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Higher-Cost Therapies for ARMD Could Contribute to Heightened Medicare Costs; Biosimilars Could Help


Drug maker payments to ophthalmologists were associated with the choice of higher-cost therapies for age-related macular degeneration (ARMD) that could increase Medicare costs, but biosimilars could help.

Drug manufacturer payments to ophthalmologists were linked with the selection of higher-cost therapies for age-related macular degeneration (ARMD) that presents as a factor in heightened Medicare, and biosimilars can act as a possible cost-saving solution in the future, according to JAMA Health Forum.

Roughly 4 million beneficiaries of traditional Medicare used Part B-covered drugs in 2020, where total payments hit $38.5 billion. The entrance of new, nonbiosimilar drugs between 2016 and 2020 accounted for $12 billion of the increased spending (80%), while price increases and use shifts among existing single-source brand drugs accounted for the leftover spending increase.

Old eye stock photo | © Shutterstock

Old eye stock photo | © Shutterstock

Reference aflibercept (Eylea) and ranibizumab (Lucentis) are amid the costliest Medicare Part B drugs, even though off-label use of lower-cost bevacizumab is not clinically inferior.

Researchers aimed to evaluate the link between manufacturer payments to ophthalmologists and ARMD treatment choice and to pinpoint ophthalmologist-level qualities linked with prescribing lower-cost ARMD therapies.

There exist 3 anti-vascular epithelial growth factor treatments that are equally recommended by the American Academy of Ophthalmology for ARMD. ARMD is the leading cause of blindness in adults aged 50 and older, and it impacts approximately 19.5 million people in the US.

This was a retrospective cross-sectional study of longitudinal (2013-2019) Medicare Part B data that was conducted from December 2021 to December 2022. The study included ophthalmologists who prescribed aflibercept, ranibizumab, or bevacizumab for ARMD treatment of Medicare Part B beneficiaries.

Currently for bevacizumab, there are 4 biosimilars in the United States (US) and 8 approved biosimilars in the European Union (EU). For ranbizumab, there are 2 approvals in the US and 3 in the EU. At present, there are no aflibercept biosimilars in the US and 1 approved product in the EU (Yesafili). Reference ranibizumab (Cimerli) came out as the first ranibizumab biosimialr to receive an interchangeable designation in July 2023.

Celltrion was granted an approval from the Therapeutic Goods Administration (the FDA equivalent in Australia), for its bevacizumab biosimilar (Vegzelma), which references Avastin. It’s currently indicated for some cancers, but not ARMD, though some providers use it off-label.

The percentage of bevacizumab prescribed by ophthalmologists among all ARMD therapies comprised the primary outcome of the present study. Regression analysis evaluated variation in bevacizumab prescribing.

“Savings were estimated by projecting the change in bevacizumab use had ophthalmologists not accepted manufacturer payments, controlling for all ophthalmologist and patient characteristics and comparing with observed use and costs,” the researchers continued.

A total of 21584 ophthalmologists comprised the cohort. Ophthalmologists who accepted payments from manufacturers were significantly less likely to prescribe bevacizumab (28.0% of patients) compared with those who did not accept payments from manufacturers (45.8%). Ophthalmologists who encountered dual-eligible beneficiaries had higher bevacizumab prescribing (50.0%) in the highest quartile vs 36.1% in the lowest quartile; P < .001), while ophthalmologists who saw patients with higher mean beneficiary risk scores had lower bevacizumab use 38.0% in the highest quartile vs 48.2% in the lowest quartile; P < .001).

Manufacturer payments were linked with less prescribing of lower-cost therapies, and ophthalmologists who accepted manufacturer payments prescribed lower-cost therapies almost half as often as ophthalmologists who did not accept manufacturer payments (28.0% vs 45.8%).

“The choice to use a more expensive therapy over bevacizumab cost an additional $5231.35 per Medicare beneficiary per year. For beneficiaries without a Medigap policy to cover their 20% coinsurance, the out-of-pocket cost would be $1046.27,” said the researchers.

Ophthalmologists with a higher percentage of dual-eligible beneficiaries in their patient population were significantly more likely to prescribe bevacizumab.

Those who saw patients with a higher risk score were significantly less likely to prescribe bevacizumab, and relatedly, ophthalmologists with older patients were, on average, less likely to prescribe bevacizumab.

Manufacturer payment models that urge ophthalmologists to choose lower-cost therapies need to be developed.

This study has some limitations. Differences in billing for off-label bevacizumab use might impact the estimates. Secondly, the patient qualities mirrored the entire patient mix observed by the ophthalmologist, not just those who received ARMD treatment.

“Given that ophthalmologists appeared to gain greater profits when choosing higher-cost therapies, policymakers should counter this incentive by developing manufacturer payment models that encourage ophthalmologists to choose lower-cost therapies,” concluded the researchers.


Dickson SR, James KE. Medicare part B spending on macular degeneration treatments associated with manufacturer payments to ophthalmologists. JAMA Health Forum. Published online September 8, 2023. doi:10.1001/jamahealthforum.2023.2951

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