Earlier this summer, ACR members expressed concerns regarding underwater reimbursement for infusing patients with biosimilar versions of certain drugs, particularly infliximab and rituximab. Evidence has strongly backed the cost effectiveness and clinical results of these biosimilars. However, the average sales price (ASP) of some biosimilars has fallen faster than the acquisition cost. Thus, infusing these drugs risks putting many independent clinics at a financial loss, threatening patient access to vital treatments.
A major contributing factor for certain biosimilars being under water is the fact that rebates, which are offered to pharmacy benefit managers (PBMs) in exchange for favorable placement in formularies, are factored into the drug’s ASP, causing the ASP to decline faster than the acquisition cost.
The ACR advocacy team had several discussions with Chris Phillips, MD, chair of the ACR’s Committee on Rheumatologic Care, on potential advocacy approaches to address the issue. They opted to develop an ad hoc coalition of like-minded stakeholders of specialty societies and patient advocacy organizations. The coalition has over 40 members and has already finalized a sign-on letter to the Centers for Medicare & Medicaid Services (CMS) to urge it to work with Congress on removing PBM rebates from the ASP calculation and agree to a meeting with the coalition to discuss the issue in more depth.
The coalition is planning an introductory meeting of its members later this month and will subsequently submit the letter to the CMS. Although ensuing steps have not been solidified, letters to Congressional leadership and relevant committees are being considered as part of a strategy to get this issue on lawmakers’ agenda and make them aware that underwater biosimilars are linked to the issues behind the need for PBM reform. The ACR encourages members to send to [email protected] their personal stories on how underwater biosimilars are negatively affecting their ability to provide high-quality care.
