By Anna Rose Welch, Director, Cell & Gene Collaborative
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Earlier this summer, Cardinal Health released a report entitled, “Rheumatology Insights.” Over the past few years, we have welcomed studies showcasing the growth of biosimilar knowledge in physician populations across nations and therapeutic areas. Such surveys have played a critical role in uncovering remaining knowledge gaps in specific populations. Given how difficult it has been to establish infliximab biosimilars on the U.S. market., Cardinal Health’s survey of 100-plus U.S. rheumatologists was a more-than-welcome update on where that space stands.
In a previous article, Atrium Health rheumatologist Dr. Gordon Lam shared his perspective on the work remaining for those striving to educate and successfully market biosimilars in rheumatology. The survey revealed some good news: knowledge of biosimilars among rheumatologists has grown to the point that a vast majority (98 percent) are at least very familiar to somewhat familiar with biosimilars. The theoretical willingness to use biosimilars in this population is also high, with 90 percent of those surveyed saying they would be comfortable in doing so — especially in new patients or existing patients following a payer mandate. However, as Dr. Lam pointed out, uptake will likely remain slow until there are more decisive payer policies (i.e., less parity) and stiffer price competition.
I had the opportunity to continue this conversation with Sonia Tadjalli Oskouei, VP of Biosimilars for Cardinal Health. Tadjalli Oskouei’s former role as director of pharmacy program development and biosimilars for Premier put her in a great position to discuss how she’s seen the biosimilar opportunity in the rheumatology space progress. From some of the earliest days of the U.S. biosimilar market, she has published a number of resources on factors affecting health care provider knowledge and acceptance and how biosimilar makers can best work with health systems to seamlessly incorporate their products.
I wanted to learn more about her biggest takeaways from this newest data, in particular how she would use the survey findings as a jumping off point for Cardinal Health (with its manufacturing partners) to improve biosimilar education and engage the rheumatology community.
Experience-Sharing Critical For Building Clinical Confidence
In the past few years, the biosimilar industry has talked ceaselessly about the need to educate all stakeholders — whether that be defining biosimilarity, the regulatory pathway, or terms like extrapolation, switching, and interchangeability. In 2016, when I penned what would turn into the first of an annual “Top 5 (or 6 or 7) Biosimilar Developments of the year” series, one of the biggest evolutions in the space was increasing physician comfort with extrapolation. Those who attended the FDA advisory committee meetings for Erelzi and Amjevita will know just how big a deal it was for certain therapeutic communities to understand and accept extrapolation in the beginning.
Given the results of Cardinal Health’s survey, it would seem these concerns are still lingering in the rheumatology community. According to the data, 45 percent of surveyed rheumatologists said they were comfortable with the FDA approval process as long as there was clinical trial data to substantiate the biosimilar’s safety and efficacy. Interchangeability and extrapolation remain concerning to these surveyed physicians.
This was one of the most surprising aspects for Tadjalli Oskouei upon reviewing the data. “We hear so much about the challenges for uptake posed by payer policies and the reimbursement landscape that we often take for granted that safety and efficacy concerns persist in provider populations,” she explained.
As many of us are aware, no therapeutic areas are created equally. While the oncology space is blossoming and biosimilars are being more widely embraced, rheumatology has been a tricky space in which to establish a solid foundation. Though there have been widely publicized positive experiences with biosimilars in other therapeutic areas, rheumatology has seemingly remained an island unto itself. This is one aspect Tadjalli Oskouei believes wholesalers will be able to change with future educational initiatives.
“In many of the early conversations I’ve had in this space, as well as the conversations I’ve had with rheumatologists since the release of this survey, I’ve learned that a lot of the education they receive comes directly from the manufacturer. There’s a much bigger opportunity for wholesaler organizations, like Cardinal Health, to engage with their provider networks and approach education in different ways.” Beyond the basic biosimilar education around the pathway and extrapolation, she believes that communicating biosimilar experiences from practices that have realized greater financial sustainability should be used to build clinical confidence.
Experience sharing has proven to be a successful strategy in Europe and certain U.S. healthcare systems. A great conference panel at a 2019 European conference highlighted that one of the sure-fire biosimilar education techniques in EU hospitals has been to encourage cross-collaboration amongst physicians of all different specialties. This strategy has played out well for the U.S.’ Kaiser Permanente system as it increased its own biosimilar usage. In the Articularis Health Group, 40 rheumatologists had regular meetings to learn how their peers were using biosimilars — an effort that quelled lingering clinical concerns and raised awareness of sustainable prescribing habits.
Tadjalli Oskouei pointed out that wholesaler organizations can be better aggregators of peer-to-peer experiences in U.S. rheumatology, especially given their close relationships with clinics and hospital networks.
What Additional Knowledge Is Necessary To Improve Uptake In Rheumatology?
In addition to creating forums for information and experience sharing amongst practices, Tadjalli Oskouei also pointed out the importance of helping practices — particularly small practices — understand the financial aspects of the biosimilar puzzle.
In many of the larger and/or integrated health systems, Tadjalli Oskouei pointed out that pharmacy and therapeutics (P&T) committees play a large role in educating providers and evaluating the product from a clinical and financial standpoint. Pharmacist teams typically create the necessary framework for guiding physicians to the necessary products via formulary decisions and EHR system implementation.
Smaller practices or independent clinics, on the other hand, are likely to have limited support when making internal formulary and treatment decisions. As she explained, many of these practices may have only one administrator tasked with evaluating and making the practice’s financial decisions. In fact, a recent MJH Life Sciences webinar highlighted just this: many of the “unsung heroes” are the financial teams broaching the cost implications for patients transitioning to the biosimilar.
However, as multiple biosimilar products for each originator continue to launch, the financial implications and discussions with patients become even more complicated to manage — especially given the U.S.’ fragmented payer landscape and product preferences (vs. parity). This is one area that Tadjalli Oskouei highlighted as an ongoing educational need from wholesalers and manufacturers. In addition to the clinical profile of a biosimilar, there could also be more resources outlining the current payer coverage for each manufacturers’ product. (In fact, this was one of the resources the MJH panel of physicians highlighted as a particularly valuable resource for manufacturers to provide these days, as well.)
Overall, there is a great need for resources that administrators and practices can use to analyze and understand the financial impact of product selection and certain prescribing patterns on a practice and its patients. After all, as Tadjalli Oskouei concluded, “There seems to be a theoretical comfort with the concept of biosimilars and integrating them into a practice. However, it’s clear from current uptake numbers and the concerns expressed in this survey that actually implementing biosimilars into practices remains a whole different ballgame. The practical aspects of biosimilar integration into practices is deserving of our attention moving forward so providers and their staff know what decisions will make the most financial and clinical sense for their practice and patients.”