MY THOUGHTS - California’s SB 1094 could lower spending by expanding the use of biosimilars. But patients who have finally found a treatment that works deserve more than a cost-saving calculation.
California has a prescription drug affordability problem, and lawmakers are right to look for solutions. But there is a line that cost-cutting should not cross: changing a patient’s successful treatment primarily because another medication costs less.
That is the difficult question raised by Senate Bill 1094, legislation by state Sen. Akilah Weber Pierson that is now before Gov. Gavin Newsom. The measure would allow certain substitutions of brand-name biologic medications with lower-cost biosimilars while providing advance notice and allowing physicians to object.
The financial argument is significant. According to the figures reported in the legislative analysis, SB 1094 could reduce premiums paid by employers, enrollees and government by roughly $87.7 million annually. Depending on insurance coverage, the analysis also estimated potential annual out-of-pocket savings of $92 to $310 for the average Californian affected by the policy.
Those savings deserve attention. So does the extraordinary cost of specialty drugs. State data cited in reporting on the legislation show that specialty drugs represent a small percentage of prescriptions but an outsized share of prescription drug spending.
Biosimilars can be an important part of the solution. The U.S. Food and Drug Administration says an approved biosimilar is highly similar to its reference biologic and has no clinically meaningful differences in safety, purity and potency. That means this debate should not be framed as good medicine versus bad medicine. Biosimilars are legitimate, FDA approved treatment options.
The more difficult issue is who should decide when a patient switches.
For someone living with rheumatoid arthritis, lupus, ulcerative colitis or another serious autoimmune disease, finding an effective medication can be the end of a long and exhausting process. Patients may spend months or years trying different treatments, dealing with side effects, insurance authorizations and recurring symptoms before finally achieving stability.
Once that stability is achieved, it has value that cannot be measured solely by the price of a prescription.
A patient whose rheumatoid arthritis is finally controlled isn’t thinking about statewide pharmaceutical expenditures when she wakes up without debilitating joint pain. A patient whose ulcerative colitis is under control isn’t calculating insurance savings when he can finally return to work, school or an ordinary daily routine.
That is why California should be cautious about changing successful treatment principally for financial reasons.
Where Do the Savings Go?
There is another important question surrounding SB 1094: If switching patients to less expensive medications saves the health care system millions of dollars, how much of that money actually reaches patients?
Research and experience with biosimilars have raised questions about whether lower drug costs consistently translate into lower out-of-pocket costs. A medication may cost the health system less without producing an equivalent reduction in what an individual patient pays.
SB 1094 includes reporting requirements intended to provide greater transparency about where savings go. That is worthwhile, but transparency alone should not be the finish line.
If patients are being asked to accept medication changes partly in the name of affordability, Californians should be able to see measurable benefits, whether through reduced cost-sharing, lower premiums or slower growth in health care expenses.
Otherwise, California could generate impressive savings on paper while patients see little change in their own bills.
Keep Doctors and Patients at the Center
One of the most important safeguards in the legislation is physician involvement. The bill’s notice provisions are intended to give doctors time to review affected patients and object when maintaining an existing medication is medically appropriate.
That safeguard needs to be meaningful in practice.
A rheumatologist who has treated a patient for years knows the patient’s medical history, previous treatment failures, adverse reactions and response to the current medication. An insurer understandably considers costs. A physician must consider the individual patient sitting in the examination room.
Both considerations matter, but they are not interchangeable.
California can encourage biosimilars without treating physicians as obstacles to savings. If a doctor and patient determine that switching to a biosimilar is appropriate, the lower-cost medication can offer an important alternative. But when a physician determines that a stable patient should remain on an existing biologic, keeping that treatment should not require an unnecessarily burdensome administrative battle.
Affordability and Patient Choice Can Coexist
California does not have to choose between controlling prescription drug costs and protecting patients.
It can encourage competition from biosimilars. It can demand greater transparency from insurers and pharmaceutical companies. It can scrutinize rapidly rising prescription costs and look for ways to reduce premiums and out-of-pocket expenses.
At the same time, it can protect continuity of care and preserve meaningful physician oversight.
That is the balance policymakers should seek as SB 1094 reaches the governor’s desk.
Lower-cost medicine is important. So is giving Californians access to FDA-approved alternatives that can reduce health care spending. But the success of this policy should not ultimately be measured only by how many millions of dollars the health care system saves.
It should also be measured by what happens to the patients whose medications are changed.
Because when a treatment is finally working, the decision to change it should begin with medicine not merely money.
(Yonthan Mendal writes on Jewish community issues, antisemitism, Israel, and public policy. His articles focus on civic engagement, education, and issues affecting Jewish communities.) Photo: Vidar Sandnes
