High cost of drugs puts doctors in the middle
In an effort to make the U.S. healthcare system more transparent, Medicare began in 2013 to release records of reimbursements to doctors. That data revealed some startling numbers which left doctors in the middle between the drug makers and the government.
Among specialty doctor groups, ophthalmology tops the list with $3 billion in Medicare payouts. In 2012, 151 out of the 344 doctors billed more than $3 million. An ophthalmologist in Florida topped the list with $21 million in reimbursements, according to records released by Medicare.
Coming in second was hematology/oncology at $2 billion, followed by cardiology at $1.6 billion.
The reason ophthalmology ranks so high is because of the cost of drugs used to treat wet age-related macular degeneration (AMD). AMD is a chronic eye disease that causes blurred vision or a blind spot in the visual field, generally caused by abnormal blood vessels that leak fluid or blood into the macula. It is a leading cause of vision loss in Americans 60 years of age and older, affecting as many as 11 million.
The drugs are injected into the eye to limit leaking submacular vessels, prolonging patients’ vision, and preventing blindness.
One drug, called Lucentis, costs $2,000 per treatment, and another drug, Eyela, is $1,850 per treatment.
Ophthalmologists also use a third drug, called Avastin, to treat the condition, and its cost is $50 per treatment.
The reason for the discrepancy in price is that Avastin, while FDA approved to treat colon and other cancers, is not approved to treat AMD. Before the advent of Lucentis and Eyela, Avastin was tried, it worked, and patients clamored for it.
Avastin has proven to be effective, and numerous studies have concluded that there are minimal differences in risk between the three drugs, including those from the National Eye Institute and in reports from the American Academy of Ophthalmology.
A 2014 study from Health Affairs, a peer-reviewed health journal, shows that Medicare, and American taxpayers, could save $18 billion over the next 10 years if physicians switched to Avastin.
For doctors, however, the discrepancy is not just about cost.
“Among eye doctors, it’s well known that there is a lot of broad brush data out there (about the drugs), but that’s not really a fine grained enough picture. There is a lot of variability of how patients respond to the drugs, with more subtlety involved. There is also a fine level of detail with a very clear difference between the drugs,” said Stephen Meffert, an ophthalmologist at Northbay Vitreoretinal in Santa Rosa.
Northbay Vitreoretinal is one of the largest organizations in the area that treats AMC. In August, the office, among five doctors, performed 1,000 injections: 522 with Eylea, 429 with Avastin, and 130 with Lucentis.
One drawback of using Avastin, Meffert said, is that it tends not to last as long for patients, about 4 – 6 weeks compared to 6 – 8 weeks with Eylea.
For an elderly population, longer-acting drugs are advantageous in saving trips to the office for treatment, he said.
For the doctors, the decision of which drug to use is also affected by how the drug is prepared and marketed. The more expensive Lucentis and Eylea are delivered to ophthalmologists as convenient eye injectables, usually stored in the ophthalmologist’s office and available for use whenever they are needed. Avastin needs to be compounded by a pharmacy, an extra step that also carries a small degree of risk of contamination.
Aside from not lasting as long, there is also a liability issue with using non-FDA approved Avastin, and patients can also be resistant to using an off-label drug.
Dr. Patrick Caskey, also at Northbay Vitreoretinal, has been treating forms of macular degeneration for almost 30 years. He explained that cost is not a motivating factor to use a particular drug. He uses Avastin with about 30 percent of his patients, and rarely uses $2,000 per treatment Lucentis as the efficacy data doesn’t support the cost.
Meffert concurred.
“Lucentis is being used less and less as it doesn’t justify the cost. My job is to provide the best care for the patient in front of me. The cost is a secondary responsibility,” he said, adding if affordability is an issue for the patient it will be taken into consideration but it’s not the primary determinant.
According to Medicare records, in 2014 Meffert was reimbursed $1.5 million for Eylea and $367,000 for Lucentis. Caskey was reimbursed $1.5 million for Eylea and nothing for Lucentis. Information on Avastin reimbursements were not included.
The manufacturers of Lucentis and Eylea also offer strong resources with patient assistance programs to help subsidize the costs, he said.
