Part 1: Ryan Cox on What Employers Need to Do to Boost Biosimilar Uptake

The Center for Biosimilars® (CfB): Hello, I’m Matthew Gavidia. Today on MJH Life Sciences™ Medical World News, CfB is pleased to welcome Ryan Cox, vice president of the Access Experience Team at PRECISIONvalue. Can you just introduce yourself and tell us a little bit about your role at Precision Value?

Cox:Thank you. PRECISIONvalue is a market access marketing agency. We work with pharmaceutical manufacturers to help them launch and place their medications with payer decision makers by bringing our experience of helping drug launches and providing value perceptions to their products and helping them to maximize their commercial success.

As you noted, I'm part of a team called the Access Experience Team. We are something that's distinct in this industry in that we are a team of more than 20 prior key decision makers from payers, PBMs [pharmacy benefit managers], integrated delivery networks [IDN], health systems, specialty pharmacy, and the like. And we bring our expertise into helping to craft those messages and making sure that they resonate and are meaningful to those decision makers, whether it be at a health plan, a PBM, a specialty pharmacy, or an IDN.

I actually joined PRECISIONvalue in January 2019. So, I've been here going on 2 years. Prior to that, I spent about 20 years in managed care, most recently with Highmark Blue Cross Blue Shield in Pittsburgh, Pennsylvania, where I was the director of the Specialty Pharmacy Strategies and prior to that role, I was the director of Clinical Pharmacy, holding decisions on P&T [pharmacy and therapeutics committees], formulary, utilization management, and managing a prior authorization center.

Before Highmark, I had leadership roles at Humana, CareSource, which is Managed Medicaid in Ohio, and Anthem and Wellpoint, which is really where I got my start. I am a pharmacist by training. I got my start in retail pharmacy. I did that for about 10 years before moving into managed care.

CfB: And to clarify for our audience, are you a consultant to payers or consultants to employers?

Cox:Actually, to neither. We are a consultant to pharmaceutical manufacturers. So, we work directly with them. We do help bridge and bring together the opinions and thoughts of not only ourselves in our experience, but also through a proprietary network of decision makers that we're able to tap into to either do rapid pulse questionnaires or some panels, whether they're blinded or unblinded, and bring those together with that. So, we act more as a consultant to the pharmaceutical manufacturers.

CfB: What has been the problem with biosimilar uptake as employers see it, and have they been getting the support they want from payers?

Cox:I think there's a few things to kind of break down there. And I wish it was a simple answer and say, "Here's how we would solve that." Over the last 10 years, since the biosimilar pathway was developed, there have been some savings. Obviously, I think we have approached close to $5 billion since 2010, as of the end of last year, but about half of that occurred last year. So, we are seeing some increased uptake.

One of the challenges I think that we're running into is a lack of interchangeability. I think everybody sees the savings that were generated from small molecule traditional generics when they launched, [like those for] Lipitor (atorvastatin) when they came out. They have interchangeability and they have a lot of competition and there are also some regulations at the state level that require the use of generics first.

Biosimilars are a little different. One, the science is a little newer than what we saw on the other. So, understanding and getting that comfort level. That blends into the next thing which is the education. Are they safe? Are they effective? From the science that we understand, yes, they are. But having providers and the patients themselves have that level of comfort, I think that is still in the process and that needs to continue to grow.

From the employer perspective, I think understanding that what the total net cost is of these products is probably also a challenge for them. Looking at just that gross price, the AWP [average wholesale price] or the WAC [wholesale acquisition cost] price of these things may look like the biosimilar is actually less expensive, but when you look at the net costs after rebates that are typically passed almost all back to the employer, that net cost of the originator may actually be less expensive for them. So, helping them to understand and have some visibility, and I think the transparency within that is probably still something that needs to occur to help them to understand that.

CfB:Can you discuss some examples of how large employers have been taking the initiative on biosimilars?

Cox:With respect to some large employers, there was some information that came out earlier in this year that discussed CalPERS, Costco, and Disney and some of their approaches, and they're looking at the opportunity to look at what they're paying for these products. I think that what they're doing is the right thing. They need to be able to distinguish and maybe look at dissociating rebates, to looking at just the cost of the products themselves and looking to push and embrace biosimilars.

Right now, what we've seen is they're focusing in on infliximab and filgrastim. But looking at using or requiring new starts to start on the biosimilar, I think, is a good way to start that transition. And then, looking at that, I think Disney's model,—and they refer to it, as Disneyfying it—I think they installed an infusion clinic in Epcot that allows their employees to actually go there. So, that gives them a sense of control and, also, convenience for their employees. But if they have either the provider or the physician on site then, obviously they can actually direct that therapy a little bit more effectively.

So, I think these are good things. It still doesn't address some of the issues, [such as] the total net cost of the product. I think that still needs to be decided. But again, looking at your gross cost difference, I think that they will see some expected savings, just if you're looking at it through that lens.

CfB: How meaningful is this dynamic in terms of how it may require a shift in priorities at the payer/PBM level now and as you foresee it in the future?

Cox:I think from the payer perspective, looking at—and I talked about the difference between that gross and the net cost at the end of the day—infliximab, Remicade [reference infliximab] specifically, was highly utilized. It still is and it's also a rebatable drug. So, those rebates are used for various things. They're passed back, in some portion, to the plan, and that could be the employer in some instances. So, those things have to be accounted for, and looking at that difference in the gross versus the net cost, at the end of the day, their priority is to make sure that they're getting the lowest net cost product on there.

However, from a health plan/payer perspective, you don't want to be the last one that's not out there embracing the biosimilar. So, I think prioritizing that is really going to be something that we're going to see in the future. Some differences that I've seen, and this is more of a recent trend, but with biosimilars now available for oncology products; so, Herceptin [trastuzumab], Avastin [bevacizumab], Rituxan [rituximab]]—we've already started to see from a utilization perspective a shift toward increased use of biosimilars. The difference here is that those products are more acute. They're used in a short-term and a defined window, versus Remicade, which tends to be used over the course of somebody's life because they have a chronic immune disease. So, there are some differences there.

But we have seen that there is has been a shift, and it can happen. So, providers who are in the oncology space are starting to embrace that. I think the next big challenge and the big thing to watch for is biosimilars for Humira [adalimumab]. In 2023, we will see the launch of several biosimilars, I think it was 6 or 7. Amgen is first; I think Merck with Samsung Bioepis is second; Boehringer Ingelheim will be third, with several other products following on during that first 12 months. There was some talk about potentially 1 of those first 3, or maybe all 3, going after interchangeability. I think that will be a game changer if there is interchangeability approved for that, but that definitely is something that I think will help to shift that.

CfB: What policy or cultural shifts might you be suggesting to payers to ensure a seat at the table during this transition?

Cox:I think, as I've noted, that interchangeability is something that is really going to help with that transition from a payer perspective, as they are looking at noninterchangeable products. You're just increasing the competition within the space. And they're going to be looking at managing these very much like they've been managing specialty drugs all along. It's something that a doctor wouldn't have to write a new prescription for. So, whether I was—and I'll go back to some of those old small molecule traditional products—switching from Lipitor to Crestor [rosuvastatin] or from Crestor to Zocor [simvastatin] would require a new one. But moving from Lipitor to an atorvastatin generic doesn’t require a new prescription. In fact, that is something that could be facilitated at the pharmacy itself.

From a payer perspective, learning how to balance and look at rebates, as opposed to just being driven by them, I think that's something that does need to change. There was some talk in late 2019 about trying to reduce or remove rebates. I think that is something that could drive [biosimilar prices] down to that low net cost. It’s something to consider. Where does that additional revenue come from once, and if, rebates do go away? I think that's really what's driving the continued use of the originator product in this case.

To watch part 2 of this interview, click here.