High costs of biologics and their use for often long-term care poses a burden to healthcare systems, which could be alleviated by the adoption of biosimilars. Since cancer severely impacts older patients, it is important to evaluate the connection between biosimilars and value-based oncology care models.
The use of biologics has increased due to the increase in cancer diagnoses, earlier treatment practices, and improved patient outcomes; these variables, along with high manufacturing costs and increasing healthcare costs, have increased cancer spending.
U.S. organizations are developing oncology-focused value assessment frameworks. Some aid physicians and patients in making educated treatment decisions, while others may be beneficial in coverage and reimbursement choices. These frameworks only serve as a guide, however, and have not been adopted as part of an official policy.
The U.S. Centers for Medicare & Medicaid Services (CMS) has created frameworks intended to improve quality of care for Medicare beneficiaries. One CMS model was designed to move from fee-for-service (FFS) to more value-based care. This payment model focused on high-quantity—but not necessarily high-quality—health care. The Medicare Access and Children’s Health Insurance Program Reauthorization Act implemented the CMS Quality Payment Program (QPP), which launched in January 2017 and will be completely implemented by January 2019. The QPP has two payment tracks: The first is a Merit-Based Incentive Payment System, which focuses on predetermined care measures based on quality. The second is Advanced Alternative Payment Models (APMs), which incentivize clinicians to provide high-quality care while remaining economically strategic.
The Oncology Care Model (OCM) is an Advanced APM that seeks to provide patients with high-quality care at equal to or better than FFS standards. Under OCM, providers must meet certain metrics and practice reforms, which is a benchmark for payment consideration. As of July 2017, 192 practices and 14 commercial payers were participating in OCM.
Physician practices participating in OCM take part in a two-part payment system: a per-beneficiary Monthly Enhanced Oncology Services (MEOS) payment and a performance-based incentive payment. The MEOS payment aids in management and coordination of patient care, and the performance-based incentive payment is based on the practice’s semi-annual quality measure progress, as well as how efficiently it minimizes Medicare expenditures.
Under the OCM, biosimilars can help reduce costs and increase accessibility to biologic treatments. In addition to their lower cost, biosimilar presence in the market will likely cause manufacturers to lower the prices of the reference products. According to the RAND Corporation, biosimilars will save the U.S. healthcare system an estimated $13 billion to $66 billion between 2014 and 2024.
For these savings to occur, biosimilars must be implemented. A Biosimilars Forum 2015-2016 survey revealed that U.S. specialty physicians—including oncologists—still lack a certain degree of knowledge about biosimilars. Knowledge gaps include using biosimilarity, the FDA’s approval process for biosimilars, the required evidence for a biosimilar safety and efficacy claims, and the definition of interchangeability.
Despite these gaps, healthcare providers are warming up to the idea of biosimilars, according to a different survey. When deciding whether to prescribe biosimilars overall, U.S. physicians put the greatest value on efficacy (89%), safety (81%), and patient costs (72%). As more biosimilars hit the market and physicians gain more knowledge, utilization of biosimilars will likely increase. For this to happen, and for potential savings to occur, healthcare providers must be educated on biosimilars. As biosimilars gain traction, value-based incentive programs will benefit providers, payers, and patients.
Source: Cancer Management and Research
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