Competition From Biosimilars Drives Price Reductions For Biologics In The French Single-Payer Health System

Comparison of Two Financial Incentives to Encourage the Use of Adalimumab Biosimilars: Results of a French Experiment Close to Clinicians

BACKGROUND

In 2018, the French government introduced two mutually exclusive financial incentives to increase etanercept and insulin glargine biosimilar use. The general case redirects 20% of the price difference between the reference product and its biosimilars to hospitals for every biosimilar dispensed in community pharmacies from hospital prescriptions. The experimental case redirects 30% to prescribing clinical units after hospital selection. Adalimumab was added to these incentives in 2019, after its first biosimilar was launched.

OBJECTIVE

This retrospective observational study aimed to compare both general and experimental incentives after 19 months to assess the impact of directly incentivizing clinical units for adalimumab biosimilars.

METHOD

The monthly number of adalimumab boxes dispensed in community pharmacies was linked to the corresponding hospital's prescription using IQVIA Xponent data from November 2017 to October 2020. The monthly mean rate of adalimumab biosimilars was compared between incentive groups and subgroups depending on hospitals' prior experience with the etanercept experimental case.

RESULTS

General case hospitals had a significantly lower mean biosimilar uptake (16.7% vs 23.2%, p = 0.029) than those included in the experimental case. Twenty-three of the 40 hospitals in the experimental case and ten out of the 91 hospitals studied in the general case had already taken part in the etanercept experiment. Biosimilar uptake was higher, but not statistically significant, for hospitals with prior experience in the adalimumab general case group (p = 0.086).

CONCLUSIONS

This study confirmed that incentivizing close to physicians was more effective in increasing the biosimilar rate. It also suggested that previous incentive experience positively influenced biosimilar penetration.

Challenges of Incorporating Life Cycle Drug Pricing in Cost-Effectiveness Models: A Review of Methods and Modeling Suggestions

OBJECTIVES

This study aimed to conduct a review of existing methods used to incorporate life cycle drug pricing (LCDP) in cost-effectiveness analyses (CEAs), identify common methodological challenges, and suggest modeling approaches for prospectively implementing LCDP in CEA.

METHODS

Two complementary searches were conducted in PubMed, combined with hand searching and reference mining, to identify English language full-text articles that explored (1) how drug prices change over time and (2) methods used to apply dynamic pricing in cost-effectiveness models (CEMs). Relevant articles were reviewed, and authors discussed the common methodological practices used in the literature and their associated challenges on prospectively implementing LCDP in CEMs. For each key challenge identified, we provide modeling suggestions to address the issue.

RESULTS

We screened 1200 studies based on title and abstract; 117 were reviewed for eligibility, and 47 individual studies were included across both searches. Variations in prices over a product's life cycle are complex and multifactorial, and models applying LCDP in CEA varied in their methodology. We identified 4 key challenges to modeling LCDP in CEA, including how to model price trends before and after loss of exclusivity, how to capture the effect of price changes on future patient cohorts, and how to report results.

CONCLUSION

Accurately quantifying the impact of LCDP requires careful consideration of multiple aspects pertaining to both the evolution of drug prices and how to reflect these in CEA. Although uncertainties remain, our findings can aid implementation and evaluation of LCDP in economic evaluations.

Role of supply chain intermediaries in steering hospital product choice: Group Purchasing Organizations and biosimilars

Over 95% of hospitals in the United States use pooling alliances, known as Group Purchasing Organizations (GPOs), to purchase medications, devices, and supplies. While GPOs create savings for hospitals through lowered prices and reduced administrative burden, critics allege that these supply chain intermediaries reduce competition, particularly if GPOs concentrate purchasing from larger, dominant manufacturers. Using a mixed-methods design, we studied whether GPOs influence hospital purchasing behavior and explored the contracting mechanisms used by GPOs. Focusing on 4 high-cost biologic molecules that face competition from generic-like biosimilars between 2015 and 2019, we found that biosimilar uptake was 16%-23% higher among Traditional Medicare patients in hospitals associated with 2 of the 3 top GPOs as compared with smaller GPOs. The increase in biosimilar use was driven by single biosimilar brands that varied by GPO. Based on qualitative interviews, these 2 GPOs used more aggressive contracting strategies to steer member hospitals to specific biosimilar brands. To date, the use of GPOs and these aggressive contracting strategies appear to have increased biosimilar use, suggesting savings for payers and patients. However, single-source GPO contracting could inhibit competition or create shortages in the long term. Transparency on GPO practices and pricing strategies is needed for further GPO evaluations.

Landscape Analysis of Generic Availability for Oncologic Drugs

BACKGROUND

Improving generic drug development in oncology is a key long-term goal in providing safe, effective, and affordable care to patients with a diagnosis of cancer in the United States. There are multiple drug and non-drug related variables that may influence generic drug development. To illustrate pertinent associations relevant to generic drug competition in oncology, our study assessed variables that have potentially led to difference in generic competition as compared to drug products in other therapeutic areas, i.e., cardiovascular disease in this case.

METHODS

Using a combination of FDA and publicly available data, we categorized individual drug approvals from 1950 to 2021 with either an oncology or cardiovascular indication. Descriptive statistics highlighted the timeline of approval as stratified by indications. Machine learning methodology was used to assess variables associated with abbreviated new drug application (ANDA) availabilities (i.e., generic drug availabilities). Kaplan-Meier analysis with log-rank test compared the difference in the time to approval of first ANDA among products that were off-patent at the time of analysis. A multivariable Cox proportional hazards model with forward selection was used to identify variables (e.g., regulatory recommendation issued, dosage form) that were associated with ANDA availability among products that were off-patent.

RESULTS

434 separate reference listed drugs (RLDs) with varying strengths were identified, 212 (49%) for oncology and 222 (51%) for cardiovascular indications. Compared with cardiovascular products, a greater proportion of RLDs with an oncology indication were approved after 2000 (61% vs. 34%). Also, a smaller proportion of oncologic products had generics (49% vs. 80%). Machine learning methodology revealed RLD age, patent status, product complexity, sales/prescriptions, and regulatory recommendations as variables that were associated with generic availability. Among products off-patent at the time of analysis, the median time from RLD approval to the first ANDA approval was longer for oncologic products compared to cardiovascular products (15.4 years (95% CI 13.8, 17.9) versus 12.3 years (95% CI 10.7, 13.5), p = 0.008). Cox regression analyses identified the variables of product dosage form and regulatory recommendation of requiring patient enrollment for bioequivalence (BE) establishment as being associated with reduced likelihood of ANDA approval for oncologic drugs.

CONCLUSION

Oncology indications were found to have a longer time from RLD approval to first ANDA approval compared with cardiovascular drugs. Our work has identified variables that may influence time to ANDA availability, with the requirement of patient enrollment for BE assessment as one important opportunity for future stakeholder engagement and regulatory considerations.

Hospital-based health technology assessment of innovative medical devices: insights from a nationwide survey in France

OBJECTIVES

To better understand the process of hospital acquisition of innovative medical devices (MDs) and the hospital-based health technology assessment (HB-HTA) pathways in France, an in-depth study based on a quantitative approach is needed. The aim of the present study was to assess through a national survey how HB-HTA is currently implemented in French hospitals and to identify its level of formalization.

METHODS

A quantitative online survey was conducted among hospitals performing HB-HTA in France, with a focus on the acquisition of innovative MDs for individual use. The survey, conducted between March and June 2022, was developed by a scientific board composed of members of the French-speaking Society for HB-HTA.

RESULTS

Sixty-seven out of 131 surveyed hospitals with HB-HTA activities responded, including 29 university hospitals, 24 nonprofit private hospitals, and 14 local hospitals. Sixty-one respondents (91 percent) reported the existence of a process dedicated to evaluating innovative MDs; of these, 16 declared that their hospitals had a formalized unit with HB-HTA activity. These units were more frequently found in larger hospitals with more than 500 inpatient beds (n = 16, p = 0.0160) and in university hospitals (n = 12, p = 0.0158). No hospital reported any collaboration with HAS, the French national HTA agency.

CONCLUSION

A diverse range of HB-HTA organizations with different structural levels exist in France for MD procurement linked to the category of hospitals. The study highlights the need for recognition of HB-HTA activity at the regulatory level in France and for direct collaboration between HTA activities performed at local and national levels.

What About Offering a Financial Incentive Directly to Clinical Units to Encourage the Use of Biosimilars? Results of a Two-Year National Experiment in France

BACKGROUND

Regarding the low penetration of biosimilars in the French market, in 2018, the government introduced two mutually exclusive financial incentives to increase biosimilar use. They redirect 20% (general case) or 30% (experimental case) of the price difference between the reference product and its biosimilar to hospitals for every biosimilar delivered in retail pharmacies from these hospital prescriptions. The experimental case specifically targets prescribing clinical units.

OBJECTIVES

Our study aimed to assess whether the new payment scheme closer to physicians (experimental case) improved etanercept biosimilar penetration after 25 months.

METHOD

We evaluated hospital prescriptions using IQVIA Xponent data. The monthly number of etanercept boxes delivered in retail pharmacies was linked to the corresponding hospital prescription. The impact of the experimental case on the etanercept biosimilar rate was assessed by a difference-in-difference method.

RESULTS

Among the 39 hospitals studied in the experimental case compared with the 169 belonging to the general case, a similar growing trend of etanercept biosimilar use was observed before October 2018. At the start of the experiment, there was an acceleration of biosimilar penetration in the experimental group, until both groups reached a plateau. A significant double difference estimator of 9.72 percentage points in favor of the experiment confirmed this (p < 2.2.10-16).

CONCLUSION

The French experimental incentive appeared to be more effective at increasing biosimilar use. As it is expected to be implemented in all hospitals, the knowledge gained during this testing phase should allow adjustment of some of its terms and increase physician engagement.

Assessing US Pharmaceutical Policy and Pricing Reform Legislation in Light of European Price and Cost Control Strategies

This article compares the pharmaceutical pricing policies employed by public and private insurers in the United States with seven price and spending control strategies employed in the United Kingdom, France, and Germany. Differences between American and European policies explain why American pharmaceutical prices and per capita spending are higher than in European nations. The article then analyzes two recent bills as examples of significant American reform ideas-H.R. 3, the Elijah E. Cummings Lower Drug Costs Now Act (introduced in 2019) and the Build Back Better Act (BBBA, introduced in 2021)-and compares them with European cost control strategies. Key drug price provisions of the BBBA were incorporated into the recently enacted Inflation Reduction Act (IRA). H.R. 3 would have used an international (mostly European) price index to cap U.S. prices; the BBBA would cap Medicare prices at a discount from average U.S. market prices. Neither bill would employ the key cost control strategies that European nations do. Both bills would have significantly less impact on prices than legislation that employs European-style cost controls. This article proposes steps that Congress could take in line with European strategies to lower purchase prices and costs for patients. These measures would have to overcome political obstacles that currently stymie reform.

Association of Generic Competition With Price Decreases in Physician-Administered Drugs and Estimated Price Decreases for Biosimilar Competition

IMPORTANCE

Price decreases of biologic and biosimilar products in Medicare Part B have been minimal, even with biosimilar competition. Medicare reimburses clinicians for biologics and biosimilars differently than for brand-name and generic drugs, which has generated greater price reductions.

OBJECTIVE

To characterize the nature of price competition among brand-name and generic drugs under Medicare Part B and to estimate the cost savings to the program of subjecting biologic and biosimilar therapies to a similar price competition.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed all brand-name drugs and their approved generic versions as well as biologics and biosimilars that were reimbursed under Medicare Part B from quarter 1 of 2005 to quarter 2 of 2021. Two separate data sets were created: brand-name and generic drugs as well as biologics and biosimilars data sets. Brand-name products with generic versions that were introduced before 2005 were excluded, and so were vaccines.

EXPOSURES

Number of generic and biosimilar competitors over time.

MAIN OUTCOMES AND MEASURES

Price change as a percentage of the brand-name drug or biologic price in the quarter before generic or biosimilar competition. Price change was modeled using a linear, fixed-effects time series regression, with the number of generic or biosimilar competitors as the main covariate. Time was expressed as the number of quarters since the first generic or biosimilar competitor entered the market. Savings were estimated by projecting the regression model of brand-name and generic drug competition to observed biologic and biosimilar competition and by applying the estimated price reduction to actual Medicare spending for those products from 2015 to 2019.

RESULTS

Of the 988 Healthcare Common Procedure Coding System codes identified, 50 (5.0%) met the inclusion criteria for the brand-name and generic drug data set and 28 (2.8%) met the criteria for the biologic and biosimilar data set. The first generic competitor was associated with reduced drug prices by 17.0%, the second competitor with a 39.5% decrease, the third competitor with a 52.5% decrease, and the fourth and more competitors with a 70.2% decrease (price decline was measured from brand-name drug price before the first generic competitor rather than from price established with fewer competitors). If biologics and biosimilars were subject to the same Medicare reimbursement framework as brand-name and generic drugs, Medicare spending on these products was estimated to have been 26.6% lower ($1.6 billion) from 2015 to 2019.

CONCLUSIONS AND RELEVANCE

This study found minimal uptake of biosimilars and limited price reductions for biologics and biosimilars under the current Medicare Part B reimbursement policy. Adopting the bundled biosimilar reimbursement structure for biologic and biosimilar therapies may be associated with substantial savings and encourage greater biosimilar market entry.