The Role of Biosimilars in Value-Based Oncology Care

December 19, 2018

Can expanded use of oncology biosimilar agents and supportive care agents help support the CMS' value-based care efforts?

Expanded use of oncology biosimilar agents and supportive care agents may serve as an important tool for clinicians participating in the Centers for Medicare & Medicaid Services’ (CMS’) value-based care initiatives, resulting in cost savings and effectively delivered, high-value care, according to a review article published in Cancer Management and Research.

Despite their documented benefits, the cost of biologics remains high and has spurred widespread debate and discussion. Biosimilars may be able to curb costs and provide access to more patients, as well as increase the choice of agents.

“Biologic agents-particularly in cancer but now for many other diseases, too-have revolutionized treatment,” said Gary H. Lyman, MD, MPH, Senior Lead, Healthcare Quality and Policy at Fred Hutchinson Cancer Research Center in Seattle and a professor at the University of Washington School of Medicine, in an interview with Cancer Network. “But they come with extraordinarily high price tags. Many of these drugs cost patients between $10,000 and $20,000 a month. Biosimilars [present an] opportunity as their patents expire to bring competition based on the U.S. market economy, and use that as a way to rein in prices on these very expensive drugs.”

Value-based care refers to maintaining quality of care while keeping costs down. The CMS created value-based care programs that financially incentivize improvements in quality of care as an alternative to fee-for-service reimbursement. Experts predict that CMS remuneration for cancer care will be increasingly linked to measures of performance in the near future-including price-cutting from the prescription of biosimilars.

Due to the rapidly rising costs of healthcare, in June 2016, the CMS deployed a novel voluntary Oncology Care Model (OCM) to make specialty care more effective. The program, which is scheduled to run until 2022, aims to provide better quality, better coordinated care at a lower price. The OCM tethers payment with provider performance based on specific quality metrics and practice reforms. To date, some oncology practices have already initiated payment arrangements with CMS that reflect both financial and performance accountability.

The OCM is composed of a two-part payment system. The first part is a per-beneficiary Monthly Enhanced Oncology Services (MEOS) payment, which helps physicians manage and coordinate cancer care. The second is a performance-based incentive program, under which performance-based incentive payment is figured retrospectively (semi-annually) based on the practice’s quality-measure achievements and savings in Medicare expenditures.

“Biosimilars may provide an additional tool for providers participating in value-based care initiatives such as the MSSP and OCM, resulting in cost savings and efficiencies in the delivery of high-value care through expanded use of biologic treatment and supportive care agents during episodes of care,” the authors concluded. “These savings may then be realized through the MSSP [Medicare Shared Savings Program], OCM, or other incentive programs, with benefits passed on to health care providers, payers, and patients alike.”