The Biosimilar Economic Conundrum: Where We Stand

Biosimilars have an increasingly large footprint in rheumatology practices as physicians become comfortable with their use and as payers increasingly favor them for cost savings. However, biosimilars are relatively new to markets, so pricing and reimbursement policies for these drugs are still fluctuating. One consequence is market instability in drug pricing, which has created an economic conundrum—rheumatology practices are paying more to acquire biosimilars, like infliximab-axxq (Avsola) and infliximab-dyyb (Inflectra), than payers are reimbursing. Compounding this problem is that payers require patients to use biosimilar infliximab products despite the lack of adequate reimbursement.

Trapped in Biosimilar Economic Complexities

Dr. Phillips

When payer formularies require use of such “underwater” drugs, the burden of drug costs shifts to physicians and practices. Rheumatology practices that infuse certain infliximab biosimilars must do so at a loss and risk their financial solvency. Physicians are forced to choose between infusing a drug at a loss or moving the infusion to a hospital outpatient infusion center, where treatment is more expensive, wait times are longer and out-of-pocket fees are higher. In addition, the patient’s rheumatologist may not be able to provide direct oversight of treatment.

This payment inequity can lead to another dangerous consequence: being forced to change the biologic medication for the patient entirely, which risks the loss of control of disease, explains Chris Phillips, MD. Dr. Phillips chairs the ACR’s Committee on Rheumatologic Care (CORC) and faces these difficult issues firsthand in his own private rheumatology practice in Paducah, Ky. “Our members are caught in the middle of an unfortunate economic experiment,” Dr. Phillips says.

Advocating for Biosimilar Safety on All Fronts

As more biosimilar versions of more originator drugs come to market, CORC is concerned about the possibility that fluctuations in drug prices may lead payers to repeatedly change their formularies and, in turn, attempt to force-switch patients through multiple versions of a drug, putting patients at increased risk for adverse events.

In 2015, CORC drafted the ACR’s first Biosimilars Position Statement, which the committee continually updates to articulate the latest practice issues and recommendations for safe biosimilar use. Dr. Phillips describes the position statement as an important resource to inform rheumatologists and those outside the profession who make decisions that impact biosimilar use in rheumatologic care.

Dr. Shepherd

With the rapidly changing landscape of biosimilar use and reimbursement, ACR Insurance Subcommittee (ISC) Chair Rebecca Shepherd, MD, and the advocacy team continue to work with members to understand payer issues with biosimilars and advocate with payers on behalf of rheumatology practices.