Market-Access Considerations for Biosimilars in Oncology

Bruce Feinberg, DO: Thanks for setting that up so well. It brings us to that conversation around market-access considerations. I wanted to involve Karina in this, because we’re starting to get a little more flesh on the bone. In that first segment, it was starting to sound as if we had this uniform, very optimistic response around biosimilars and their adoption, and it seemed to be out of sync with what the marketplace is telling us. In this last segment, we started to peel the onion a bit. We got a sense that it is more complicated than that. The stakeholders may be aligned philosophically, but perhaps not aligned operationally. That’s leading into some of that. Karina, help me understand at a payer level. You also have a complex situation, and you have to deal with your bottom line, as well as trying to make good medical policy. Help me understand that approach and why Kathy Oubre is conflicted. She also has multiple payers, not just 1 payer, but she has to try to make this decision of what’s best for her practice environment and if she can afford to stock multiple versions of the same drug. I’m curious from that payer side, so get me started here and we’ll all join it.

Karina Abdallah, PharmD: Thank you, Bruce. I completely agree. We’re starting to peel back these layers and realize the complexity. I’ll start by saying that I agree with what Kathy said. Bruce set it up really well in terms of, where are we sitting when we’re making these decisions? I think you brought up, Kathy, the marriage between your providers versus what the physician is saying on the clinical end and then what you’re going to do on your practice side.

Payers have a very similar setup where we’re kind of in the middle, as well. What we’re really looking for is our providers in not only our network of physicians but also large health systems. Looking at last year and into the future, where we’re going to really change and upset the market a bit with strategy is being a lot more collaborative. I think that is really what is missing and what has been missing.

What I’ve noticed in the industry so far has been almost a waiting game, in which the payer is looking to the large health systems where most of their membership is affected to see which product they are going to use. Are they going to stick with the reference? Are they going to go ahead and make a deal with the biosimilar? Vice versa, I think that the large health institutions and even smaller practices are also looking to the payer to make a decision, and without the collaboration that’s necessary, it really just becomes a waiting game.

Of course, we really haven’t touched on this much, but I think that’s a big segment of this and the decision-makers are largely affected. We talked a bit about contracting, but we have our colleagues in pharmaceuticals that are like the go-betweens. It does become a bit of a strategic game of what the other payers are doing, versus what the health systems are doing and what the providers and patients are going to tolerate in terms of pricing and contract. It is a bit cloak-and-dagger, but I do see that we are starting to move away from that and try to work together much more collaboratively. Looking to the past, I believe that is the biggest issue that caused a lot of the price setting and market share disruption that happened when biosimilars came in and didn’t get as big a market share as we were hoping for.

Bruce Feinberg, DO: Karina, while I’ve got you, I’m going to ask 1 more question because I’m curious. Payers, even in the US, have been fairly quick to look at infliximab in the rheumatologic space and started to mandate substitution, whether they were thinking about step therapy, tiering, and mandatory substitutions. Do you think there is a very different tolerance for that with regard to oncology?

Karina Abdallah, PharmD: Absolutely. You hit it on the head.

Bruce Feinberg, DO: If that does happen, it’s going to be much slower and in quite a bit of time. It’s not going to be a rapid change?

Karina Abdallah, PharmD: Yes, I completely agree with that. We look to infliximab. We at Blue Cross Blue Shield of Michigan had a really high adoption rate—a mixture between new starts using the biosimilar products versus switching over. We had fairly decent adoption. I will make a note that it is indication based, which then will lead us into your point, Bruce, about oncology being different. Even looking at different indications, we had the most work being done on both our side, as the payer, and the provider’s side in the gastrointestinal and pediatric spaces when it came to the infliximab biosimilars. We did spend a lot of time looking at clinicals, looking at postmarket research and studies, and even case-by-case, indication-specific differences. We did tailor our strategy according to that.

That brings up, again, what I mentioned. Looking at indication based, we are treating it as such and being a lot more collaborative with the high touch-point indications. Of course, oncology is 1 of them. One that is going to be coming up soon is rituximab. That’s going to be pretty big, as well as bevacizumab.

Bhavesh Shah, RPh, BCOP: There is a disproportionate market share between nononcology drugs versus oncology drugs. If you look at the current market share for infliximab products, it’s about 14% nationally. Then if you look at the oncology market share for biosimilar adoption, it’s about 25% to 30%. There is definitely a higher and faster adoption because infliximab has been around for 40 years and it’s such a slow adoption rate. But with oncology, there is a much higher adoption rate for biosimilars, and I think 1 of the biggest payer examples is Kaiser Permanente. They have 12.5 million lives, and they’ve converted over 80% of their patients to biosimilars in oncology.

It really speaks to the difference in practice. Oncologists are probably more comfortable using biosimilars than nononcologists are, just based on the adoption rate that I’m seeing across the country.

Bruce Feinberg, DO: Those are pretty high numbers. They are surprising to me. I didn’t realize they were that high. It feels as if it’s awfully early to make those kinds of estimates. Availability has been a matter of months.

Bhavesh Shah, RPh, BCOP: Yes. Kaiser Permanente actually publicized their data. Within 6 months, they were able to get that market share for bevacizumab when it was approved, and the same with trastuzumab. IQVIA is the company that publishes the market share. It’s on their website.