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Dang S, Parke DW, Sodhi GS, Eichenbaum D, Nielsen J, Danzig C, Lalwani G, Moinfar N, London N, Kimura A, Jumper JM, Lord K, Sheth V, Pieramici D, Orlin A, Madson A, Horton M, Blim J, Cao JA, Thompson J, Khanna S, Wykoff CC, Shah AR. Anti-VEGF Pharmaceutical Prior Authorization in Retina Practices. JAMA Ophthalmol 2024:2820324. [PMID: 38935350 PMCID: PMC11211988 DOI: 10.1001/jamaophthalmol.2024.2217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/28/2024] [Indexed: 06/28/2024]
Abstract
Importance Anti-vascular endothelial growth factor (VEGF) intravitreal injections, a mainstay of treatment for many retinal diseases to optimize visual outcomes, have been included in prior authorization (PA) initiatives. However, if clinicians are extremely accurate in their use of anti-VEGF medications, such administrative burdens may need reconsideration. Objective To quantify PA for anti-VEGF medications (aflibercept, ranibizumab, and bevacizumab) that were approved and determine associated administrative burdens experienced by retina practices. Design, Setting, and Participants Prospective multicenter quality improvement study conducted from January 2022 through June 2022, and participants were 9 private retina practices across the US. Main Outcomes and Measures Overall rate of approval of PA requests, reasons for requesting PA, and overall rate of delay of care resulting from PA procedures. Results In total, 2365 PA requests were recorded, 2225 of which met inclusion criteria. Overall, 2140 (96.2%) requests were approved. The most common reason for requesting PA, at 64% (1423 of 2225 requests), was reauthorization for a previously utilized medication. Of the 2140 approvals, 59.6% (1277) resulted in a delay in care greater than 24 hours, and 40% (863) were given on the date of service. In a granular analysis of a subset of delayed approvals, 23.9% (173 of 725) were approved within 1 day, 15.9% (115 of 725) were approved within 2 to 3 days, 21.5% (156 of 725) were approved within 4 to 7 days, 26.3% (191 of 725) were approved within 8 to 31 days, and 12.4% (90 of 725) were approved within more than 31 days. Overall, PA denial for step therapy was 2.9% (65 of 2225) of requests and uncovered diagnoses was 0.9% (20 of 2225) of requests. The median staff time spent to obtain a single PA was 100 (range, 0-200) minutes. Conclusions and Relevance In this study, PA requests were almost always approved but led to a delay in patient care in most patients. The current study suggests that the PA process may not be effective for retina specialists if these results can be generalized to other practices in the US and if less burdensome and less costly approaches could result in similar approval rates. Potential short-term solutions may include eliminating the PA process for bevacizumab and reauthorizations for established patients.
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Affiliation(s)
- Sabin Dang
- The Retina Institute, St Louis, Missouri
| | | | | | | | | | - Carl Danzig
- Rand Eye Institute, Deerfield Beach, Florida
| | | | | | | | | | | | - Ken Lord
- Retina Associates of Southern Utah, St George
| | | | | | | | - Allison Madson
- American Society of Retina Specialists, Chicago, Illinois
| | - Monica Horton
- American Society of Retina Specialists, Chicago, Illinois
| | - Jill Blim
- American Society of Retina Specialists, Chicago, Illinois
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Desai S, Sekimitsu S, Rossin EJ, Zebardast N. Trends in Anti-Vascular Endothelial Growth Factor Original Medicare Part B Claims in the United States, 2014-2019. Ophthalmic Epidemiol 2024:1-10. [PMID: 38315793 DOI: 10.1080/09286586.2024.2310854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/20/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE To characterize trends in use of and expenditure for the intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents aflibercept, ranibizumab, and bevacizumab among the population enrolled in Original Medicare from 2014 to 2019. METHODS The Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File was used to extract Medicare Part B fee-for-service outpatient injection claims data submitted by ophthalmologists. Multivariable linear regression models were used to evaluate the association between reimbursement, ophthalmologist availability, and agent administration rate. RESULTS Between 2014 and 2019, 17,588,995 intravitreal injection claims were filed by 4218 US ophthalmologists. Medicare costs for anti-VEGF injections increased from 2.51 B USD in 2014 to 4.02 B USD in 2019. Increased state-level ophthalmologist availability and incremental increases in average reimbursement amounts were found to be significantly associated with a 6.8-fold variation in 2019 overall anti-VEGF injection rates across states. CONCLUSIONS Medicare injection rates and costs for anti-VEGF injections have both increased between 2014 and 2019, largely driven by increased aflibercept use. There is a significant association between ophthalmologist availability and anti-VEGF injection rate on the state level, suggesting access to care may contribute to the observed state-level disparities in intravitreal injection rates. Further characterization of factors contributing to the state-level variation in injection rates of individual anti-VEGF agents may help inform interventions promoting equitable access to and use of these drugs.
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Affiliation(s)
- Sarishka Desai
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | | | - Elizabeth J Rossin
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Nazlee Zebardast
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
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3
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Hostovsky A, Moroz I, Katz G. Aflibercept monotherapy or bevacizumab first for diabetic macular edema. Indian J Ophthalmol 2024; 72:S260-S264. [PMID: 38271421 DOI: 10.4103/ijo.ijo_2107_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/22/2023] [Indexed: 01/27/2024] Open
Abstract
PURPOSE Clinical outcome and switch patterns with bevacizumab first treatment strategy for patients with newly diagnosed neovascular age-related macular degeneration (nAMD). METHODS Retrospective observational study of the number of intravitreal injections of bevacizumab and treatment switch in patients who started intravitreal bevacizumab injections between January 1, 2016 and December 30, 2018. RESULTS From January 1 2016 to December 31 2018, 608 eyes of 565 patients started intravitreal injections of bevacizumab for a new diagnosis of nAMD. Average visual acuity (VA) at presentation was 0.60 logarithm of the minimum angle of resolution (logMAR), which improved to 0.47 after six injections (P < 0.001) and decreased to 0.63 at the last follow-up (P = 0.543). Switch of treatment was recommended for 190 eyes (31.3%), and of them, 91 patients (15%) were switched during the first 6 months and defined as primary failure of bevacizumab. The switch of treatment resulted in a statistically significant improvement in VA in the first 6 months after the switch. The gain in VA was not sustainable over time. CONCLUSION Bevacizumab first treatment strategy produced results that were comparable to previous real-world outcomes publications of ranibizumab and aflibercept treatment with low rates of failure of bevacizumab treatment. Treatment switch to second-line treatment yielded a significant VA improvement, mainly in patients with primary bevacizumab failure.
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Affiliation(s)
- Avner Hostovsky
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Singh Y, Aderman CM, Song Z, Polsky D, Zhu JM. Increases in Medicare Spending and Use after Private Equity Acquisition of Retina Practices. Ophthalmology 2024; 131:150-158. [PMID: 37557920 DOI: 10.1016/j.ophtha.2023.07.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/19/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023] Open
Abstract
PURPOSE Private equity (PE) firms increasingly are acquiring physician practices in the United States, particularly within procedural-based specialties such as ophthalmology including retina. To date, the potential impact of ophthalmology practice acquisitions remains unknown. We evaluated the association between PE acquisition and Medicare spending and use for common retina services. DESIGN Retrospective difference-in-differences analysis using the 20% Medicare fee-for-service claims dataset from January 1, 2015, through December 31, 2019. PARTICIPANTS Eighty-two practices acquired by PE during the study period and matched control practices. METHODS We used novel data on PE acquisitions of retina practices linked to the 20% sample Medicare claims data. Retina practices acquired by PE between 2016 and 2019 were matched to up to 3 non-PE (control) practices based on characteristics before acquisition. Private equity-acquired practices were compared with matched control practices through 6 quarters after acquisition using a difference-in-differences event study design. Data analyses were performed between August 2022 and April 2023. MAIN OUTCOME MEASURES Medicare spending and use of common retina services. RESULTS Relative to control practices, PE-acquired retina practices increased the use of higher-priced anti-vascular endothelial growth factor (VEGF) agents including aflibercept, which differentially increased by 6.5 injections (95% confidence interval, 0.4-12.5; P = 0.03) per practice-quarter, or 22% from baseline. As a result, Medicare spending on aflibercept differentially increased by $13 028 per practice-quarter, or 21%. No statistically significant differences were found in use or spending for evaluation and management visits or diagnostic imaging. CONCLUSIONS Private equity acquisition of retina practices are associated with modest increases in the use of higher-priced anti-VEGF drugs like aflibercept, leading to higher Medicare spending. This finding highlights the need to monitor the influence of PE firms' financial incentives over clinician decision-making and the appropriateness of care, which could be swayed by strong economic incentives. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Yashaswini Singh
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | | | - Zirui Song
- Department of Health Care Policy, Harvard Medical School, and Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel Polsky
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island; Carey Business School, Johns Hopkins University, Baltimore, Maryland
| | - Jane M Zhu
- Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon.
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Zhang C, Friedman S, Mruthyunjaya P, Parikh R. The Biosimilar Paradox: How Anti-Vascular Endothelial Growth Factor Biosimilars Could Increase Patient and Overall Health Care Costs. Ophthalmology 2023; 130:966-972. [PMID: 37116720 DOI: 10.1016/j.ophtha.2023.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/28/2023] [Accepted: 04/20/2023] [Indexed: 04/30/2023] Open
Abstract
PURPOSE Anti-vascular endothelial growth factor (VEGF) medications for intraocular use are a major and increasing cost, and biosimilars may be a means of reducing the high cost of many biologic medications. However, a bevacizumab biosimilar, which is currently pending Food and Drug Administration (FDA) approval (bevacizumab-vikg), paradoxically may increase the cost burden of intravitreal anti-VEGF agents, because off-label repackaged drugs may no longer be allowed per the Drug Quality and Security Act (DQSA). We aimed to investigate the potential impact of biosimilars on costs in the United States. DESIGN Cost analysis of anti-VEGF medications. PARTICIPANTS Medicare data from October 2022 and previously published market share data from 2019. METHODS Average sales prices (ASPs) of ranibizumab, aflibercept, and bevacizumab were calculated from Medicare allowable payments. The ASPs of biosimilars were calculated from wholesale acquisition costs from a representative distributor. The cost of an intraocular bevacizumab formulation is modeled at $500/1.25-mg dose and $900/1.25-mg dose. MAIN OUTCOME MEASURES Costs of anti-VEGF drugs to Medicare Part B and patients. RESULTS If an intraocular bevacizumab biosimilar were to be priced at $500, costs to Medicare would increase by $457 million from $3.01 billion to $3.47 billion (15.2% increase). Patient responsibility would increase by $117 million from $768 million to $884 million. Similarly, if intraocular bevacizumab were priced at $900, Medicare costs would increase by $897 million to $3.91 billion (29.8% increase), and patient responsibility would increase by $229 million to $997 million. If bevacizumab were $500/dose, switching all patients currently receiving ranibizumab or aflibercept to respective biosimilars would compensate for only 28.8% of the increased cost. Current prices of ranibizumab and aflibercept biosimilars would have to decrease by an aggregate of 15.7% to $616.80/injection, $1027.97/injection, and $1436.88/injection for ranibizumab 0.3 mg, ranibizumab 0.5 mg, and aflibercept, respectively. CONCLUSIONS An FDA-approved bevacizumab biosimilar for ophthalmic use could increase costs to the health care system and patients, raising concerns for access. This increase would not be offset by ranibizumab and aflibercept biosimilar use at current prices. These data support the need for an exemption of section 503B of the DQSA and continued use of repackaged off-label bevacizumab. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Casey Zhang
- Department of Ophthalmology, Grossman School of Medicine, NYU Langone Health, New York, New York
| | | | | | - Ravi Parikh
- Department of Ophthalmology, Grossman School of Medicine, NYU Langone Health, New York, New York; Manhattan Retina and Eye Consultants, New York, New York.
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Fairbanks AM, Husain D. Controversies and Disparities in the Management of Age-Related Macular Degeneration. Semin Ophthalmol 2023; 38:134-142. [PMID: 36602457 DOI: 10.1080/08820538.2022.2152705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Age-related macular degeneration is a leading cause of blindness in patients aged 50 years and older. Prior to the 21st century, there were no effective treatments for this devastating disease. However, the last 20 years have heralded the development of treatments for both the nonexudative and exudative forms. The invention of AREDS vitamin supplements and anti-VEGF therapies forever changed the treatment of dry and wet age-related macular degeneration, respectively. The rapid adoption and expansion of these vision preserving treatments has created controversy regarding their cost, burden of administration, development, and use of new technologies, genetic considerations, and observed societal disparities. Many of these controversies and disparities persist today and will require further research to resolve.
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Affiliation(s)
- Aaron M Fairbanks
- Retina Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Deeba Husain
- Retina Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
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Siddiqui ZA, Dhumal T, Patel J, LeMasters T, Almony A, Kamal KM. Cost impact of different treatment regimens of brolucizumab in neovascular age-related macular degeneration: A budget impact analysis. J Manag Care Spec Pharm 2022; 28:1350-1364. [PMID: 36427338 PMCID: PMC10373014 DOI: 10.18553/jmcp.2022.28.12.1350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND: Brolucizumab is a new anti-vascular endothelial growth factor (anti-VEGF) approved for treating neovascular age-related macular degeneration (nAMD). Multiple treatment regimens are available for treating nAMD. These regimens include manufacturer-recommended regimens, pro re nata (PRN) regimens, and treat-and-extend (T&E) regimens, which are based on clinical practice guidelines and data observed in the real-world clinical setting, classified as real-world evidence (RWE). Most budget impact models predict the financial consequences of adding a new drug to the formulary based on the manufacturer-recommended regimen. With different anti-VEGF treatment regimens being used in nAMD by ophthalmologists, it is OBJECTIVE: To estimate the budget impact of different treatment regimens of brolucizumab in nAMD from a US payer perspective. METHODS: A Microsoft Excel-based budget impact model was developed for different treatment regimens of brolucizumab over a 1-year time frame from a US payer perspective. A separate analysis was performed to estimate the budget impact from a US patient population perspective. Model inputs included drug costs, administration costs, physician visit costs, and disease monitoring costs. Outcomes in the budget impact model included the cost per member per month, annual health plan cost, and the US patient population-based annual cost. Based on the prevalence of nAMD in public and commercial health plans, a scenario analysis was conducted on the US population to account for the differences in the drug cost to the public and commercial payers. Further, 1-way sensitivity analyses were conducted to test model assumptions and uncertainty in model inputs. RESULTS: The addition of brolucizumab to the formulary increased the net budgetary impact under PRN and T&E regimens. The maximum increase in expenditure for a hypothetical health plan with 1 million enrollees was associated with the PRN regimen ($824,696), followed by the T&E regimen ($163,101). In contrast, using the manufacturer-recommended and RWE regimens led to an annual saving of $93,068 and $94,170 for the health plan, respectively. In the US patient population model, the introduction of brolucizumab resulted in savings in the manufacturer-recommended ($30.99 million) and RWE regimens ($31.35 million) but led to an increase in annual expenditures for the PRN ($274.58 million) and T&E ($54.30 million) regimens. CONCLUSIONS: Payers need to evaluate the cost impact of different treatment regimens of existing and new anti-VEGFs when making formulary decisions in nAMD management. DISCLOSURES: Mr Siddiqui, Ms Dhumal, Dr Patel, and Dr LeMasters have nothing to disclose. Dr Kamal has received research funding from Cerevel Therapeutics, served as a consultant to Pfizer/Cytel Inc, and received honoraria from Pharmacy Times Continuing Education. Dr Almony has served as a consultant to Cardinal Health and received honoraria from Pharmacy Times Continuing Education and Prime Education.
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Affiliation(s)
| | - Trupti Dhumal
- School of Pharmacy, West Virginia University, Morgantown
| | - Jay Patel
- College of Public Health, Temple University, Philadelphia, PA
| | | | - Arghavan Almony
- Carolina Eye Associates, Southern Pines, NC, and School of Osteopathic Medicine, Campbell University, Lillington, NC
| | - Khalid M Kamal
- School of Pharmacy, West Virginia University, Morgantown
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Wai KM, Begaj T, Patil S, Chen EM, Miller JB, Kylstra J, Aronow ME, Young LH, Huckfeldt R, Husain D, Kim LA, Vavvas DG, Eliott D, Mukai S, Gragoudas ES, Patel NA, Sobrin L, Miller JW, Parikh R, Wu DM. The Effect of Sample Medication Use on Subsequent Anti-VEGF Agent Selection for Neovascular Age-Related Macular Degeneration. Semin Ophthalmol 2022; 37:902-908. [PMID: 35923110 DOI: 10.1080/08820538.2022.2107398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
PURPOSE Medication samples of anti-VEGF agents can represent a good option for retina specialists to provide timely treatment for newly converted neovascular age-related macular degeneration (nvAMD) while prior-authorizations (PA) are pending. Our study examines the effect of medication sample use (ranibizumab or aflibercept) on future anti-vascular endothelial growth factor (VEGF) agent selection in nvAMD. DESIGN Retrospective cohort study. PARTICIPANTS nvAMD patients who underwent an initial anti-VEGF injection with a sample medication were compared to nvAMD control patients who never received a medication sample. METHODS Charts from 2017 through 2020 were reviewed for data regarding demographics, anti-VEGF agent selection, and visual acuity outcomes for both groups. The utilization of different anti-VEGF agents in each group was compared at various time points using chi-square tests for independence of proportions. MAIN OUTCOME MEASURES Anti-VEGF agent selection for the first four injections and at one year were examined. RESULTS Adherence to the initial agent was high between first and subsequent injections (2nd, 3rd, 4th injection, and 1 year) in sample (96.2%, 95.9%, 91.9%, 93.4%, respectively), and control groups (98.1%, 94.2%, 94.9%, 87.8%, respectively). Bevacizumab usage was significantly lower among eyes receiving samples relative to controls at the second (1.9% vs. 38.7%, p < .001), third (3.1% vs. 41.3%, p < .001), fourth injections (4.7% vs. 40.4%, p < .001), and at 1 year (0% vs. 33.8%, p < .001). Aflibercept usage was significantly higher in sample eyes relative to controls at the second (78.3% vs. 43.4%, p < .001), third (76.3% vs. 41.5%, p < .001), and fourth injections (76.7% vs. 43.4%, p < .001), and at 1 year (77.0% vs. 52.7%, p < .001). CONCLUSIONS Sample medications in nvAMD may be initiated for many reasons, including awaiting PA approval. Our study found that eyes receiving a sample anti-VEGF agent (ranibizumab or aflibercept) for their initial injection were less likely to receive bevacizumab at future visits relative to eyes that did not receive an anti-VEGF sample, even after one year of treatment. Given the persistent use of more expensive medications at subsequent injections for patients who were initiated on samples, insurance payors may consider waiving PA requirements for bevacizumab to avoid a paradoxical increase in health-care costs.
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Affiliation(s)
- Karen M Wai
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Tedi Begaj
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Sachi Patil
- Department of Ophthalmology and Visual Sciences, New York University School of Medicine, New York, New York
| | - Evan M Chen
- Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - John B Miller
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Jan Kylstra
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Mary E Aronow
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Lucy H Young
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Rachel Huckfeldt
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Deeba Husain
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Leo A Kim
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Demetrios G Vavvas
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Dean Eliott
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Shizuo Mukai
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Evangelos S Gragoudas
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Nimesh A Patel
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Lucia Sobrin
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Joan W Miller
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Ravi Parikh
- Department of Ophthalmology and Visual Sciences, New York University School of Medicine, New York, New York.,Manhattan Retina and Eye Consultants, New York, NY
| | - David M Wu
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Williams GA, Repka MX, Glasser DB. The Promise and Perils of Biosimilars in Ophthalmology. Ophthalmol Retina 2022; 6:537-539. [PMID: 35809913 DOI: 10.1016/j.oret.2022.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 06/15/2023]
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Sood S, Mandell J, Watane A, Friedman S, Parikh R. Cost of Ranibizumab Port Delivery System vs Intravitreal Injections for Patients With Neovascular Age-Related Macular Degeneration. JAMA Ophthalmol 2022; 140:716-723. [PMID: 35708679 DOI: 10.1001/jamaophthalmol.2022.1819] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance The study team investigated costs associated with the ranibizumab port delivery system (PDS) for neovascular age-related macular (nAMD), an alternative to conventional intravitreal anti-vascular endothelial growth factor (VEGF) injections. Objective To investigate costs of intravitreal anti-VEGF injections vs ranibizumab PDS for patients with neovascular AMD (nAMD). Design, Setting, and Participants This cost analysis used trial data and Medicare reimbursement rates and included patients with nAMD who were receiving ranibizumab, aflibercept, bevacizumab injections, or ranibizumab PDS. Main Outcomes and Measures The number of intravitreal ranibizumab, aflibercept, and bevacizumab injections to break even with costs of ranibizumab PDS. Total direct medical costs over 1 year and 5 years for the ranibizumab PDS arm with refills at fixed 6-month intervals compared with monthly or bimonthly injections were calculated using Medicare rates. Scenario and sensitivity analyses accounted for uncertainty and variation. Results The mean (SD) number of ranibizumab, aflibercept, and bevacizumab injections to break even with the cost of ranibizumab PDS with 1 refill was 10.8 (1.3), 9.3 (1.1), and 34.5 (4.2), respectively. Ranibizumab PDS with fixed 6-month refills over 1 year cost $21 016 ($2102). Comparatively, monthly intravitreal ranibizumab cost $1943 (95% CI, -$3047 to $6932; P = .34) more, aflibercept cost $5702 (95% CI, $253-$11 151; P = .04) more, and bevacizumab cost $16 732 (95% CI, -$20 170 to -$13 294, P < .001) less. For bimonthly injections, aflibercept cost $7658 (95% CI, -$11 649.52 to -$3665.61; P = .006) less. Over 5 years, monthly intravitreal ranibizumab projected to cost $25 581 (95% CI, $2275-$48 887; P = .04) more, aflibercept cost $44 374 (95% CI, $18 623-$70 125; P = .008) more, and bevacizumab cost $67 793 (95% CI, -$82 501 to -$53 085; P < .001) less than PDS with fixed refills (mean [SD] cost, $89 218 [$8921]). For bimonthly injections, aflibercept cost $22 422 (95% CI, -$40 287 to -$45,56; P = .03) less. In scenario analyses, ranibizumab PDS with refills as needed offered cost savings compared with real-world intravitreal ranibizumab or aflibercept use at 5 years but not at 1 year. Conclusions and Relevance In this cost analysis, ranibizumab PDS with 1 refill cost more than intravitreal ranibizumab or aflibercept injections if less than or equal to approximately 11 or 10 injections, respectively, are required within the first year. Long term, if less than 4.4 and 3.8 injections are needed per refill, intravitreal ranibizumab and aflibercept is lower cost. Ranibizumab PDS costs more than intravitreal bevacizumab injections throughout scenarios.
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Affiliation(s)
- Shefali Sood
- New York University School of Medicine, New York
| | - Jordan Mandell
- Miller School of Medicine, University of Miami, Miami, Florida
| | - Arjun Watane
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut
| | | | - Ravi Parikh
- Manhattan Retina and Eye Consultants, New York, New York.,Department of Ophthalmology, New York University School of Medicine, New York
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Guest JM, Malbin B, Abrams G, Parendo A, Das S, Okeagu C, Ross BX, Kumar A, Lin X. Accuracy of intravitreal injection volume for aflibercept pre-filled syringe and BD Luer-Lok one-milliliter syringe. Int J Retina Vitreous 2022; 8:27. [PMID: 35382900 PMCID: PMC8981608 DOI: 10.1186/s40942-022-00375-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/20/2022] [Indexed: 11/23/2022] Open
Abstract
Background To evaluate the accuracy of intravitreal injection volume of the pre-filled syringe (PFS) in which aflibercept is packaged compared to the BD Luer-Lok 1-mL syringe. Methods Ophthalmologists injected their typical intravitreal volume for aflibercept using either the PFS or BD Luer-Lok 1-mL syringe for 5 times each. The injected fluid was weighed using a micro-scale and converted to volume. The volume of fluid injected was also evaluated when the 0.05 mL line on the PFS was lined up to the tip or base of the dome-shaped plunger. Results Injection volume was measured for 12 physicians. The average injected fluid volume was 74.22 ± 15.87 µL for PFS and 53.42 ± 4.61 µL for the BD Luer-Lok 1-mL syringe (p < 0.0001). The average deviation in volume injected for the PFS was higher compared to the BD Luer-Lok 1-mL syringe (11.36 µL vs. 3.35 µL, p < 0.0001). When the PFS was lined up with the tip of the dome-shaped plunger at the 0.05-mL line, the average injected volume was 71.03% higher. Conclusions The intravitreal injection volume and variability using the new PFS were significantly higher than the volume injected using the BD Luer-Lok 1-mL syringe previously used, potentially leading to higher rates of visually significant elevation of intraocular pressures.
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American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry and the IRIS Registry Analytic Center Consortium. OPHTHALMOLOGY SCIENCE 2022; 2:100112. [PMID: 36246182 PMCID: PMC9560568 DOI: 10.1016/j.xops.2022.100112] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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13
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Watane A, Kalavar M, Patel M, Yannuzzi N, Vanner EA, Kuriyan AE, Sridhar J. A 5-Year Analysis of Physician-Industry Interactions, Physician Gender, and Anti-VEGF Use in US Ophthalmologists. Semin Ophthalmol 2021; 36:804-811. [PMID: 34024227 DOI: 10.1080/08820538.2021.1922710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: To explore physician gender, industry payments, and prescribing habits of anti-vascular endothelial growth factor (VEGF) agents.Methods: Retrospective review of U.S. ophthalmologists prescribing and receiving industry payments for aflibercept and/or ranibizumab (brand anti-VEGF injections) between August 2013 to December 2017.Results: Men receiving industry payments were older and had longer post-residency experience than women (both P < .001). Men were more likely to receive industry payments (P = .01), receive >5 payments (P = .003), and receive payments totaling >$1000 (P = .008). Men administered more injections on average than women when receiving >3 industry payments (P < .001) or when receiving >$100 (P < .01). On multivariate analysis, years in practice, male gender, number of payments, and total value of payments were independent factors associated with the number of brand injections administered (all P < .001).Conclusions: A positive association between industry payments and brand anti-VEGF use was identified, however, causality was not determined. Gender bias may be present in physician-industry relationships.
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Affiliation(s)
- Arjun Watane
- Department of Ophthalmology, Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine, Miami, FL
| | - Meghana Kalavar
- Department of Ophthalmology, Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine, Miami, FL
| | - Marissa Patel
- Department of Ophthalmology, Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine, Miami, FL
| | - Nicolas Yannuzzi
- Department of Ophthalmology, Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine, Miami, FL
| | - Elizabeth A Vanner
- Department of Ophthalmology, Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine, Miami, FL
| | - Ajay E Kuriyan
- Mid Atlantic Retina, Retina Service for Wills Eye Hospital, Philadelphia, PA
| | - Jayanth Sridhar
- Department of Ophthalmology, Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine, Miami, FL
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14
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Browning DJ, Greenberg PB. Quantifying Conflict of Interest in the Choice of Anti-VEGF Agents. Clin Ophthalmol 2021; 15:1403-1408. [PMID: 33854294 PMCID: PMC8039845 DOI: 10.2147/opth.s298575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/08/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To quantify the economic incentives associated with the choice of anti-VEGF drugs for retinal diseases. Methods An economic model was created based on the distribution of use and number of injections of bevacizumab (B), versus aflibercept or ranibizumab (AR); published Medicare reimbursement rates; published rebates; estimated unreimbursed drug use; estimated use of drug company samples; and published costs-of-drugs. Differential economic incentives associated with the choice of drugs were calculated over a range of distributions of drug use. Results The splits in drug choice ranged from 92% AR/8% B to 31% AR/69% B, and in annual injection numbers from 2000 to 6000 with a median of 4000 in one 5-person retina service. Assumed values for rebates were 1% for drug company rebate, 1% for group purchasing organization rebate, and 5 for number of unreimbursed injections per year. The differential economic incentive of a 92% AR/8% B split compared to a 31% AR/69% B split for the median annual number of injections was $266, 893. Conclusion Using real-world data, the economic incentive associated with a choice of more expensive anti-VEGF drugs is large. Accounting for unreimbursed drug use and the cost of additional staff required to manage expensive drug inventory does not nullify the incentive. To what degree this financial incentive influences ophthalmologists’ choice of drugs is unknown, but not trivial. Financial disclosure of the conflicts of interest in the drugs recommended for treatment should be discussed with patients.
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Affiliation(s)
- David J Browning
- Charlotte, Eye, Ear, Nose, and Throat Associates, Charlotte, NC, 28210, USA
| | - Paul B Greenberg
- Division of Ophthalmology, Alpert Medical School, Brown University, Providence, RI, USA
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15
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Repka MX, Glasser DB, Cohen CG, Li C, Lum C, Lum F, Williams GA. Use of Bevacizumab Injections in Medicare Fee For Service in the IRIS® Registry. Ophthalmol Retina 2021; 5:935-936. [PMID: 33689905 DOI: 10.1016/j.oret.2021.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Michael X Repka
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland; American Academy of Ophthalmology, San Francisco, California
| | - David B Glasser
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland; American Academy of Ophthalmology, San Francisco, California
| | - Cathy G Cohen
- American Academy of Ophthalmology, San Francisco, California
| | - Charles Li
- American Academy of Ophthalmology, San Francisco, California
| | - Christine Lum
- University of Southern California Medical School, Los Angeles, California
| | - Flora Lum
- American Academy of Ophthalmology, San Francisco, California.
| | - George A Williams
- American Academy of Ophthalmology, San Francisco, California; Oakland University William Beaumont School of Medicine, Rochester, Michigan
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16
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Go JA, Weng CY. Process Mapping and Activity-Based Costing of the Intravitreal Injection Procedure. Curr Eye Res 2020; 46:694-703. [PMID: 32940071 DOI: 10.1080/02713683.2020.1825747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE/AIM OF THE STUDY To quantify the cost of performing an intravitreal injection (IVI) utilizing activity-based costing (ABC), which allocates a cost to each resource involved in a manufacturing process. MATERIALS AND METHODS A prospective, observational cohort study was performed at an urban, multi-specialty ophthalmology practice affiliated with an academic institution. Fourteen patients scheduled for an IVI-only visit with a retina ophthalmologist were observed from clinic entry to exit to create a process map of time and resource utilization. Indirect costs were allocated with ABC and direct costs were estimated based on process map observations, internal accounting records, employee interviews, and nationally-reported metrics. The primary outcome measure was the cost of an IVI procedure in United States dollars. Secondary outcomes included operating income (cost subtracted from revenue) of an IVI and patient-centric time utilization for an IVI. RESULTS The total cost of performing an IVI was $128.28; average direct material, direct labor, and overhead costs were $2.14, $97.88, and $28.26, respectively. Compared to the $104.40 reimbursement set by the Centers for Medicare and Medicaid Services for Current Procedural Terminology code 67028, this results in a negative operating income of -$23.88 (-22.87%). The median clinic resource-utilizing time to complete an IVI was 32:58 minutes (range [19:24-1:28:37]); the greatest bottleneck was physician-driven electronic health record documentation. CONCLUSIONS Our study provides an objective and accurate cost estimate of the IVI procedure and illustrates how ABC may be applied in a clinical context. Our findings suggest that IVIs may currently be undervalued by payors.
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Affiliation(s)
- Jonathan A Go
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Christina Y Weng
- Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA.,Department of Ophthalmology, Ben Taub General Hospital, Harris Health System, Houston, Texas, USA
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