EHR can help automate biosimilar selection, streamline prior authorization
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An electronic health record tool has demonstrated the potential to automate the selection of biosimilars.
Biosimilars are projected to reduce spending on biologic drugs in the United States by an estimated $54 billion between 2017 and 2026. However, barriers such as prior authorization and step therapy processes for commercial insurance often prevent or delay use of these therapies.
Researchers at The Ohio State University Comprehensive Cancer Center — Arthur G. James Cancer Hospital and Richard J. Solove Research Institute developed an electronic health record tool that extracts information from the EHR to automate biosimilar selection based on the individual patient’s insurance and the hospital formulary preferences. This automation to simplify the prior authorization and approval processes.
“One of the great assets we had was that we were able to bring folks to the table who have great vision, whether in patient care, nursing and infusion, finance or supply chain,” Sarah Hudson-DiSalle, PharmD, RPh, FACCC, assistant director of infusion reimbursement services at The James, told Healio. “All those team members played a major role in the development of the biosimilar tool, and our multidisciplinary steering committee provided ideas on how to decrease the administrative burden and increase the usage of biosimilars across the medical center.”
The Association of Cancer Care Centers presented the biosimilar tool’s developers with one of its Innovator Awards, designed to recognize visionary and compelling ideas in oncology.
Healio spoke with Hudson-DiSalle about the advantages of biosimilars, the challenges related to their use, how her team developed the HER tool and the benefits it is designed to provide.
Healio: What motivated you to develop this tool?
Hudson-DiSalle: There are about 58 biosimilars on the market in the United States, and 17 of those agents impact cancer care delivery. It really has a very significant economic impact. Then we introduce the prior authorization process, which we know is one of the largest administrative burdens in health care. Insurance companies have preferred agents that we are required to use, and navigating that payer preference can be very difficult. I practice in a large academic medical center, and my teams work to get authorizations and denial management. We were seeing increased insurance denials and a lot of plan changes, and patients were becoming frustrated with us. The process needed to change. We initially were working off a spreadsheet that would include an insurance company and their preferred agents, and that might not have reflected what was populated in the patient’s treatment plan when it got placed into the chart. That was the impetus for this — we knew we could do better.
Healio: How did you develop the program and how does it work?
Hudson-DiSalle: We brought together a multidisciplinary steering committee of some very intelligent people, including oncology infusion leaders, people from our prior authorization team and finance team, our supply chain and our pharmacy informatics people. We asked them how we could do this. The committee produced ideas for how to decrease the burden and leverage our medical record for some type of automated tool.
Initially we had our finance folks create a calculator. Proprietary information is loaded into this calculator, including what our payment rate is based on the contracts from our facility, the individual payer preference lists, the contractual rate for that drug, and our contract price with the pharmaceutical company or from our group purchasing organization.
I think of it almost like an assembly line. We gather all this information, and it gets popped into the tool and then it produced a list of preferred products for each of our major payers. Then we used what EPIC calls an advanced order group. You can create rules within this order group. That rule will trigger looking at the primary payer, selecting the preferred product, and then automatically updating the treatment plan all the way through for that patient’s journey.
Healio: Will this program evolve or expand?
Hudson-DiSalle: Yes. We’ve already expanded it for use in IV iron replacement, and we’re in the process of working with 505(b)(2) agents, and then agents with different formulations that are chemically the same drug. This includes agents like leuprolide and other drugs within the same class of medications. These aren’t true biosimilars. There are some different steps we will have to take, and it might vary for different insurances.
Healio: Could other institutions replicate this effort and, if so, what advice would you give them about implementation?
Hudson-DiSalle: Yes, absolutely. This could be implemented at other centers, regardless of size. It helps to bring the right people to the table. That was one of our assets. All these folks play a major role in care, and we made sure everyone had a voice. EPIC has been very helpful to us in providing these opportunities for us to use this solution.
It’s also important to ensure that there is a regular review of the payer preferences for these medications and a review of our contracted rates. The list is checked each month, and some of the pricing is updated each quarter. It’s at the forefront of many of the conversations we have with our teams. We also check to be sure our advanced order groups are correct, and to make sure that maintenance occurs. That’s another piece for facilities to keep in mind — they should make sure they have a maintenance plan in place and have an ability to track that, as well.
Reference:
- Association of Cancer Care Centers. Leveraging the EHR to automate biosimilar selection (press release). Available at: https://www.accc-cancer.org/acccbuzz/blog-post-template/accc-buzz/2024/05/09/leveraging-the-ehr-to-automate-biosimilar-selection. Published May 9, 2024. Accessed Oct 14, 2024.
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