July 17, 2020

Considerations for Managing Changes in Biosimilar Policies

Payor policies, reimbursement changes and cost fluctuations of biosimilar are creating complexity for gastroenterologists and rheumatologists who have in-office infusion centers.

The introductions of Infliximab biosimilars over the last five years has significantly changed the landscape for rheumatologists’ and gastroenterologists’ in-office infusion centers. Some payors are instituting policies mandating biosimilar switches, while reimbursement and costs are changing rapidly for Infliximab, creating an administrative burden and impacting revenue for independent practices who are already under pressure.

History of Biosimilars: Remicade; Renflexis and Infliximab

Remicade (infliximab) was introduced in 1998 and was a game changer for patients suffering for Rheumatoid Arthritis. The drug was widely adopted by rheumatologists, in-office infusion centers became a staple for rheumatologists adding an important source of ancillary revenue to independent practices facing significant revenue pressure. In the early 2002 infliximab was approved for other indications, such as Crohn’s disease, and opened the doors for Remicade to be prescribed by Gastroenterologists. For years, prescribing Remicade was relatively simple, as reimbursement and costs were generally stable from quarter to quarter. In 2015, Pzizer released the first infliximab biosimilar, Inflectra, while [Merck] released the second infliximab, Renflexis in 2017.


For years, adoption of biosimilars was slow,as physicians were unwilling to move stable patients off of Remicade and onto biosimilars. However, in 2018, several payors began instituting polices that i)required new infliximab patients to be started on biosimilars and ii) mandated Remicade patients be switched to biosimilars; a practice defined as "Non-Medical Switching". Adoption has increased, leading to a more complex Infliximab market.

In the last several years Rheumatologists and Gastroenterologists have seen reimbursement for Infliximab decline significantly. Quarterly changes, posted by CMS, are making it more difficult for physicians to accurate forecast revenue for their practice, even as their overhead costs remain steady, if not increase. To make the situation more complicated, the Remicade or biosimilar question must be answered on a patient by patient basis, as patient-level insurance plans can drastically change what drug may be administered.

How can Gastroenterologists and Rheumatologists navigate this environment?

There are a few processes gastroenterologists and rheumatologists should follow to ensure patients are able to follow the Infliximab treatment plan most appropriate for them.

1.   Develop a proforma per therapy type: Each quarter, you should create a proforma monitoring the reimbursement of Infliximab and its biosimilars so that you may determine the economic feasibility of each option. Understand that the reimbursement will change depending on the payor type, so you should incorporate multiple plans into the proforma.

2.   Create a list of all of your infliximab patients and their corresponding insurance plans and treatment plans: You will want to track down and stay up to date with each patients’ payor policy to ensure they are able to receive the treatment you prescribe. This can be very cumbersome and complicated, as these policies can be updated once a quarter.

Cross-referring the list of patients and their policies, with information about the economic feasibility of each therapy is crucial to be able to ensure i) you are able to administer the therapy your patients require and ii) your practice is able to do so in a financially beneficial way.

A Better Option

Another option is partnering with a management company, like OI Infusion. OI Infusion manages in-office infusion centers on behalf of multiple gastroenterologists and rheumatologists; helping them to navigate a successful biosimilar strategy and removing the risk and confusion with setting up and operating their in-office infusion center. If you are interested in learning if an in-office infusion center is right for your practice, or if a management company could be beneficial, please schedule a consultation.

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