Biosimilars can provide significant savings and revenue for health systems, but how do you operationalize a streamlined workflow for providers and pharmacy to best support your patients? Baptist Health found success by dedicating a resource to lead a cross-functional workgroup consisting of Providers, Nursing, Data Analysts, Prior-Auth, Patient Assistance, and Pharmacy to build out an automated strategy for biosimilars within their Electronic Medical Record, which is Epic.
While biosimilars are highly similar to their FDA‐approved biologic reference product, there are very few that are considered therapeutically equivalent. Therefore, each biosimilar has its own billing code and reimbursement, which would necessitate a new prior authorization with the patient’s insurance if you want to switch a patient across products. For this reason, the scope of this initiative was limited to new patients initiating therapy.
One of the first challenges you face is insurance dictating what products you can use on a patient. The dedicated resource was able to pull the top 80% of insurance plans for patients that received the biosimilar reference product and identified which biosimilar(s) and/or reference products were covered by each insurance company.
Next a Request-for-Proposal (RFP) went out to manufacturers for sub-340B, sub-WAC, and discounted GPO pricing. Once those were received, a financial evaluation was performed by the data analytics team. The financials will be specific to your institution, since pricing, charging, and reimbursement will vary across health systems. Biosimilars will not always be the most cost advantageous agent and sometimes a reference product makes the most fiscal sense.
Armed with what products are available under each insurance plan, and the profitability of each of those agents, Baptist identified the preferred agents for each insurer. The Epic Beacon team then built the preferred agents as the default in the treatment plan. So, when a provider is initiating therapy the preferred biosimilar or reference product for that insurer will default in the order. The provider can still change the product, if for example a pegfilgrastim patient was more appropriate to receive the Neulasta OnPro onbody device because they have travel concerns, and it will save them a subsequent trip for their second dose. Providers loved this solution, as this required no additional steps to their workflow, and they have the flexibility to change the order to a different agent if they deem appropriate.
While this has been a very effective and efficient solution for Baptist’s providers and patients, this is not a one-time exercise. Reimbursement and pricing changes quarterly, so every quarter a new financial evaluation is performed. Automation is key to continually evaluating the profitability of outpatient therapies, like biosimilars, because of the constant changes and the lack of resources to perform all the necessary financial evaluations. More to come around automating analytics in a future article. Hope you enjoyed and please comment below or reach out directly with any questions.
