Bruce A. Feinberg, DO: Marcus, you brought up this issue of the payer’s intervention, particularly more in rheumatology than we see in oncology. But, my guess is you’re just leading the way for us in oncology. With that concern about compassionate care giving and patient-centricity, again, do we want to put the patient in that position where they’re going to be told, “You can’t have the drug that your doctor prescribed?” And, is it in our best interest? Is it in their best interest? Is it really appropriate for us to know what that drug is that’s going to be allowable, and then tell the patient? It’s kind of like, “This is my first choice, but your insurance company won’t pay for it and it’s $35,000 a year. I know, as a school teacher, you can’t afford that. But, I just wanted to let you know that I can’t give you that.” Or, do you just say, “The agent we’ve selected is approved for this,” and just go with it? It raises questions—not just on adoption, but also in terms of the patient relationship with the physician and what our responsibility is to that patient.
Marcus H. Snow, MD: You know, that’s a great question, and I deal with that right now. If I tell my patient, “I’m going to place you on etanercept,” then I get the phone call or the message from the pharmacy and they say, “Etanercept is not the approved product of this insurance company. The approved product is adalimumab.” Or, we are reminded that there are 5 of them in the class. And so, I’ve been through that discussion before.
What I tell the patient is, “Look, there are 5 medications in this class. We think that they’re all about the same, and there are some with which one patient might respond to one or the other. There’s no way to know which one you are going to respond to. I prefer 1 of these 2 medications. This is what I normally start with. If you end up on something else, I will only let you get a medication that I think is right for you.” I have that discussion with them. And, I will tell them, “If I think this is not right for you, I will fight for you and I will call whoever I can call to get this taken care of.” I think if you have that discussion up front, they’re not blindsided when I’ve given them information on etanercept and they end up with adalimumab.
Bruce A. Feinberg, DO: But, you could have known in advance, right? You could have looked. Someone in your office could have checked.
Marcus H. Snow, MD: I could, but the problem is that one year an insurance company might have etanercept. Then the next year, or even in the middle of the year, their preferred agent may change due to contracting. And so, long ago, I stopped trying to predict. It was so variable. It was so all over the board. The time that I really put my foot down is when I have a patient who’s doing great on one medication, and then I get a notice.
My patient comes to me, usually, with a letter and says, “My insurance company says this is going to cost me a lot more and I should switch over to this medication.” That is something that I fight, tooth and nail. If I have someone who’s under great control with rheumatoid arthritis, I do not want to give up that control, even if the other medication may be, on the surface or superficially, the same. That’s the big thing. As rheumatologists, moving forward with any kind of concern about biosimilars, that, right there, is probably the biggest concern that we have: we’ll have a patient who’s under really good control and they will switch interchangeable medication—for example, will go from adalimumab to a biosimilar of etanercept. And switching complete medications is a huge concern and is something that I think, as rheumatologists, we are really opposed to.
Hope S. Rugo, MD: I think that I’ve seen a difference in oncology. For example, the only people who are staying on antibody therapy forever have metastatic disease. Some of them are cured of their disease, but it’s a limited number who have metastatic HER2-positive breast cancer. We tend to keep them on trastuzumab, unless they’re using an alternative product like trastuzumab emtansine for life. So, people are on it until they die of their disease. Switching wouldn’t bother me so much. We’re not going to give a different drug altogether. It would be a biosimilar of trastuzumab, right? So, if you had somebody on etanercept, would you feel the same way if the company said, “I want them to switch to a biosimilar of etanercept?” Or, is it more concerning for switching to an entirely different product?
Marcus H. Snow, MD: As a provider, it would be much easier to be content with the fact that you’re switching to a biosimilar once the evidence is out there of the same product.
Hope S. Rugo, MD: Right.
Marcus H. Snow, MD: But, I think that our worry is that the application of the biosimilars by the payers, insurance companies, and PBMs (pharmacy benefit managers) will shift things and we’ll start to lose control of what our patients get. We don’t have much control to begin with, but, at the same time, that’s the biggest concern. So, yes, I think that, initially, there’s going to be some pushback amongst providers switching to a biosimilar of a medication. It remains to be seen on how that will play out. But, I think the biggest nightmare scenario for us is then, all of a sudden, one year they’re on a biosimilar of adalimumab, and then the next year they’re on something else. It just bounces around, and that could have devastating consequences for some of our patients.