully adopted biosimilars, and how can those insights be applied to improve the adoption of biosimilars in the United States from a managed care perspective?

Evans: Biosimilar uptake has been most vigorous in “top down” systems where the payers, usually European governments or the Veterans Affairs system in the US, benefit directly from the savings lower down the supply chain. Although remaking the US health care delivery system is not likely, learning the lesson of these systems is critical. Employers or other purchasers of insurance, pharmacy benefit managers, insurers, providers, pharmacies, and patients must all share in the benefits biosimilars offer or uptake will remain slow.

What regulatory and legislative changes may be needed to address the complex financial mechanisms that distort the healthcare market in the United States and ensure that patients can access affordable and effective biosimilars?

Evans: Transparency across health care and pharmaceutical payment would help address the challenges of biosimilar uptake. If individual links in the health care payment chain can siphon off the cost benefits of biosimilars while leaving no benefit for the patient, ultimately it will be difficult to justify their use.

How can increased transparency in drug pricing, rebates, and fees empower prescribers to make value-based decisions that prioritize the best interests of their patients?

Evans: Speaking as a provider, it feels almost impossible to know in real time what the cost of a given prescription will be to the patient, especially when this cost or even access to the recommended treatment cannot even be calculated until prior authorizations have been completed. It is also impossible to know the myriad web of costs, rebates, deductibles, and other factors that control not only the cost to the patient but also to the system at large. Transparency across the system would provide doctors the ability to make the best and most cost-effective care decision with their patients.