Bruce Feinberg, DO: Michael, you set us up very nicely in regard to the next topic of evidence-based care. You introduced this issue of cost. Cost and shared risk are relatively new to the provider space. We were always very segmented, and cost was the purview of the payer, but to large degree, not the purview of the provider or patient who via their payer was covered. There has been a lot of debate, and we’re not getting into the data around that shared risk story, but it exists today.
To some degree, when you have shared financial risk for treatment, it can be seen as in conflict with evidence-based care. Does evidence drive, and if it does, where does cost fit in?
I want you to touch on that next and tell me how you, as a clinician, align at a practice level and on a national level, because you’re involved with various organizations. How do you start to align the cost and evidence, especially given the fact that in biosimilars, the evidence is—by nature of the way they’ve been approved—less robust?
Michael Diaz, MD: That’s a really good question. I remember from back in my medical school days in 1 of my ethics classes that it is in the AMA Code of Medical Ethics: as physicians and health care providers, we’re ethically obliged to try to make the best use of the resources that we have. As a society we are growing to realize that we don’t have unlimited resources. That’s something that’s always going to be in the back of my mind. But first of all, just because it’s part of how we practice medicine, is to make sure that we’re giving our patients the best care possible.
That’s where evidence-based care has evolved. We have learned through clinical trials and studies what seems to be the most efficacious for our patients. When we have more than 1 option that seems to be equally effective and there are no unique contraindications for treatments or preferences for treatments based on patients’ comorbid medical conditions, then in the big picture of things, 1 of the ways we’re starting to approach medicine is, what’s the most cost effective way to try to manage this? That’s an interesting concept for doctors because most doctors aren’t even aware of how much these drugs or medications cost.
Bruce Feinberg, DO: No, and I think there’s also complexity in the cost, right? Is it actual cost? Is it the cost to society, the cost to the practice, or the cost to the patient out of pocket? It gets very confusing in terms of payer contracting, rebates, and contract design, to determine what that total cost picture is. There’s not a lot of transparency to it, which makes it that much more difficult to try to address.
Michael Diaz, MD: It’s layers of complexity upon layers of complexity. You might have 2 treatments that are equivalent, and 1 is a third of the cost of the other treatment, but it requires 3 times as many treatments. Where are you in that mix? That’s why there are multiple things to take into consideration, and it’s not as simple as people would like. This is not as simple as looking at the flat drug cost. We’re trying to look at the total cost of care.
Given the unique situations, in which you have something like a biosimilar and a reference product where they have the same protocols and the same number of visits, it makes it a bit easier in that scenario. If the biosimilar is approved for the same indications as the reference product and it is of a lower cost, then that’s where you have a discussion with the patient and you let them know why you’re recommending it. Explain the evidence behind the rationale, not just the fact that it costs less. Explain that it has been demonstrated to be noninferior and that for all that we know and all we’ve seen, it looks like it should work just as well. Patients are getting to be more and more inclined to say, “Yes, that sounds like a reasonable option. That’s something that I would like to try.”