Adventist Health
Roseville, California
Due to diagnosis related group (DRG) billing for inpatient hospital services, selecting a formulary biosimilar with the lowest acquisition cost has become standard of practice. In outpatient settings, the trend is shifting towards identifying the payor preferred reference or biosimilar product. With the exponential growth of biosimilar FDA approvals and their insurance coverage nuances, health systems are faced with either adopting a single biosimilar to their infusion center formulary OR permitting commercial payor coverage to dictate which product to dispense. While the first option minimizes inventory, payor fee schedules change quarterly, which can cause complications if the formulary biosimilar isn’t authorized by a specific insurance. To capture maximal reimbursement without compromising clinical efficacy, there is a need for an enhanced multidisciplinary approach between infusion pharmacists and prior authorization (PA) staff. This manuscript outlines how Adventist Health implemented a robust biosimilar selection strategy to maximize profit margins by analyzing acquisition costs and reimbursement rates and leveraged application of a Biosimilar Matrix amongst their multidisciplinary outpatient infusion team.
To optimize biosimilar utilization, Adventist Health developed a Biosimilar Matrix which identified the formulary biosimilar with the highest profit margin for each of their top payors. During the initial stage of the insurance approval process, PA staff leverage this matrix to identify the most financially beneficial biosimilar to dispense based on a patient’s insurance coverage. System leadership collaborated with infusion staff to develop an optimized workflow. This incorporated PA staff Biosimilar Matrix application, and subsequently, pharmacist biosimilar EHR substitution, all while minimizing disruption to current processes. Most biosimilars do not have interchangeability status. Therefore, a systemwide Biosimilar Substitution Policy was created to permit pharmacist substitution of an insurance approved, preferred biosimilar without further provider intervention. By applying constructive feedback from staff, Adventist Health was able to make improvements throughout the process to meet daily infusion demands. Successful implementation required multidisciplinary collaboration, strong communication, robust data analytics, and effective project management.
Adventist Health initially selected three of its hospital-based 340B eligible infusion centers to pilot this modified workflow. Upon realizing immediate reimbursement value through successful application, this initiative was implemented on a rolling basis at the remaining hospital-based infusion centers. In 2021, Adventist Health’s biosimilar utilization comprised 11% of their total spend across five reference products. Eight months post implementation, biosimilar utilization increased by 55%, generating greater than $1,000,000 in additional revenue from drug profit across seven hospital-based infusion centers.
As biosimilar approvals continue to inundate the market, a more sophisticated approach to product selection is essential to meet the demands of commercial payor coverage. Despite requiring a more complex execution, opting for a payor-specific biosimilar strategy can reap a larger financial benefit.
Top Row, Left to Right: Nuthana Naidoo, Hanna Kenney, Jose Guzman Garcia
Bottom Row, Left to Right: Shelly Oppong, Thomas Jacobsen, Colin King