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Strategies for Incorporating Biosimilars Into Care Plans


Bhavesh Shah, RPh, BCOP: As Karina said, early conversations with payers are really the way to drive this. We got burned in the infliximab market when it came out. We didn’t have the conversations with payers saying that we are going to go and make this change in our formulary. By the time they actually decided which formulary they were going to use, we were still deciding which 1 we were going to use for our formulary. Of course, they couldn’t wait for us to make that decision because there were millions of dollars at stake for them.

What we do now is go to our local payer market and let them know that we are evaluating these for adoption and we are very interested in switching. We don’t want them to actually choose a biosimilar. We would like to be the entity that chooses it. We have a blanket statement from our local payers that for oncology biosimilars, they will not be choosing 1 versus the other.

In the states in which they haven’t been able to do that, I’ve seen very extreme levels of regulation that a lot of institutions have pushed through, where they actually do not allow payers to choose a biosimilar in that state.

There is definitely government influence that can be used, but I think it is more appropriate to work collaboratively with the payer to give them a heads-up and have those early conversations. That will help reduce the number of biosimilars you have to carry in your formulary.

It’s hard when you have institutions that actually have a majority of the patients coming from out of state for consults and treatment. Those are the most challenging, where you have hundreds and hundreds of payers from out of state to deal with and it’s impossible to control the formulary there.

Bruce Feinberg, DO: Michael, is there some saving grace in that, for the most part, oncology is more weighted toward Medicare than any other specialty? Almost every oncology practice’s dominant payer is Medicare, and you don’t have to deal with playing these games and figuring it out.

Michael Diaz, MD: That is partially correct. I have to agree with that, but it really depends where you are. You can see a lot of geographical differences. A lot of people tend to retire in Florida—which is where I am—so obviously it’s the dominant payer here.

I think I agree with what I’ve heard so far in that it requires a lot of collaboration with your payers. It just so happens that the largest overall percentage of our patient care is covered under some form of a value-based contract. Medicare is under a value-based contract with the oncology care model. The vast majority of our commercial plans are as well. The only plans that aren’t are Medicaid and some of the Medicare Advantage plans. In those value-based contracts, all the incentives are aligned. The overall goal is to take the best care of patients and to do it in the most reasonable fashion.

If you remove the obstacles and align incentives, then you can get the best results overall for your patients. It helps make the situation win-win for everybody, not only for the patients but also for the providers and the payers. It’s the collaboration that’s required.

Bruce Feinberg, DO: Are your value-based care collaborations with your commercial payers as well?

Michael Diaz, MD: Correct. They are.

Bruce Feinberg, DO: Kathy, are you seeing any interest or willingness among the commercial payers? In every state, it is going to be the state’s Blue Cross Blue Shield that is going to be, by far, the No. 1 commercial payer on the list you want to collaborate with. Are they receptive?

Kathy W. Oubre, MS: Funnily enough, yes, we are working on that. They do have an interest in bringing down that total cost of care, and we have had that discussion. Yes, we are working on a biosimilar value-based contract with our state Blue.

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