How Biosimilars Will Fare In Integrated Delivery Networks
By Anna Rose Welch, Editorial & Community Director, Advancing RNA
In the biosimilar industry, it often feels as though the market is taking shape both rapidly and eternally slowly. The past few months, my pipeline of interviews has been full, research reports have been released, and I jumped on a plane to broaden my focus in Bangkok, Thailand for a week. As such, it’s not unusual for me to return to the office and find notes from conference panels held months ago I was hoping to write about at the time, but that got lost in the shuffle. But what I often find in reviewing these notes is that not a whole lot has changed to render the experts’ comments inapplicable to the current market.
Such is the case with this article, which draws from a panel I attended at the CBI 12th Annual Biosimilars Summit. Though the panel took place in January, there are still many questions — and a surprising lack of articles — dedicated to how biosimilars will fare in integrated delivery networks (IDNs) and retail pharmacies.
As I discussed in a wrap-up article from the conference itself back in January, one of my takeaways was that 2017 was going to be a standstill year. Payers, who have been heralded as the gatekeepers to high uptake, emphasized their current watch-and-wait plans. And when it comes to retail pharmacies — in particular, Walmart — and the UVA Health System (an IDN), it’s clear these different systems are also still in the watch-and-wait phase.
Following are some thoughts I had about the current presence and role of biosimilars in these different types of organizations, as well as how the structures of the organizations themselves could impact the uptake and prominence of biosimilars. One of the biggest takeaways I had after hearing from the experts working in the IDN and retail pharmacy setting is that each has a decidedly different stance on biosimilars: one is cautious, the other confident. In the first of this two-part article, I address the current “cautious” biosimilar climate in one IDN and some of the challenges hindering uptake.
Inside An IDN: UVA Health System’s Biosimilar Approach
The IDN that often takes the spotlight in terms of biosimilar experience is Kaiser Permanente. As of last year, the organization had upwards of 95 percent uptake on Zarxio. But having learned more about another IDN — the UVA Health System — it would seem Kaiser is one of the more aggressive organizations in terms of biosimilar uptake.
According to Noah Greenberg, a pharmacist in specialty medication services for UVA Health System, the institution’s current strategy, like many others, is to watch and wait. This is partially because of the way the organization is structured. In order for a drug to be approved to the hospital formulary for in-patient care, it has to be reviewed by the IDN’s Pharmacy and Therapeutics (P&T) Committee. The real challenge to getting a biosimilar on this formulary will be the education of the system’s physicians. In order for a biosimilar to be reviewed by the P&T committee, a physician will need to recommend it.
However, the type of biosimilar — supportive care vs. therapeutic — will likely be a major influence in a doctor’s decision to promote one, at least in the beginning. For instance, according to Greenberg, biologics are not heavily used in in-patient settings because of poor reimbursement. But for a product like Zarxio (filgrastim), which is a supportive care product rather than a chronic, long-term therapeutic like Humira or Enbrel, there might be a more proactive attitude by doctors.
Greenberg argued physicians will likely feel more comfortable switching a patient to a supportive care biosimilar because there’s an immediate measurable response. The patient’s white blood cell count will either increase if the treatment is effective or will not be affected at all. (In fact, Greenberg referenced one situation in which he couldn’t get Neupogen covered. He suggested Zarxio or Teva’s quasi-biosimilar Granix to a doctor, who, without pause, said to get whichever version of filgrastim they could.) Greenberg argued the same comfort would likely translate to erythropoiesis-stimulating agents (EPAs) as well.
When it comes to the cancer realm, however, patient response is not going to be as immediate or as easy to measure, especially when it comes to the different indications. Cancer care requires multiple months and treatment cycles. And, even though a chronic-care drug taken for a life-long condition like Crohn’s disease or colitis affects a patient’s quality of life, there is very little threat of mortality as there is with cancer.
Even for Greenberg, there was clearly discomfort over the notion of using a biosimilar — for instance, rituximab — in the treatment of cancer. “If I’m talking about choosing for a family member a product that’s been out there for 10 to 12 years versus something that just got approved, especially for extrapolating an indication, I might push my physician to go with the brand versus a biosimilar,” he explained.
Besides the obvious need for education, it’s also important to note that some hospitals, including UVA Health System, have a 340B program. Because of this program, there are a number of costly biologics distributed on the outpatient side that already have, as Greenberg called it, an “advantageous” price tag. Since a big value proposition of biosimilars is their cheaper cost, the lower pricing of the reference product could be enough to keep the originator in play. Now, this isn’t to say that a physician couldn’t write a prescription for an Enbrel or Humira biosimilar to be filled at a Walgreens or CVS pharmacy. A patient just couldn’t have those biologics administered in a UVA physician’s office.
But overall, Greenberg warned that biosimilar products of Humira and Enbrel, for instance, could find 340B programs to be yet another hurdle to usurping their reference product competition.