Dismayed at the low biosimilar uptake and the lost savings, large employers are taking matters into their own hands.
Employers asserting their own desire to see biosimilars implemented among their employees was the theme of a Pacific Coast day of discussions involving representatives from Walt Disney, Costco, and CalPERS, the California Public Employees’ Retirement System.
The talks were sponsored by the Pacific Business Group on Health and the Integrated Benefits Institute. Employer health plan representatives discussed how they struggled to understand why biosimilar usage is so low and began putting the building blocks together to drive more patient use and greater savings.
Melissa Mantong, PharmD, MS, FCSHP, a pharmaceutical consultant at CalPERS, said the system went through a complex analysis stretching over 2 years during which it tried to decide the best way to implement a “biosimilar-first” program that would get these drugs into play.
CalPERS has 1.4 million members and spends $2.15 billion on drugs each year. Of that, $828 million is spent on specialty drugs, which include biosimilars, so the potential savings is vast.
Starting on January 1, 2021, the system plans to require that adult patients use an infliximab biosimilar first in preferred provider health plans. Currently, the originator infliximab, Remicade, has a 96.4% share of the market, with the remainder divided between the biosimilars Inflectra (3.2%) and Renflexis (0.4%), Mantong said, citing IQVIA data.
Getting to that step began in 2018, when CalPERS began analyzing data and discussing biosimilar goals with manufacturers. The company then talked with health plans about their biosimilar preferences. Barriers to biosimilar use that became evident included claims support issues and misalignment with health plan goals.
Those issues contributed to a decision to switch to implementing a biosimilar-first strategy with CalPERS’ pharmacy benefits manager. However, in the planning it was determined that the complexity of doing it this way was overwhelming and it was better to try increasing biosimilar use on the health plan medical benefit (specialty drug) side. The scope was limited to patients new to therapy and over the age of 18. The health plan was willing to go along and the plan appears to be on the approach path, Mantong said.
The most significant barriers encountered were aligning strategy with the health plan’s goals, limitations of the health plan system, and the complexity of medical benefits, she said. “If I had a magic wand, these are the limitations I would make go away,” she said.
“CalPERS is committed to supporting biosimilars, and we want to make sure biosimilars stay on the market to provide alternative price competition to the reference products,” she added.
Ladd Carmen, BPharm, director of specialty pharmacy services for Costco, said the discount, bulk retailer saw a need to drive higher use of biosimilars among its employees. Costco has 500 retail locations, each of which has a pharmacy, so it was well set up to implement such an initiative.
“We were really perplexed why these lower cost products weren’t being utilized more frequently,” Carmen said. He noted that the cost for Remicade was 30% higher than for biosimilars, “yet nearly 100% of our claims on the medical benefit remain for Remicade.”
That was counter to Cosco’s emphasis on competition and low prices, and Carmen said the company realized that if it didn’t intervene, it’d only be contributing to the use of higher-cost medicine despite the availability of lower-cost biosimilars. “It ultimately ends up costing us as an employer more.”
Negotiations between manufacturers and medical carriers play a large role in the continuing use of higher cost reference products, he noted. Also, “there can be a misalignment of incentives from the prescriber standpoint.”
When implementing a biosimilar plan, Costco decided to focus on infliximab to keep it simple. The company turned to its medical carrier to assess utilization patterns and how much could be saved with a switch to biosimilars. Costco officially launched a pilot biosimilar program on January 1, 2020.
As part of that, the company inserted a precertification requirement so that intervention was possible whenever a physician requested the originator product, Remicade. Use of the biosimilar was mandatory before the innovator product. Efforts were also made to ensure that patient coverage would be the same whether the product was covered on the medical benefit or pharmacy benefit side.
Bill Dinger, MBA, CPA, director of Healthcare Innovation & Labor Support for The Walt Disney Company, said the entertainment company is just getting started with a biosimilars program. It recognized the trend toward biosimilars but had to push a little to start things moving.
Disney has a small amount of biosimilar usage among its employees and when it investigated the potential for higher employment of these drugs, the typical answers the company got from its health partners were that biosimilars are still a far-off concept and putting them front and center was not a priority, Dinger said.
Disney health officials heard good things about biosimilars so they decided to “dig in a little bit further.” They also noted that a large amount of drug spending was driven by doctors’ offices and that it was very difficult to get clarity on that spending; and further, it was unclear whether providers had an incentive to switch to biosimilars. “There’s really none unless they’re on some form of contract,” Dinger said.
It also became clear that the pipeline of biosimilars was large and could replace a significant amount of the pharmaceuticals currently used by Disney employees at a savings.
Moving further into biosimilar use would require expertise and a cost justification with regard to the upfront investment, Dinger said.
The company had biosimilar manufacturers step forward with offers to partner, and Disney narrowed the initial field of biosimilars it would target. “We don’t want to get ourselves too far in until we get good at this, so how many drugs should we focus on? Right now we’re only looking at 4 or 5 [biosimilars], and honestly, the amount of savings from those 4 or 5 drugs more than justifies the investment we’ll be making—significantly exceeds the investment,” Dinger said.
The next question was how to drive patient volume to the infusion center. They found they had enough patient volume based on patient treatment at existing facilities and could engineer the change via referrals.
They decided to build a small infusion center at the Epcot theme park in Florida and “Disney-fy” it, Dinger said.
They made it convenient with “fast pass” scheduling to minimize time away from work, created a bright environment with lots of windows, comfortable seating, and Disney+ programs, wifi, and cable television options. “What we’re trying to do is take this process that is difficult and make it better. We’re also trying to drive some savings and align with our ‘whole person approach’ and hold everybody together,” Dinger said.