After "you have cancer," the worst thing patients can hear is “This is how much you owe,” said Andre D. Harvin, PharmD, during his keynote address at the ACCC 49th Annual Meeting & Cancer Center Business Summit.1
According to Harvin, who is executive director of Pharmacy, Oncology Services at Cone Health, when biosimilars first became available, providers and patients alike questioned how much financial benefit they could offer compared with reference products. This was particularly true for those already on patient assistance programs (PAPs) for the reference drug. For them the expense was still extremely high despite the lower cost of biosimilars.
"Yes, it’s cheaper. But you’re talking about the difference between a Lamborghini and Ferrari; they’re still expensive, [and patients] still can’t afford them,” Harvin explained. “So what’s the difference if it’s like 20% or 30% cheaper if it’s still really, really expensive?"
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Pharmacists have been working hard to answer that question, he said, and fortunately, many biosimilar manufacturers offer PAPs that are comparable to, and sometimes more robust than, those offered by the company making the reference drug. Nevertheless, connecting patients to the resources for which they qualify can still be challenging.
During an interview with Pharmacy Times, Harvin noted that many outsiders forget that the pharmacy is a profit center. “That’s a really big part of the conversation,” he said. “Yes, we are one of the most expensive departments to have in a cancer center practice, but when you look at the revenue...generated for those services, it typically far outpaces the costs.... When you look at the finances of your oncology practice, you’re going to see that typically pharmacy is at the top. If not, they’re going to be in the top 2 in terms of your profit center.”
Without the financial work of the pharmacy, oncology practices that have implemented biosimilars may not be maximizing their bottom line partly because of the challenges of connecting patients with the right sources of financial assistance and of determining which is the best biosimilar in terms of reimbursement.
"That’s the part that’s actually a lot harder,” Harvin said. "There are so many nuances...that I think a lot of practices don’t understand.” One such nuance, for instance, is that biosimilars are not generics but rather drugs that are highly similar to the reference or brand-name products. “A biosimilar is just a new kind of classification that the FDA put out to say that...[there are] no clinically significant differences,” Harvin observed.
Following this designation, insurance companies decided that, although there may be several biosimilars on the market, they would choose only a few as preferred drugs. Thus, even if they contain the same biologic, other biosimilars in the same class would not be designated as preferred. “Therefore, it’s hard for any practice to say, ‘You know what, we’re just going to put everybody on this pegfilgrastim [Neulasta; Amgen] biosimilar’ because you may have several different payers that have a [different] preferred drug,” Harvin said.
Generally, providers cannot track month-to-month changes in terms of insurer preference, but pharmacists can. “Remembering...that Blue Cross Blue Shield likes this pegfilgrastim and not that pegfilgrastim—that’s not something we want them to spend their time on,” Harvin said. But pharmacists can, through the “electronic medical record...see what is available in terms of the preferred [drug] for the 2 or 3 different biosimilars that they say they will allow.”
Beyond that, pharmacists can analyze the best net acquisition cost or net cost recovery for each. Because prices may differ, payer reimbursement rates may also differ and impact the net margin for a given biosimilar. “Even though they’re all [biosimilars for] pegfil-grastim, [the price] may be drastically different from one product to the next,” he said. "So, the question would be, ‘If you’re going to administer a prefilled syringe of pegfilgrastim, and you’ve got 3 options, and one can give you a higher reimbursement rate...for the same exact work, wouldn’t you choose that one?’ That’s what we do.”
Patients also make decisions based on treatment cost. In a recent survey, 74% of patients with cancer said that they would skip or delay medical care based on cost. “We know that in cancer care that could mean death. But we know that they’re doing that because of the financial toxicity sometimes associated with [therapy],” Harvin said during the presentation. “We can sit here and say, ‘Well, hey, I don’t set the prices.’ But we participate. So we have a role to play as well.”
Although biosimilars may not be perfect, they are currently the very minimum helping to make cancer therapies a little bit more accessible, according to Harvin. Therapeutic interchange allows oncology practices to establish internal systems that designate certain drugs as interchangeable and let pharmacists take the lead in terms of substituting a biosimilar for a reference drug based on the particular financials of that drug for that patient.
“If a patient qualifies to move to a biosimilar, and we find that it’s cheaper for them...our pharmacists can automatically change it,” Harvin said. “We also found a way to automate that. So within our [electronic medical record, we can] say, ‘What is that patient’s insurance, which biosimilars are preferred on that insurance, which one provides the best financials for us?'"
Before a pharmacist started making biosimilar interchange decisions at Harvin’s practice, the process was far less streamlined than it is today. With the pharmacy department involved, however, all that has changed.
"Pharmacists, first and foremost, can be some of the most powerful advocates for you and your program,” Harvin said. “This is what we do. We are here for the patients at the end of the day. We are fantastic at bringing new information to the table. You have to unleash us and make sure that we’re at elbow level, not only with providers, but with patients as well.”
Reference
Harvin AD. Robots, biologics, and advocates: lessons from the pharmacy. Presented at: 49th ACCC Annual Meeting & Cancer Center Business Summit; March 10, 2023; Washington, DC.
