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.

The ISC has reached out to three payers—Aetna, Cigna and United Healthcare (UHC)—whose formularies all prefer Inflectra and/or Avsola over other infliximab biosimilars and with which rheumatology professionals have had the most concerns regarding reimbursement loss, Dr. Shepherd says. She summarizes these payer actions as a direct result of ACR advocacy:

• In response to concerns raised by the ACR, Aetna adjusted its fee schedule for commercial and Medicare Advantage plans in July 2023, increasing reimbursement for the underwater drugs.
• UHC is looking at a short-term solution to keep infusions in rheumatology practices instead of shifting patients to hospital outpatient settings. It is also exploring a longer-term solution that would help mitigate the impact of the instability in pricing for certain products.
• The ACR is in communication with Cigna to address biosimilar reimbursement for underwater drugs.
• The ACR is in the process of reaching out to the Centers for Medicare & Medicaid Services (CMS) to make it aware of reimbursement issues that might affect access to biosimilars to infliximab in the Medicare Advantage market. 

In conversations with payers, the ACR is also communicating the cost reduction of branded drugs since the introduction of biosimilars. Specific to infliximab, the cost of the branded version Remicade has dipped 60% since biosimilars entered the market: at the end of 2016, the average sales price of Remicade was $828.72 compared to $326.37 at the end of 2023.

“Ultimately, we want payers to understand the ACR’s position that rheumatology practices should be appropriately reimbursed for using any version of the most cost-effective infusible biologic drug, whether it’s a biosimilar or not,” Dr. Shepherd adds.

Speak Up to Share Your Concerns with Biosimilars

Dr. Phillips and Dr. Shepherd encourage every ACR member to reach out with any issues regarding biosimilar drugs. They would especially appreciate any updates from ACR members with regard to Aetna reimbursement of biosimilars to infliximab in their practices.

Here are two ways rheumatology professionals can communicate biosimilar concerns to the ISC’s attention:

• Send an email to [email protected] with details about your concern.
• Submit insurance issues through a Health Insurance Complaint Form at https://rheumatology.org/insurance-advocacy.

Carina Stanton is a freelance science journalist based in Denver.