One Canadian Payer's Experience With Biosimilars

This story has been edited.

Much of the discussion about biosimilar uptake revolves around challenges in the United States, but other areas of the world are also working toward adopting these cost-saving products and are encountering challenges along the way. During the BioTech Pharma third annual Biosimilars and Biologics Summit, held March 21 to 22 in Porto, Portugal, Ned Pojskic, leader of pharmacy and health provider relations at the not-for-profit Green Shield Canada (GSC), the fourth largest private payer in Canada, discussed his organization’s efforts toward broad biosimilar adoption.

“The Canadian experience has been an incredibly dynamic one,” said Pojskic, who explained that Canada has a publicly funded healthcare system in which hospitals and physician services are covered under the national plan. However, prescription drug coverage is split between public coverage (for those over 65, in long-term care, or without income) and private, employer-based coverage (for all others).

Traditionally, Canada has had high per capita drug spending, with its costs coming in just behind Switzerland and the United States, and far outpacing European nations like Sweden and Norway. Overall spending on drugs reached CAN $40 billion (approximately US $30 billion) for 37 million people in 2018; said Pojskic, “a lot of that is driven specifically by biologics.”

One reason for that fact, he noted, is that the mostly costly drug for the healthcare system, brand-name infliximab (Remicade), has a higher list price in Canada than anywhere else in the world. Pojskic said that Canada comprises approximately 20% of the global market for Remicade, in terms of sales, despite having only 2% of the global population of patients taking the drug. And while just 0.6% of GSC’s membership receive biologics, these patients’ therapies are responsible for 22% of drug costs.

For the biosimilars that have entered the Canadian market, discounts have ranged from 17% (for Grastofil, a biosimilar filgrastim referencing Neupogen) to 50% (for Renflexis, a biosimilar infliximab referencing Remicade). “Prices are all over the place," but the big story in Canada has been Renflexis’ discount on Canadian drug with the highest annual spending, he said.

In addition to short-term savings through biosimilar discounts, said Pojskic, GSC took a long view on biosimilars, and asked itself “what kind of market forces are we stimulating by ensuring that we prefer biosimilars?” He noted that, when new drugs in a thearapeutic class come on the market, they will have to compete against the price of biosimilars that are already available, and “these are all very positive market forces,” he said.

Biosimilars have gotten a boost on the public payer side from Canada’s health technology assessment body, which made public the results of its price negotiations. Public plans have also effectively delisted brand-name Remicade, he explained, and patients are offered only a biosimilar. Private plans have been sluggish to take such bold action, however; Pojskic explained that most private payers have signed deals with originator product developers to keep originator biologics on their formularies, and Canadian physicians “simply choose the originator. That’s the Canadian experience.” GSC was “pressured to take that deal,” said Pojskic, “but we chose not to do that…. We would shut the market for biosimilars and not be serving the long-term perspective.”

GSC’s biosimilars strategy has been to list biosimilars preferentially, and all new starts must receive biosimilars. Once biosimilar penetration began to show successes, and once data on switching grew, transitioning existing patients to biosimilars became a strategy of interest for GSC. However, the payer has come up against a hurdle: a perceived lack of evidence on which to conduct a switch.

“One of the biggest battles we have is this notion that there’s not enough evidence…it’s just a tagline—if you say it enough, someone will believe it. Unfortunately, there’s been a lot of malicious activity by manufactures in the Canadian marketplace to distort the evidence. To pick out an individual chart from 1 study, to say ‘it looks like there’s a little concern here.’”

Another complicating factor is the fact that, in Canada, infusions are most often carried out in free-standing clinics, most of which are owned by Janssen and supply Janssen’s drugs, not biosimilars.

Despite resistance from the brand-name drug makers, GSC began a transition of existing patients to biosimilars of infliximab and etanercept. The program, which was optional for GSC’s clients, has been highly successful, as reported previously, and patients were largely accepting of the switch.

However, approximately 20% of GSC’s patients who were eligible to move to a biosimilar chose to remain on the reference drug. That raised questions about how patients were paying for the difference in price between the biosimilar and the reference: “what our patients told us [is that] they’re not,” said Pojskic. “The originator manufacturer stepped in and paid the difference for them so they could keep [the patients].”

Pojskic also noted that Janssen has offered Remicade for the price of 1 cent to many Canadian hospitals—a statement backed by results of a recent investigation—which provided substantial savings to the healthcare system and allowed new patients to be treated. Therefore, in GSC’s policy that only requires treatment-naïve patients to start with a biosimilar, these patients cannot be given a biosimilar unless they are taking part in a switching program “because you just came out of the hospital with 1 infusion.”

These challenges and the strategies of innovator product sponsors notwithstanding, Pojskic sees the effort toward adopting biosimilars as a necessary process. “I think 5 years from today, we’re going to look at biosimilar transitioning as a no-brainer…but we have to go through this.”