In total, 44 interviews were carried out. Participant characteristics are shown in ESM 1.
Towards Improved Biosimilar Use in Clinical Practice
Stakeholder challenges and proposals to improve biosimilar switch implementation are shown in Fig. 1.
What to Consider When Deciding to Switch
Most physicians, pharmacists, and nurses found that patients may be switched safely and felt reassured by the available data regarding switching. Although some patients also felt reassured by the available data, several remained hesitant about switching. Some patients requested studies over a longer timeframe to better evaluate the long-term effects of switching. Furthermore, the willingness to switch could depend on the product’s complexity. Several interviewees argued that the uncertainty surrounding switching mostly resulted from misinformation from the pharmaceutical industry.
Several HCPs advocated for a pragmatic approach when deciding whether to switch. Initiating only bio-naïve patients with a biosimilar in certain cases, such as shorter treatment periods, was preferred: “It would be a lot of hassle and time investment to switch a patient in the last four months of [their] treatment.” Also, several patients favoured only starting new patients with a biosimilar, regardless of the treatment setting (acute vs. chronic).
Forcing a switch was believed to be counterproductive and could result in distrust of biosimilars. Across stakeholders, most interviewees felt that the physician should remain in control of treatment decisions and be able to decide whether to switch based on individual patient circumstances. It was believed that giving patients the option to return to the reference product would reassure patients.
Several interviewees argued for continued monitoring and ensuring product traceability when switching.
How to Implement a Switch and Minimize the Nocebo Effect
Almost all interviewees indicated that switching should follow a structured process that is agreed upon and carried out by an aligned HCP team. Several pharmacists explained that the switch should follow a stepwise approach. First, a discussion about the switch should be organized among the relevant stakeholders, allowing for shared decision making. Second, the patient should be informed that a switch will be organized at the next administration. Some interviewees referred to the Dutch Association of Hospital Pharmacists (NVZA) toolbox  as a supporting tool to implement a structured switch. Careful planning was considered necessary: “building trust takes a lot of time, and only one incident to dissolve [it] again.”
Several interviewees contended that the HCP team must be well informed and educated to coherently communicate and transfer confidence to the patient. Informing patients with an aligned, unified message was deemed essential. Verbal and non-verbal signals from HCPs could also impact the patient’s perception: “If the nurse looks unsure and cannot respond satisfactorily to questions, it doesn’t build patient’s trust.” Several interviewees believed that the physician’s confidence is key to minimizing a nocebo effect, as “the patient is confident when the physician is confident.” Moreover, a specialized nurse may help to guide the switch process more smoothly.
Several interviewees voiced that patient concerns and possible nocebo effects need to be taken seriously: “To patients, those effects feel very real” and “Switching them from an active drug that induced remission of a previously very impactful disease is very sensitive.” One patient remarked that distinguishing between a nocebo-related and true side effect may prove challenging. Several interviewees mentioned that communication should be fully transparent to build trust between patient and provider.
Almost all interviewees mentioned that starting a dialogue with the patient and informing them about the switch is important. Several nurses, physicians, and regulators considered that dedicating time to explain the change to the patient was a necessity. Although interviewees generally agreed that patients should be informed about the switch, they disagreed about exactly how to involve them, with most believing that patients should not be involved in the decision making and others arguing that patients should be involved to reduce reluctance, avoid nocebo effects, and build trust in their HCPs.
There was no consensus over the level of detail that patients should receive about biosimilar concepts. One nurse argued, “If the HCP tells the patient that the medicine is good, it is not very interesting for the patient if it is an original drug or a biosimilar.” Several nurses voiced that patient communication should not be overcomplicated: “Now we said ‘Well, we don’t have the original product, so we treat everybody with the biosimilar’, and I haven’t heard any problems.” One nurse questioned the need to inform patients about biosimilars altogether: “It is an ethical problem. Must you inform patients when in fact there is no difference for them as far as you expect?” Another interviewee mentioned that no questions were asked when they switched to a filgrastim biosimilar: “Everybody called it another type of growth factor. As it was communicated that the product had all the same side effects and the same precautions were needed, there was no big deal about it.” Several interviewees considered that striking a balance between the amount and type of information to provide to patients is challenging: “A patient might be triggered to think that there is something wrong if a lot of emphasis is put on the switch.”
Most interviewees mentioned that patients need to be informed as to why a switch is being made and about its positive impact. Some interviewees counter-argued that not all patients are interested in the cost benefit. Furthermore, it was argued that it should be made clear to the patient that less expensive does not equal inferior when discussing the financial benefits of the switch.
Generally, it was believed that information should be centred on explaining that the biosimilar is equally as safe and effective as the reference product and that patients may expect the same outcomes. Both nurses and patients considered that reassurance regarding safety was important. Some regulators claimed that the nocebo effect may be minimized if HCPs and patients were informed that biosimilars are only authorized if their efficacy and safety profiles are shown to be equal to those of the reference product.
Several interviewees across the groups advised that information should include the practical implications for the patient: “what does the switch mean for the patient.” It was mentioned that patients should be provided with a contact in case they have questions or experience adverse effects. Other patient-communication aspects that were deemed important were to inform patients in a timely manner, provide multiple opportunities to discuss the switch, and provide follow-up after the switch. Some patients mentioned that additional follow-ups could serve as opportunities to monitor for side effects.
It was stated that patient information should be understandable, readable, and concise. Layman’s terms (such as those used in the patient biosimilar question & answer brochure from the European Commission [EC]  or the Dutch Medicines Evaluation Board biosimilar booklet , repeatedly mentioned as examples) should be used, and materials should be available in the patient’s first language. Providing written information that patients can read and re-read was considered important. Several interviewees argued that there is no one-size-fits-all approach for good patient communication and that tailoring the communication strategy and level of detail to the needs and wishes of the patient is important.
Several interviewees mentioned that special consideration should be given to patients who self-administer their therapy, as they may need to receive training about the injection device.
One physician argued that patient communication should focus on the medicine’s international nonproprietary name, as this requires a less active mindset shift among patients when switching as physicians are able to maintain their treatment terminology.
Several HCPs and one patient mentioned that the patient’s treatment outcome expectations should be managed, as response to treatment may naturally wane over time for certain types of medicines. Patient trust in the HCP may be negatively affected if this were to coincide with the timing of the switch: “It would only take one patient treated with infliximab that reached tolerance at the same time as the switch to undermine our complete programme.”
Furthermore, interviewees mentioned that objectively assessing any changes before and after the switch by monitoring specific disease parameters for certain product types and patients may help to reassure patients and HCPs throughout the switch process.
In summary, the general opinion was that a switching operation should be set up as a multi-stakeholder project, with clear decision lines, education for a unified approach, and a well-planned implementation and follow-up procedure.
Figure 2 provides a structured overview of key steps regarding switch management.
Multiple Switching, Switching Between Biosimilars of the Same Reference Product, and Switching Between Administration Routes
Several HCPs and patients had reservations about multiple switching and indicated that constant changes should be avoided. It was argued that more information and data were needed because of a lack of experience with this. Some interviewees mentioned that data on multiple switches are increasingly being generated. Several physicians contended that multiple switching discussions are misused to “bring noise to the discussion,” as it suggests that the physician could lose control over the process. Overall, most physicians and nurses maintained that frequent switches should be avoided because it could lead to traceability issues and confusion among the HCPs and patients involved. It was mentioned that agreements about multiple switching should be made with the payer or hospital: “Now we decide that we can switch everyone, but that we cannot switch again within the first years. This is not based on evidence, it’s based on distrust, thinking that there are long-term effects. Over the next years, a discussion about multiple switching is needed.” Questions arose about what would be considered an acceptable interval between switches. Furthermore, several interviewees argued that a pragmatic approach should be taken to avoid multiple switching of patients receiving chronic treatment: “Patients cannot be switched all the time.” Also, some reasoned that the cost savings of a second switch could be limited.
Most physicians and pharmacists considered switching between biosimilars of the same reference product acceptable: “For me it is the same as switching between reference product and biosimilar. You have again a high level of similarity.” It was not deemed necessary to provide confirmatory data in this regard. Sharing experiences and registries of biosimilar-to-biosimilar switches was considered informative for stakeholders. Some regulators doubted that developers would be interested in investing in biosimilar-to-biosimilar switch studies. Most nurses were hesitant about biosimilar-to-biosimilar switching because of a lack of practical experience with this.
It was argued that switching between different administration routes (i.e. from subcutaneous to intravenous products or vice versa) occurred often in clinical practice and that physicians considered it clinically unproblematic. However, changes at organizational and logistical levels would be required. In addition to these practical considerations, it was suggested that the patient’s preference should be considered, as the change could have an impact on the patient’s life (e.g. home vs. hospital administration, or the level of contact with HCPs). Most interviewees would prefer to maintain patients receiving subcutaneous treatments on their current treatment but start treatment-naïve patients with the lower-priced intravenous formulation. In contrast, one pharmacist argued that it would be fair to ask patients to switch back to intravenous administration if it would allow more patients to be treated. Participants also argued that, depending on the hospital’s organisation, any discounts provided by biosimilar competition for intravenous products would need to offset the possible increase in day clinic costs.
Stakeholder Opinions Regarding Substitution for Biologicals
Overall, most physicians and pharmacists were not against pharmacist substitution per se, provided that the physician is informed about the change, stressing the importance of physicians remaining in control over the treatment. Several patients also emphasized that the patient should be informed about any change. Physicians strongly opposed automatic substitution (i.e. change by the pharmacist without informing the physician), as this would lead to a loss of control and possibly to multiple subsequent transitions. Most nurses did not object to substitution as they deemed it a physician/pharmacist decision and responsibility: “If we agree that biosimilars are as safe and effective as the originator, and we can treat more people and reduce the cost for the healthcare system, why shouldn’t we do automatic substitution?”
Overall, several interviewees considered that substitution practices for biologicals would likely evolve over time and perhaps be introduced in the future. Most interviewees emphasized that introducing substitution for [monoclonal antibody (mAb)] biologicals would be premature, as the level of trust in biosimilars is still considered too fragile: “Everyone is still learning about biosimilars.” Enforcing or prematurely introducing substitution could negatively affect the acceptance of biosimilars. Most pharmacists compared the discussions about substituting biologicals with those at the time of generic market entry. Similarly, the debate was considered to stem from fears that the patient would not respond as well to the treatment and that there would be problems tracking which product the patient receives. Another pharmacist argued that, as the originator also changes over time because of manufacturing changes, the patient is already exposed to different versions over time.
In addition to psychological considerations, several regulators and pharmacists explained that organizational and policy barriers exist: “Substitution could be done, but the conditions need to be appropriate.” An information system that allows good pharmacist–physician communication is necessary. Furthermore, some pharmacists mentioned that a clear mandate from national authorities is required. Several interviewees also stated that an adequate system for reporting adverse reactions is essential. Pharmacists should also be trained to educate patients about a possible (change in) injection device. Alternatively, specialized pharmacies could be nominated to carry out substitution.
Furthermore, interviewees also noted that differentiation between therapeutic areas and product types could be applied (proportionality of risk) and physicians should be allowed to veto a substitution if appropriately motivated. For example, where product effects are known to possibly wane over time, development of tolerance at the time of substitution could adversely affect the patient–HCP relationship.
Stakeholder considerations regarding substitution for biologicals are shown in Fig. 3.
Towards Improved Stakeholder Willingness to Use Biosimilars: Biosimilar Value Proposition and Stakeholder Incentives
Stakeholder-specific considerations are presented in Figs. 4 and 5.
Reasons to Use Biosimilars and Possible Differentiators Between Products
Generally, the lower price of biosimilars was recognized as the most important benefit, with some viewing it as the only benefit. Several interviewees acknowledged that, with the introduction of market competition, savings could also be derived from reduced prices for reference products. Some interviewees argued that biosimilars should not be favoured per se over the reference product, as the price of the reference product will generally also decrease.
Interviewees often mentioned that lower treatment prices could translate to improved patient outcomes as more patients could be treated within the same budget or patients could be treated earlier in the treatment pathway as it becomes more cost effective to do so.
Some interviewees reasoned that biosimilar savings could create budgetary headroom for the reimbursement of innovative medicines. Some mentioned increased freedom for physicians to prescribe new therapies as a benefit.
Some interviewees argued that reasons to use biosimilars will vary regionally. In regions with good access to biological therapies, savings derived from biosimilar use are expected to be reinvested in the reimbursement of innovative medicines, whereas in regions with limited access, biosimilar entry could translate to increased patient access.
Several physicians and regulators indicated that biosimilars could also improve delivery of care, including improvements in the administration device or by providing administration routes that do not (yet) exist with the reference product. Furthermore, packaging differences can potentially impact positively on patient co-payments (e.g. introducing more units per package while retaining the same out-of-pocket cost). Respondents thought these differentiation strategies could stimulate originator companies to also introduce extra services, and one patient mentioned that the availability of different products could positively impact the patient’s product choice.
Some pharmacists mentioned that the availability of biosimilars (i.e. the presence of different suppliers of the product) could also be beneficial to secure supply in case of shortages.
Several interviewees remarked that more effort is required to ensure that the market becomes or remains sufficiently attractive, ensuring continued investment in the development of new and market presence of already approved biosimilars. A few interviewees mentioned that decreased interest in the biosimilar segment and subsequent competition may lead to shortages. “If prices are driven down too much, some players will go out of the market, certainly in smaller markets, putting such markets at risk of drug shortages.”
Most interviewees identified price as the main, or sole, differentiator between the reference product and its biosimilar(s), as they perform equally in terms of efficacy and safety. Some interviewees considered factors beyond price when choosing between products. These included supply reliability, value-added services such as information support, and the delivery device and injection material for subcutaneous products. Some nurses argued that the patient friendliness of the product and its ease of use should be assessed together with the patient. The presentation of different concentrations was mentioned by a few pharmacists as another possible differentiator.
It was argued that additional services should be considered as a bonus and should not trump price differences. Some interviewees questioned the value of some differentiators, such as the citrate-free formulation for some adalimumab products: “How much weight do we want to award to these, sometimes, low impact differences?” Several pharmacists advocated for transparent award criteria to assess differentiators.
Motivating Stakeholders to Use Biosimilars
Creating Awareness About Medicine Prices and Calling Upon Stakeholders’ Societal Responsibility
Some interviewees expressed the need for increased awareness of medicine prices among HCPs and the public. Several regulators and physicians argued that it is the duty of the physician to prescribe and that of the society to use medicines in a cost-effective manner: “As a society, we have the obligation to look at the economic aspects once the product is considered equal.” Some physicians and regulators argued that decisions should be made from a common good perspective (“what is best for society”) and that the stakeholders involved should not expect compensation. As a Danish nurse mentioned, “It is money for the Danish people, it is not for our hospital to gain money. It is not the Danish way to gain something. Savings should go towards the society.” Most pharmacists agreed because they considered biosimilar implementation to be part of the job. Some physicians mentioned that discounts should be sufficiently substantial to offset the effort invested in biosimilar implementation. Some argued that the government should take a more active role in guiding which product(s) to use.
Raising Awareness About Biosimilar Benefits and Reporting Usage Data
Several physicians and pharmacists felt that information about the benefits derived from biosimilar use was often lacking but was an important motivational factor for biosimilar use. One regulator mentioned that a powerful incentive for patients to use biosimilars would be increased patient access, but some nurses asserted that such arguments are not always convincing for patients: “You should treat patients at patient level and not tell them, ‘You create access for many other patients worldwide.’ It’s not convincing.” Several patients and nurses explained that it is difficult to persuade patients who are satisfied with their current treatment to switch. In contrast, one physician indicated that a few patients asked to be treated with the biosimilar. Earlier treatment access when using a biosimilar might be a more convincing incentive, as it could lead to a personal benefit for a patient. Overall, several interviewees across groups considered that the benefits derived from biosimilar use should be communicated more clearly: “As sustainability of healthcare is for all of us, we should try to stimulate education about the impact of biosimilars as much as possible.”
Several patients mentioned that there is no tangible incentive for patients to use biosimilars when treatment is fully reimbursed and that the willingness to switch may be greater in settings where these medicines are only partly reimbursed. Furthermore, with regard to motivating patients, one Dutch interviewee mentioned that lowering the patient’s ‘own risk’ insurance payment when agreeing to switch has been effective in the Netherlands.
Apart from improving awareness about biosimilar benefits, some physicians believed another stimulus for biosimilar use would be to transparently report biosimilar usage data among prescribers and hospitals, as this provides useful insights into colleague prescriber behaviour and, subsequently, gives confidence to less experienced stakeholders.
Allocation of Savings: Balancing Societal and Stakeholder Benefits and the Need for Transparency
Some HCPs and patients felt that the savings should (partially) remain at the departmental level or within the therapeutic area that helped to realize the savings. Others were indifferent to the allocation level as long as savings were reinvested in healthcare. Some interviewees expressed concerns that savings would be reinvested towards structural or practical improvements (e.g. hospital infrastructure) and not towards patient care per se. Some argued that the government should decide on how to allocate savings. Overall, interviewees asked for transparency regarding the allocation of money saved.
Providing Tangible Incentives When Switching: Applying a Gainsharing Model
Most physicians and nurses and some regulators considered that a tangible incentive would be appropriate to compensate stakeholders when biosimilar use requires significant HCP effort in terms of planning and time, i.e. when switching. Several regulators and HCPs considered that physicians lack the motivation to invest energy and time in a switch if the impact is solely on an overarching, more abstract, financial level. Furthermore, it was argued that the incentive should be proportional to the effort (e.g. a larger incentive for switching to a subcutaneous product, as this may require more time for injection device training). Most interviewees considered direct financial benefits on an individual level to be inappropriate but considered that allocating part of the realized savings to improving patient care, such as financial support for the hospital ward or hiring new staff (i.e. gainsharing), would be an adequate and acceptable stimulus. An additional nurse may help balance the extra workload and enable more active follow-up of the switch. Reinvesting some savings in increased monitoring to reassure patients was mentioned as another gainsharing example. Some physicians mentioned that publication opportunities may also be a motivator.
Considerations for Incentive Design in Hospital vs. Ambulatory Care Settings
Several physicians highlighted that defining incentives for biosimilar implementation in ambulatory care, particularly in countries where these are not part of the hospital budget, can be challenging. Some interviewees deemed that in the hospital context, a tender would be a satisfactory lever, lessening the need for accompanying incentives. As some pharmacists explained, introducing a negative incentive by lowering the product reimbursement level (e.g. 80% of list price) by payers (such as in Belgium) motivated hospitals to organize competitive tenders, ensuring product acquisition costs below the lowered reimbursement limit.