Kathy Oubre Discusses PBM, Payer Challenges for Biosimilar Adoption

A version of this article was originally published on AJMC.com, the sister site of The Center for Biosimilars®. This version has been lightly edited.

At this year’s Community Oncology Alliance (COA) conference, Kathy Oubre, MS, CEO of Pontchartrain Cancer Center, sat down with The American Journal of Managed Care® (AJMC®) to discuss the use of biosimilars in oncology care and the impact of pharmacy benefit managers (PBMs) and payers in this market.

AJMC: At the meeting a year ago, we were hearing that PBMs were making it difficult for practices to use biosimilars or to use the biosimilars of their choice. Can you compare the situation today to a year ago? How is COA advocating for practices in this area?

Oubre: It wasn't just PBMs. I want to be very clear—it's PBMs as well as payers. And what they have done is they've taken that biosimilar market, and through our original COA data set that we did a year and a half ago looking at the first 2 years (2018 to 2020) of biosimilars, we showed that when biosimilars entered the market in the oncology space, that it reduced ASP [average sales price], it reduced the Medicare allowable, and the corollary is it really increased patient care.

There were more administrations to cancer care patients during that time period. There was this massive uptick in the use of biosimilars during that time. But then the payers and the PBMs got wise to this, and they saw an opportunity with biosimilars.

So, you hear stories of larger rebates by the biosimilar manufacturers being given to PBMs and the payers in order to gain access to formulary, because Medicare is the only payer that has open access to the brand as well as all the biosimilars. Past that, most of the commercial carriers as well as the Medicare Advantage plan have limited formulary. So, you may have brand and 1 or 2 biosimilars, [or] you may not have the brand; you just may have a couple of the biosimilars.

And what it's done is it's split the biosimilar space. That forces practices to carry multiple biosimilars based on the patient's individual health care plan. So, it has made it a little more of a challenge. It's not something that we can't handle and operationalize for, but it is a burden. And we don't see that getting better.

What's happened since that 2018 advent is the payers and the PBMs continue to extract those large rebates or request those large rebates from the manufacturers. And what's happened is ASP is essentially eroded for all of these products.

It’s becoming a challenge. We still stocked and provided them to our patients. No one's underwater yet on these products, but it has made it more challenging when you look at the health of the overall biosimilar market to keep it in a healthy state due to the business practices of the PBMs and the insurers.