The secret is in the sauce that makes Kaiser Permanente a truly integrated payer, and in its devout avoidance of the Achilles heel of other payers.
At this week’s GRx+Biosims meeting, two sessions with KP’s executives made it startling clear—if you don’t accept rebates, the decision to move to biosimilars is simple.
Amy Gutierrez, PharmD, Senior Vice President and Chief Pharmacy Officer, Kaiser Permanente National Pharmacy Programs and Services, emphasized the organization, especially its California regions (which account for 80% of its membership), is highly integrated. The medical groups and Kaiser pharmacies “strongly collaborate,” coming up with evidence-based reviews of formulary drugs.
At a separate session, Sameer Awsare, MD, Associate Executive Director, The Permanente Medical Group, elaborated, “Our drug information services are critical in doing the evidence-based review.” When an oncology clinician is part of the review, he said, “it’s hard for other oncologists to go against these recommendations. This results in widespread buy-in to the formulary decisions.”
Formulary adherence is about 95%, according to Dr. Gutierrez, and in California, “the plan does not require prior authorizations.”
The Looming Patent Cliff
“Biosimilars are safe, and they have been shown to be as effective as innovator products,” asserted Dr. Awsare. He listed the many reasons why uptake has been slow—pay-for-delay, misinformation, patent litigation, and perverse incentives among the top factors. “Biosimilars have reduced costs because of increasing competition.”
Dr. Gutierrez stated that newer therapies can cost from $500,000 to $2 million. “How can we afford these newer treatments? The abandonment rate for medications that cost patients $250 or more is 69%, and 52% when the out-of-pocket costs are between $125 and $250.” This has significant implications for Kaiser and its 12.3 million members.
With 71 drug patents set to expire through 2023, representing $55 billion in costs, “We hope to take advantage of this with biosimilars,” she said.
Kaiser Permanente’s Biosimilar Journey
The health plan was an early adopter of Zarxio® (filgrastim-sndz). “We learned the ropes with that one,” said Dr. Gutierrez.
Dr. Awsare explained that when Zarxio first came out, the providers questioned the results of the European studies. Kaiser performed a study with its own patients (the first 700 patients to receive the product). “It turned out we saw even less neutropenia than with Neupogen—maybe it’s even a ‘biobetter’,” he stated. The result is that Kaiser Permanente now has 98% uptake on Zarxio, according to Dr. Awsare.
Kaiser decided in 2017 to cover Inflectra (infliximab-dyyb). “At that time, the professional [gastroenterological] societies were inferring this was not the best course of treatment,” said Dr. Gutierrez, and Kaiser Permanente delayed using the biosimilar for the inflammatory bowel disease indications. Kaiser started a registry to ensure that no safety signals were seen after the switch.
When Fulphila (pegfilgrastrim-jmdb) was approved, Kaiser soon decided to cover it in preference to the reference product. And when Amgen launched its biosimilar bevacizumab (Mvasi®) and trastuzumab (Kanjinti®), Kaiser Permanente jumped in with both feet. “The oncology doctors were ready to move to biosimilar trastuzumab and bevacizumab when they were launched,” said Dr. Awsare. “We went to 97% uptake on the Avastin biosimilar in only a month.”
Kaiser also focuses on covering only one biosimilar in a class, to maximize its leverage.
Dr. Gutierrez emphasized that the plan has the ability to get “immediate P&T decisions and put coverage in place rapidly.” This has resulted in biosimilar uptake of 80% to 95%, depending on the product. She explained, we’ve seen greater (and faster) adoption rates with supportive care medications versus direct treatment.” Overall, the plan has saved about $200 million since we began covering our first biosimilar.”
In cases where a product has a “skinny label,” Kaiser is open to approving off-label indications, if the evidence supports it. “We’re working with our physician groups to gain that evidence,” she said.
Dr. Gutierrez advised that supply and stocking is important. “We might be ready to start using the biosimilar immediately,” she said, “but the manufacturer may not be ready to meet our supply needs. We’re getting better at that.”
“We work to minimize use of evergreening products whenever possible to maximimize the impact of the future biosimilars market,” added Dr. Gutierrez. “We are a leader in US biosimilar use. Manufacturers know that Kaiser Permanente can switch medication coverage fast, and this gives us significant leverage.”
Note: This post was updated and corrected on December 4, 2019. We had initially characterized Ruxience as being placed on Kaiser Permanente’s formulary. This is incorrect.