Non-Medical Switching: A Lose-Lose Scenario? Lessons for Biosimilar Players
Non-medical switching (NMS) seems attractive on paper but often leads to poor clinical outcomes and higher overall costs to the payer. As biosimilars begin to enter the US market, what can manufacturers learn from previous attempts to change a patient’s medication?
Idrisa Mshelia, Senior Associate; Dr. Priya Kar, Director; and Dr. Luke Solon, Vice President
With increasing healthcare costs, including the high price of specialty drugs, non-medical switching (NMS) seems like an intuitive idea for US payers to reduce costs
The reality is that, in many situations, NMS not only leads to poorer outcomes for patients, but also higher overall costs to the payer. NMS is an established cost-saving practice where insurers or pharmacy benefit managers (PBMs) switch a patient’s medication from one on which they are established and stable to another that is cheaper. The policy is largely implemented in chronic diseases with large patient populations, such as diabetes, asthma, rheumatoid arthritis, psoriasis, psoriasis arthritis and Crohn’s disease. NMS can be implemented by insurers excluding drugs from their formularies or placing specific drugs in a specialty tier, with drugs in this tier having prohibitive out-of-pocket costs to the patient, thus making them unaffordable.¹ The increased financial burden on a patient to continue their medication often forces them to switch to the cheaper option preferred by the plan. Regardless of the approach, switching can cause significant distress for patients, as shown by a poll from the Alliance for Patient Access (n=800) to gain insight into the true impact of NMS on patients. Sixty percent of patients reported initial difficulty in finding a medicine that worked for them, with a further 88% reporting that they relied on their medicine to go about their daily lives. When asked why they had switched, patients reported various reasons: health plans had excluded their drugs from the formulary (41%), their medicines had been moved into a specialty tier (33%) or their plans had decided to withdraw validity of co-pay coupons (10%). What’s more, communication to the patient regarding the decision to switch is often “buried” in paper documents, with 48% of patients only apparently learning of the change at the pharmacy when attempting to purchase their medicine.²
NMS can negatively affect patient outcomes, including causing new side effects
Beyond the initial distress of the enforced switch, NMS can also result in re-emerging symptoms that were previously well managed or adverse interactions of the new medicine with other drugs. From a patient perspective, NMS can come with significant negative clinical, economic and healthcare utilization implications that patient advocacy groups (PAGs) have been clearly voicing to lawmakers and legislators. Despite being designed to cut insurer costs, NMS has been linked with increased overall healthcare costs. One study demonstrated that patients with rheumatological and gastroenterological diseases forced to switch mid treatment incurred 37% higher medical costs due to more ER visits, hospitalizations and physician management and 26% higher overall costs than patients continuing on successful medications.³ NMS also places an additional burden on providers by increasing the administrative burden, such as for prior authorizations and appeals. Moreover, there is a loss of prescribing autonomy. Physicians report that NMS concerns impact their clinical judgment and ability to treat according to guidelines. Further, patient care may be negatively impacted by NMS as a result of medication adherence or abandonment, thus increasing OOP costs and prescribing errors.
NMS will have critical implications for manufacturers in terms of the upcoming biosimilars of drugs with a significant budget impact on the healthcare system
To date, biosimilar penetration has been low in the US, with payers still demanding a greater discount in comparison to the originator molecules. Biosimilars of Lucentis, Eylea, Avastin and, most importantly, Humira will be launching within the next 2-3 years. As payers increasingly implement NMS, this is seen as a “dress rehearsal” for the advent of biosimilars of blockbuster drugs. The method of switching to biosimilars may not be a clear-cut process, as exemplified in the UK where stable RA patients were moved from the etanercept originator to a biosimilar: Despite the etanercept originator being more expensive, 26% of patients who switched treatment reverted to the originator or to another biosimilar. An increase in payer costs was also shown due to the increased use of healthcare resources following the switches.⁴ Where do we go from here? Increasing drug costs to both payers and patients and the lack of penetration of biosimilars in the US market are likely to continue. Both payers and patients would benefit from lower drug costs if the potential downsides of switching can be managed appropriately. As it currently stands, it would seem that any switching, whether for medical or non-medical reasons, is best enacted through dialogue with both patients and their physicians. Most of the evidence to date suggests NMS leads to a “lose-lose” scenario unless a clear communication and implementation plan is put in place, along with consideration of long-term health outcomes and clarification of costs. Prescient’s understanding of the complex US payer dynamics and formulary maintenance strategies can inform manufacturers how best to maintain or achieve preferable coverage and access for their products.
- Non-Medical Switching: Impact on Movement Disorders Patients’ Access and Care. International Parkinson and Movement Disorder Society. https://www.mdsabstracts.org/abstract/non-medical-switching-impact-on-movement-disorders-patients-access-and-care/ (September 2019).
- A Study of the Qualitative Impact of Non-Medical Switching. Alliance for Patient Access (AfPA). https://admin.allianceforpatientaccess.org/wp-content/uploads/2020/02/AfPA_Qualitative-Impact-of-Non-Medical-Switching_Report_Feb-2019.pdf (February 2019).
- Impact of Non-Medical Switching on Healthcare Costs: A Claims Database Analysis. Value in Health, Volume 18 Issue 3 (May 2015): PA252.
- Costs Associated with Non-Medical Switching from Originator to Biosimilar Etanercept in Patients with Rheumatoid Arthritis in the UK. Journal of Medical Economics, Volume 22 Issue 11 (November 2019): P1162-1170.