Kathy Oubre, chief operating officer at the Pontchartrain Cancer Center in Louisiana, president of the Louisiana Medical Group Management Association and member of the board of directors for the Community Oncology Alliance, discusses how payers, pharmacy benefit managers, and manufacturers make providing biosimilars complicated for patients and providers.
The Center for Biosimilars® (CfB): Hello, I’m Matthew Gavidia. Today on the MJH Life Sciences News Network, The Center for Biosimilars® is pleased to welcome Kathy Oubre, chief operating officer at the Pontchartrain Cancer Center in Louisiana. She's also the president of the Louisiana Medical Group Managers Association and a member of the board of directors of the Community Oncology Alliance [COA].
To get started, how much have you managed to incorporate biosimilars into practice at the Pontchartrain cancer clinics?
Oubre: Hi, there. We have actually done 100% conversion for any biosimilar on our formulary.
CfB: What kind of differences has this made in terms of budgetary efficiency for your practice, patient savings and patient access?
Oubre: It really hasn't changed patient access very much because those have always been approved by the payers. It has changed patient out-of-pocket costs a lot when there's a cost sharing component between the payer and the patient. Typically, we are seeing a savings for patients up to about 20%. Patients have deductibles. We all know that. But it's kind of like buying a car. Whether you can finance that car, you pay cash or you finance it over 60 months or so. As health care costs continue to grow for patients and they're struggling, especially during COVID— you know, mortgages, food, clothing—those kinds of cost savings [on drugs] allow them to put money towards all of those buckets instead of having to pick 1, which for cancer therapy is a really big deal.
As healthcare costs continue to grow for patients and cause them to struggle, especially during the COVID-19 [coronavirus disease 2019 pandemic], cost savings on drugs allow them to put money towards all of their buckets (mortgages, food, clothing) instead of having to pick 1, which for cancer therapy is a really big deal.
CfB: How are payer your practices on prior authorization affecting access to biosimilars at your clinic?
Oubre: It's become more complicated. So, back in October when the biosimilars for Neulasta came out, a couple of payers decided to go with 1 pegfilgrastim drug on their formulary. And perhaps it might have been the most cost effective for the plan, but maybe not the most cost effective for the patient and that was interesting. We've seen that mindset continue to grow over the last several months, where lots of payers are now starting to pick and choose originators versus biosimilars and a lot of that has to do with rebate design between the PBM [pharmacy benefit manager] and the payer. And then, there are times where the manufacturers are having agreements with those payers as well.
It presents a lot of problems, right? So, we have to stock multiple products. That could be an issue from a nursing perspective. We've now had to put additional safeguards in place to make sure that the nurse gives the patient the correct product because if we give the incorrect product or something that's not authorized by that payer, then the practice doesn't get paid for that. And then it takes a while to make up that loss and there's not much we can do about that.
It also ties our hands in being able to maximize our potential for any of these products therefore, lowering the cost for healthcare for our practice in a value-based care model, and being able to provide the best financial value to the patient. We're just seeing that payers, PBMs [pharmacy benefit managers] and manufacturers are continuing to grow [in influence] and they're making formulary decisions and are leaving the provider or the physician out of that decision-making process.
CfB: How are rebate deals and other deals struck by payers with vendors or manufacturers affecting your ability to supply the biosimilars that you prefer to use?
Oubre: They're tying our hands. It's just really that simple. So, we prefer to use 1 certain pegfilgrastim. If we pick 1 and just move forward with it from a design plan on pathways, it's very easy for us. From a nursing error perspective, it minimizes risk. When we do financial counseling, we have 1 drug that we've chosen and from a financial and an efficacy standpoint, it marries well with our practice philosophy. But when different payers and PBMS, and all those things make outside agreements, we're just the end user and it does become problematic to operationalize it.
CfB: How many payers are you currently working with and how much divergence is there in the biosimilars they want you to use?
Oubre: We probably have 18 payers within our market. In the biosimilar space, we currently have 5 payers that really are peaking forces in that market. Two of them, within the last 30 days, picked different biosimilar products that I now have to operationalize by July 1. So, by July 1, I will be using 3 [different] biosimilar products, and I'm hearing a fourth biosimilar [may be added], for just 1 [originator] drug. You have to put different safeguards in place to make sure that you're giving the correct drug to the correct patient.
CfB: I know you touched on this briefly but when it comes to factors such as stocking biosimilars, choosing the right biosimilar and potential error rates and risk, how does flexibility complicate matters in your pharmacy?
Oubre: It is complicated. So, when the nurses are ordering the drug, we have to make sure that the correct drug is assigned to the correct patient and that the correct drug was authorized for the correct patient. Then when it's time to administer it, we have to make sure that the correct drug is being given to the right patient. And then when billing it out, you have to make sure you're billing out the right drug for the right patient. There's a lot of steps in place now to ensure correct buying, correct administration, correct authorization and correct payments.
CfB: What should payers be doing to make the process more sensible for clinics and patients?
Oubre: Parity. That would make things much easier. I understand the need for cost containment because we're all trying to do that, but when you interfere with that physician-patient relationship, that's philosophically a problem. When you don't allow parity then, you're not allowing market access or patient access. You're interfering with physician decision making. There's just there's a lot of negatives for it. There's a lot of error rate. I'm not seeing a lot of positives coming out of that kind of decision making.
CfB: Can you tell us about the trickle-down effects on biosimilar savings? How are these payer actions affecting your ability to pass the savings along to the patient?
Oubre: So, just like payers have contracts, individual practices have contracts as well. [They are drafted] generally through my GPO (group purchasing organization). So, the contract might come to me and say that when it's clinically appropriate, we utilize [a certain] percentage that could be off invoice discounts or rebates. That savings goes directly down to the patient so that they don't have to pay as much for that product.
When I have to stock multiple products, it ties my hands in my ability to perform financially in an optimal manner on any of those contracts. Therefore, [the practice is] paying more for the product and the payer is going to end up reimbursing [the practice] more for the product. Any cost share that's for that patient still goes to the patient, but it's generally on a more expensive product because [the practice has] to pay more for it.
CfB: To build on that, how is this affecting your providers and their ability to prescribe as they see fit?
Oubre: What happens now in our practice is that the provider picks the product and then, it's up to the financial counsellors and those navigators to go back and do a benefits analysis. And we have to marry what the drug is with the insurance of that particular patient. Then, they have to go back to the provider and say [something like] this patient has this insurer, and this is what they're requiring, are you okay with that? So, it also requires some extra steps even within securing a drug for a patient.
CfB: To learn more, visit our website at centerforbiosimilars.com. I'm Matthew Gavidia. Thanks for joining us.