What About Offering a Financial Incentive Directly to Clinical Units to Encourage the Use of Biosimilars? Results of a Two-Year National Experiment in France

Abstract

Background: Regarding the low penetration of biosimilars in the French market, in 2018, the government introduced two mutually exclusive financial incentives to increase biosimilar use. They redirect 20% (general case) or 30% (experimental case) of the price difference between the reference product and its biosimilar to hospitals for every biosimilar delivered in retail pharmacies from these hospital prescriptions. The experimental case specifically targets prescribing clinical units.

Objectives: Our study aimed to assess whether the new payment scheme closer to physicians (experimental case) improved etanercept biosimilar penetration after 25 months.

Method: We evaluated hospital prescriptions using IQVIA Xponent data. The monthly number of etanercept boxes delivered in retail pharmacies was linked to the corresponding hospital prescription. The impact of the experimental case on the etanercept biosimilar rate was assessed by a difference-in-difference method.

Results: Among the 39 hospitals studied in the experimental case compared with the 169 belonging to the general case, a similar growing trend of etanercept biosimilar use was observed before October 2018. At the start of the experiment, there was an acceleration of biosimilar penetration in the experimental group, until both groups reached a plateau. A significant double difference estimator of 9.72 percentage points in favor of the experiment confirmed this (p < 2.2.10^-16).

Conclusion: The French experimental incentive appeared to be more effective at increasing biosimilar use. As it is expected to be implemented in all hospitals, the knowledge gained during this testing phase should allow adjustment of some of its terms and increase physician engagement.

Fig. 1

Patient circuit and rules for linking a patient prescription to a facility. In the French health system, patients can obtain prescriptions from hospital physicians who are mostly specialists or from local doctors (GPs or independent specialists). Treatments are then dispensed by retail pharmacies. As health facilities and physicians are registered with an official number (FINESS number and repository of practitioners’ word number [RPPS], respectively), prescriptions could be linked to them. According to incentive instructions, the last hospital to issue the prescription receives the remuneration

Fig. 2

Study timeline. From 2016 to 2020, the timeline places the study among the other main events that occurred for the etanercept biosimilar group in France (date of biosimilar launch, date of incentives)

Fig. 3

Difference-in-difference estimation explanation scheme (Source: https://www.publichealth.columbia.edu/research/population-health-methods/difference-difference-estimation). From November 2017 to September 2018 (period before the introduction of the experiment), the mean biosimilar rate (mBSr) difference was constant between the two hospital groups (parallel trend). After the introduction of the experiment, from October 2018 to October 2020, the mBSr rose faster for hospitals in the experimental case than in the general case. The difference-in-difference estimator consists of the difference between the observed outcome trend in the experimental group and the unobserved counterfactual outcome trend in the experimental group

Fig. 4

Calculation of hospital remuneration by incentives. The amount of hospital renumeration paid out each year is calculated by multiplying the volume of etanercept boxes delivered in retail pharmacies from the same hospital prescription by the biosimilar prescription rate (considering the private practitioner renewals) and a Factor R that is the annual compensation by box of biosimilar delivered. The R factor is given in the table for years 2018–2020 and differs in each group, as it corresponds to 20% (general case) or 30% (experimental case) of the price difference between the reference product and biosimilar for French national health insurance

Fig. 5

Etanercept market share (global volume of boxes) from November 2017 to October 2020 by hospital group. The total volume of etanercept boxes delivered by retail pharmacies is given for the months from November 2017 to October 2020. Each month, the total quantity of etanercept delivered comes from prescriptions from hospitals in the experimental case (black bars) and from hospitals in the general case and was consistent among months

Fig. 6

Etanercept biosimilar market (global volume of boxes) from November 2017 to October 2020 for the 208 hospitals studied. The total volume of etanercept biosimilar (BS) boxes delivered by retail pharmacies is given for the months from November 2017 to October 2020. Each month, the total quantity of BS delivered comes from prescriptions from hospitals in the experimental case (black bars) and from hospitals in the general case

Fig. 7

Monthly distribution of the rate of etanercept biosimilar (BSr) by incentive group. Dark boxplots illustrate the distribution of the etanercept BS rate for hospitals in the experimental case each month, from February 2018 to October 2020. White boxplots are the same for hospitals in the general case. Their concomitant observation allows us to observe that mean BS rates by group both grew until a plateau in the last 4 months and a difference in the BS rate distribution that is more concentrated in the experimental case