Lucentis vs Avastin

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OCDEMS

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As everyone has probably seen, the NYTimes, WaPo, WSJ, HuffPo, etc are running articles on Medicare billing data being released. Most of them are citing ophthalmologists prescribing Lucentis (Ranibizumab) and many of them are hounding on the fact that Avastin (Bevacizumab) has similar outcomes to Lucentis in multiple studies but is still prescribed by some ophthalmologists.

I figured there might be more to this story. My understanding from previous reading is that Avastin is not FDA approved for "wet" macular degeneration and would therefore have to be prescribed and administered off-label. Both are VEGF inhibitors, correct?

Anyway, as a medical student, I wanted the story from people actually having to make these decisions. My guess is that there is some fear of liability if Avastin was used off-label. Is this correct or are there other medically-related concerns that are being entirely skipped over by the media? Do any of you see a functional difference between the two drugs? Do any of you agree with the characterizations being put out by major media?

For background: http://www.nytimes.com/2014/04/09/b...get-big-share-of-payouts.html?hpw&rref=health

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Articles like these, and all the others that are "opening up" the Medicare books, are just a continuation of the effort to vilify "rich, greedy doctors" so the government can justify their ever declining reimbursements.
 
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Articles like these, and all the others that are "opening up" the Medicare books, are just a continuation of the effort to vilify "rich, greedy doctors" so the government can justify their ever declining reimbursements.

Agreed. This data also does not take into account what truly matters...outcomes.

This is a very controversial subject with lots of layers, but in short, while studies have not demonstrated a significant difference between the drugs, clinically there is a subtle but very meaningful difference (in favor of Lucentis or Eylea). Additionally, while there are very powerful studies to demonstrate the equivalence of these drugs for macular degenaration, no such study exists for vein occulsions or diabetes which counts for a significant number of these treatments. Finally, Avastin injections have been associated with post injection infections associated with compounding pharmacy issues. Thus, if Avastin is used there is a possible liability in place for using a non-FDA approved drug that may have a higher risk of infection (the most feared and devastating complication from intravitreal injections).

This "transparency" that Medicare is going for is only useful with careful interpenetration of very vague and muddy data.
 
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As everyone has probably seen, the NYTimes, WaPo, WSJ, HuffPo, etc are running articles on Medicare billing data being released. Most of them are citing ophthalmologists prescribing Lucentis (Ranibizumab) and many of them are hounding on the fact that Avastin (Bevacizumab) has similar outcomes to Lucentis in multiple studies but is still prescribed by some ophthalmologists.

I figured there might be more to this story. My understanding from previous reading is that Avastin is not FDA approved for "wet" macular degeneration and would therefore have to be prescribed and administered off-label. Both are VEGF inhibitors, correct?

Anyway, as a medical student, I wanted the story from people actually having to make these decisions. My guess is that there is some fear of liability if Avastin was used off-label. Is this correct or are there other medically-related concerns that are being entirely skipped over by the media? Do any of you see a functional difference between the two drugs? Do any of you agree with the characterizations being put out by major media?

For background: http://www.nytimes.com/2014/04/09/b...get-big-share-of-payouts.html?hpw&rref=health
In some parts of the country, Medicare dis-incentivizes use of Avastin, enormous savings notwithstanding.

A practice has to order the medications, Lucentis from Genentech and Avastin from a compounding pharmacy (the horror!). That takes staff time. You have to front the money, which for Avastin amounts to $50 a dose (for which Medicare will pay you only $30, a money loser from get-go, and disincentive #1 on our list. Horror, and moral terror!) For Lucentis, the cost is $2,000 per dose, so for a reasonably busy retina clinic with 20-30 injections per week, that comes out as a monthly float of $240K. That is a lot of interest and considerable risk if a payer delays or denies payment. That ordering is done by someone on the doctor's staff who draws a salary, so there are costs, and you have to store (securely!) and insure the stock. All that costs. Medicare allows a markup of 6%, which probably doesn't cover the costs of the transaction for either drug, and for Avastin, the cheap option, the doctor is punished by getting paid less than cost of the stock.

You don't have to be a Wharton grad to figure out that it doesn't pay to try to save the government or the taxpayer any money.
 
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I use avastin but honestly it's in my finanicial interest to do so. The money I lose when lucentis does not get fully reimbursed is far higher than the 4% I may make on it.

The only times I don't use avastin is when the patient won't let me use an off-label medication or avastin isn't working. I have plenty of patients who decline avastin.

There are no large studies comparing avastin to lucentis and eylea in diabetic disease or vein occlusions. So except for in macular degeneration, this is not fully "evidence based medicine" when using avastin. Even in AMD some could still argue that Eylea may be slightly better. I still use Avastin though.

The government in some states makes it harder to use avastin because we have to order compounded medications specifically for the patient. The patient has to come in for a second visit when the avastin gets shipped and their disease could progress in that time.

If the NECC outbreak were to happen with compounded Avastin, nobody would defend us. The number of people blinded by each retina office with a bad lot would be large. Lets say that happens and I blind 10-15 people that day. The malpractice suits would probably go well beyond my malpractice insurance and into all of my personal assets. I'd never work as a doctor again.

The VA hospital system will not allow compounded avastin used due to an avastin contamination there that led to at least 4 blinded veterans. They either use an entire 5ml bottle of avastin for one 0.05ml injection or use Eylea or Lucentis.

Besides why are we blaming ophthalmologists for this? It's the government that decides which medications are FDA approved and which ones aren't. They also decided how much they would pay for them. If ophthalmologists hadn't discovered avastin on our own in the first place, medicare would have lost more than twice as money on lucentis payments as it already has. It's like the government is punishing us for being able to only partly make up for their own incompetence.
 
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I predicted this a long time ago: retina docs with their endless expensive injections are going to screw all of us in Ophthalmology. The government has a big red marker, and it's going to slash Ophthalmology reimbursements to appease the public uproar that the government itself has caused.
 
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The doctor collects $108 for doing the injection. He does the collecting for Genentech--and fronts the money for them--and Genentech gets $2000.

The alternative is to hand the patient the prescription for the Lucentis and tell them to buy it at the pharmacy. Maybe it's time for the alternative.
 
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The doctor collects $108 for doing the injection. He does the collecting for Genentech--and fronts the money for them--and Genentech gets $2000.

The alternative is to hand the patient the prescription for the Lucentis and tell them to buy it at the pharmacy. Maybe it's time for the alternative.

The CMS knows the rankings will be misinterpreted. They have made little effort to explain anything. It makes the practices look as if they are collecting huge payments instead of what is the truth, that they are forced to finance the purchase of a medication for their patients, and will be vilified because they might get some frequent flier miles for purchases they are making with their own credit cards, taking full transaction risk and having to float the cost of the medication, and the interest costs, which can exceed $250,000 per month.
 
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You write as if you think this is the retina doc's fault. He doesn't set pricing for Genentech. He doesn't decide for Genentech whether Avastin could be sold in aliquots suitable for single-use in the eye. He doesn't decide whether Avastin gets FDA approval for use in the eye. He doesn't set the Medicare payment rate that is less than the cost to buy the Avastin.

He can present the choices to the patients; the patients can choose.

It isn't carved in stone that the doctor has to be the one to buy the Lucentis on behalf of the patient. He can write a prescription and tell the patient to take it to a pharmacy and have them order and ship the medicine to his office and then schedule the injection when the medication is available. That would give the patient, who has zero skin in the game the opportunity to see what the cost of the medicine is he is consuming.

This is a political move done deliberately by HHS, the administration and CMS in a pathetic attempt to vilify doctors by cynically attempting to fool people into thinking doctors are walking away with millions of dollars in profit. I sincerely hope the names of the people who thought this up are outed and that it blows up in their faces in the worst possible way. Americans deserve a more honest administration than what they have with these people.
 
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You write as if you think this is the retina doc's fault.

Not sure if this is directed at me, but I want to be clear: I'm a medical student with virtually no experience in clinical ophthalmology. I only asked this question because I was curious about the professional opinion of practicing ophthalmologist. I had a previous career in healthcare and, being critical of the media's recent doctor bashing, felt there was probably more to story. I think @Dusn's response, along with your own and several others, confirmed most of my suspicions.

Again, no hard feelings. Just trying to clarify my motivation for asking. I think one of the great things about SDN is being able to get candid and honest opinions from practicing professionals without extraneous factors (no BS).
 
I'm pretty sure it was aimed at Lightbox who seems to irrationally hold the "greedy" retina surgeon responsible for these recent developments
 
You write as if you think this is the retina doc's fault. He doesn't set pricing for Genentech. He doesn't decide for Genentech whether Avastin could be sold in aliquots suitable for single-use in the eye. He doesn't decide whether Avastin gets FDA approval for use in the eye. He doesn't set the Medicare payment rate that is less than the cost to buy the Avastin.

He can present the choices to the patients; the patients can choose.

It isn't carved in stone that the doctor has to be the one to buy the Lucentis on behalf of the patient. He can write a prescription and tell the patient to take it to a pharmacy and have them order and ship the medicine to his office and then schedule the injection when the medication is available. That would give the patient, who has zero skin in the game the opportunity to see what the cost of the medicine is he is consuming.

This is a political move done deliberately by HHS, the administration and CMS in a pathetic attempt to vilify doctors by cynically attempting to fool people into thinking doctors are walking away with millions of dollars in profit. I sincerely hope the names of the people who thought this up are outed and that it blows up in their faces in the worst possible way. Americans deserve a more honest administration than what they have with these people.

I had read that it was the Dow Jones / WSJ that intervened to overturn the previous law that protected docs, not HHS or CMS
 
I'm pretty sure it was aimed at Lightbox who seems to irrationally hold the "greedy" retina surgeon responsible for these recent developments

Well, retina guys aren't doing too much to hold back costs of healthcare. I know of many, many "ethically-questionable" retina specialists both in the community and in academics. These guys/gals don't give a damn about patient outcomes and/or whether their patient's co-pays are in the $500 range. They care more about the # of FA/ICGs/OCTs, # of 92004's, etc that they can bill out. Yes, this is rampant across all of Medicine and Ophthalmology, but it definitely is amplified among retina mills.

The biggest beef I have with Retina mills is the lack of oversight or controls for the diagnostics/procedures they do. For cataract and refractive practices, patients usually know whether or not they had a good surgery because they expect good vision. They won't return for more visits if their surgery was bad. In contrast, Retina patients have no clue whether or not their care is adequate since their vision typically begins poor anyways. And many retinologists take advantage of their patients' ignorance. Patients will allow the retinologist to run a FA/ICG or give an injection over-and-over again even if there is no benefit to them. Don't tell me this occurs rarely. I have seen many patients with end-stage, disciform scars who are seen by the retina guy monthly for repeat testing and injections, for no benefit (except the retina guy's pocket). I have heard statements like, "I'm not happy that Eyelea was approved -- that will definitely mess up my flow of monthly patient return visits!". I also have seen retinas where every last photoreceptor has been burned away with endless sessions of PRP. The retina guy can always explain why their 100th treatment didn't work with the statement: "well, your retina was bad anyways."
 
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I had read that it was the Dow Jones / WSJ that intervened to overturn the previous law that protected docs, not HHS or CMS

They may have been the ones that put in the legal requests, etc, but I guarantee you that it was only released because the powers that be decided it should be, for their own purposes.
 
Light box, if you actually look at data, you are wrong (http://www.ncbi.nlm.nih.gov/pubmed/24388973). Studies examining aggregate claims data show that patients are receiving much less frequent anti-VEGF treatment in the real world than in clinical trials. Nearly everyone I know uses a treat and extend or PRN treatment approach rather than monthly injections and this is clearly support by real data, not your impressions. This certainly lowers payments, but allows for less costs, treatment burden/risks and likely not much worse visual outcomes which is the goal. FA and ICG utilization is down dramatically in the past 7-10 years with the use of OCT, and OCT pays very little and has had about a 75% reduction in payment in the past 6 years while the units just get more expensive. Frequent OCT testing is obviously needed if you want to use less than monthly anti-VEGF treatment effectively and safely extend treatment intervals or defer injections.

Additionally, I don't know anyone that uses Lucentis or Eylea on patients that don't have it fully covered. There are very helpful copay assistance programs that typically pick up the 20% Medicare doesn't pay for patients without supplements and additional programs that provide free drug for patients without insurance. We use these frequently. There is nothing wrong with using FDA-approved medications if that is what a patient wants or if they have not responded well to Avastin.

I'm sure there are some outliers that are abusing the system, but I think your post greatly exaggerates what is going on in retina practices.
 
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Light box, if you actually look at data, you are wrong (http://www.ncbi.nlm.nih.gov/pubmed/24388973). Studies examining aggregate claims data show that patients are receiving much less frequent anti-VEGF treatment in the real world than in clinical trials. Nearly everyone I know uses a treat and extend or PRN treatment approach rather than monthly injections and this is clearly support by real data, not your impressions. This certainly lowers payments, but allows for less costs, treatment burden/risks and likely not much worse visual outcomes which is the goal. FA and ICG utilization is down dramatically in the past 7-10 years with the use of OCT, and OCT pays very little and has had about a 75% reduction in payment in the past 6 years while the units just get more expensive. Frequent OCT testing is obviously needed if you want to use less than monthly anti-VEGF treatment effectively and safely extend treatment intervals or defer injections.

Additionally, I don't know anyone that uses Lucentis or Eylea on patients that don't have it fully covered. There are very helpful copay assistance programs that typically pick up the 20% Medicare doesn't pay for patients without supplements and additional programs that provide free drug for patients without insurance. We use these frequently. There is nothing wrong with using FDA-approved medications if that is what a patient wants or if they have not responded well to Avastin.

I'm sure there are some outliers that are abusing the system, but I think your post greatly exaggerates what is going on in retina practices.


I guess my point was that the temptation for fraud and greed is amplified in retinal practices because there is no "negative feedback loop." In other words, there is no mechanism to ensure that retina guys are actually performing the procedures (or have the appropriate indications for performing) they are billing. Patients don't know if they need that one spot of focal laser or 10 spots of PRP. Patients don't know if the anti-VEGF they received is actually "working" since non-response can be attributed to the disease process itself. In contrast, it is difficult to "fake" cataract surgery, blepharoplasty, trabeculectomy, or a corneal transplant.

I think cases like the following highlight the not-so-uncommon fraud and greed that occur in retina:

http://www.memphisdailynews.com/news/2010/feb/19/yoser-sentenced-to-42-months/

Obviously, I'm not giving a blanket statement that all retinal physicians are charlatans. I actually have good friends that are retina specialists and that I would trust with my patients. But from my own personal experiences, I am very wary of Retina in general because of the lack of the aforementioned feedback mechanism.
 
I think the case you posted is very uncommon. I can't imagine there are numerous criminals committing multi-million dollar fraud among retina specialists. There is definitely a "negative feedback loop" for our treatments. If you get audited, which we do quite frequently given the expensive drugs we use, and don't have photographic evidence documenting disease, your money gets taken back. I would never do a PRP without a photo or FA showing NV. I would never do a focal without treatable MAs on FA and edema on OCT. I would never start anti-VEGF without a CNVM, DME or RVO on FA and/or OCT. Maybe some people are shady and they don't get caught, but there is every bit as much, if not more, ability to do 20/20 cataracts and claim "glare", do blephs on people without significant dermatochalasis who are "coached" on how to fake a superior field defect, and trabs on people who don't really need it. Ultimately, there is an honor system. If you have people in your community you know are committing fraud, you should report them.
 
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Retina doctors are not exempt from this "feedback loop" you speak of. Outcomes are still critical in our practice just as much as yours. Not sure where you are practicing but it sounds like you've been exposed to the wrong kind of retina specialist. I'm also not sure how much understanding you have of the subtleties of treating patients with AMD or diabeties as quite frankly you sound a bit ignorant on the topic. While it might seem unnecessary to you to treat a patient with AMD when their macula is totally dry, you probably haven't had to deal with the patient who develops a massive subretinal hemorrhage and loses most of their vision after forgoing a treatment. I've seen premium IOL's placed, yag lasers performed, and cataract surgeries done on patients who had no macular function and who's visual potential was nil. I've been taking care of a gentleman with ischemic optic neuropathy with baseline CF vision who developed endophthalmitis after cataract surgery. He's now back to baseline vision after 6 months, no thanks to this unnecessary surgery. We all have examples we could site, but that's not the point. These rare examples only distract from the larger issues and do not strengthen your argument in the least.
 
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I'm also not sure how much understanding you have of the subtleties of treating patients with AMD or diabeties as quite frankly you sound a bit ignorant on the topic.

Love it...just love it.
 
Interesting thread. Yeah, this raw CMS data is a Pandora's Box. The AAO and other medical specialty organizations have been arguing for months that it is irresponsible to release such data without context. I haven't looked at my specific data, but I imagine I'm on the lower end, as I use almost exclusively Avastin, and I treat and extend. I have only a handful of patients on Lucentis, and that's been the case since I started my practice nearly 5 years ago. It was clear from small studies back then that there was no substantial difference in efficacy between it and Avastin. For many of us, CATT was no surprise. Of course, since Eylea was released, I have found myself switching problem patients over to it with great success. There is an obvious difference there. Problem is, though, that we as doctors don't make any more money from using these more expensive drugs, and that's the main thing that isn't apparent in this CMS data. Drugs like Eylea do improve outcomes, though. It's sad to see what medicine is becoming. The government talks about quality of care, but they are really only concerned about cost of care.
 
What this should draw attention to is not the doctors, but big pharma. It's no surprise that the top 2 specialties are ophthalmology (likely skewed by retina) and heme/onc. They both use very expensive drugs at times to treat their patients. The reimbursements are much more for the drug than the doctor's fees. For instance, if I see a patient for f/u of wet AMD, I will obtain and interpret an OCT, which is the gold standard for AMD management, do a brief exam, followed by an injection. I get ~$45 for the OCT and ~$105 for the exam and injection (unless you have a separate, justifiable reason for a more detailed exam, the limited exam is captured by the injection fee). That's a grand total of ~$150 for me, regardless of what drug I choose. If I use Avastin for that injection, I get ~$50 to cover the cost (varies depending on compounder). If I use Eylea, I get $1961 to cover the cost. So, who's making more money here? I'm pretty conservative, so I only use Eylea when I think it's necessary. Fact is, though, I personally make the same amount whether I use it or Avastin. The difference is how well the patient can see afterward.

Interesting side note. My use of Eylea increased over the second half of last year, as I saw how effective it was for some of my problem cases. Because I was so used to Avastin, from a billing and reimbursement perspective, I didn't really consider the effect on my bottom line. Well, that was a business lesson. I probably do about 200-250 injections a month for various diseases. In October and November alone, I injected about 50 Eylea. When my 4th quarter numbers came out, I was $5k in the red! I hadn't thought to delay payment on the Eylea I was ordering (you can do so by ~100 days), so I had increased my overhead by ~$100k in those 2 months without yet being reimbursed, due to the turnaround from billing to payment. Fortunately, I'm in a group that was able to absorb that hit until we could make adjustments and catch up. Lesson for any new docs out there, lol!
 
There are shady characters in all subspecialties. There's one local retina specialist in our area who is notorious for billing for PRP and putting a line of 20 shots in the peripheral retina. There's another glaucoma specialist, who is no longer here, who was diagnosing every person who walked in the door as glaucoma suspect, including people with 0.3 nerves, clean fields, and pressures of 10. Some of the patients that I now take care of ended up in my care because they saw another surgeon who recommended cataract surgery in an eye with a coloboma and poor vision since birth.

I'm not sure if it's fraud or incompetence (which is worse?), but there's definitely some fishy stuff going on out there.
 
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Based on the published database, now it will be easy to see who is doing eye u/s daily.
On the flip side, I did 5 eyleas in 3 days this week alone and it will not look good on me at the end of the year, even though nothing else worked on those patients.
 
I'd like to hear about the rebates that some of the manufacturers are offering to retina doctors on their purchases of Eylea or Lucentis
 
ahhh, the sweet sound of crickets.........snicker
 
I'm not aware of any, but I don't use any of those agents in my practice. I have never heard anyone speak of receiving rebates. Do you have any evidence such rebates exist?
 
Genentech had a much maligned incentive program that isn't active anymore, from what I understand. I hardly use Lucentis. There is no such thing for Eylea. Here's the deal: I'm paid for the injection procedure. The drug reimbursement goes to paying for the drug. There's no profit in it.
 
Here's another nugget to chew on, folks. My administrative costs just to get paid for Eylea make it a money loser for me. Avastin is easily approved by any carrier for any indication really, because it's so cheap. You have to ride carriers constantly and jump through all sorts of hoops just to get paid for Eylea, even if they "pre-authorize" it. I have a single person, separate from our coding and billing staff, dedicated to tracking injectables alone. It's ridiculous. That's why I only put patients on Eylea when they've failed Avastin and when I'm "fairly" certain I can get paid for it. I'm really starting to think we should just send our patients out with prescriptions to bring us the drug to inject. Then, let's look at the numbers again. :rolleyes:
 
The 6% figure is the authorized markup for the purchase of the drug, not a "rebate." That is meant to cover all the ordering, storing, insuring, interest charges and billing for the product. That is not a rebate from Genentech. CMS pays this. The only source I have found was a November 2010 article in the NYT that says Genentech was paying between 0.5% to 1.5% as a rebate to only a select group of retina specialists who were the highest volume users of Lucentis. The terms were vague, and the article suggested there was a nondisclosure agreement and the rebates were legal, although also an inducement to select Lucentis. The unmade point was that Lucentis is FDA-approved for intraocular use (as is Eyelea and Macugen) and the alternative, Avastin was not FDA approved. Use of Avastin is off-label, and requires having the drug prepared for injection by a compounding pharmacy.

The NYT seemed to want to criticize doctors for not going off-label to save the government money, medicolegal risks notwithstanding. Go figure. If there were any profit in their doing so, I suspect they would criticize them for that too.
 
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And all it takes is one of those Eylea (or Lucentis) to not be reimbursed and the 6% margin is gone for several months. Heck, that amount doesn't even cover my administrative costs, if I do get fully reimbursed! Increased use of Eylea (for Avastin treatment failures) over the past year has really put a financial crush on my practice which I've yet to crawl out of. Fact is that this CMS release will be seized upon by the ignorant because it's completely out of context.
 
If I'm not mistaken, since the sequester the 6% margin was reduced to 4%. In my office it seems like it's even significantly less than 4%. Many times I find myself getting reimbursed significantly less than the cost of the medication. I have no idea why but then again I'll admit that my group's billing dept sucks and I don't want to spend all day keeping track of it myself.

Which brings up the reason why for most of us it is in our financial interest to use the cheaper avastin: Insurance companies will use any reason, or no reason at all, to not reimburse you. If you use high cost meds, you have to hire people who spend all day keeping track of the usage of these meds and the reimbursements for it. That alone eats up any profit you make on the med. One non-reimbursed lucentis is $2000 out of your pocket. There's not way you're going to make up that loss with your measly 4% increase in reimbursement. The costs of these medications can cost your office more than every other expense combined.

PBEA - I'd also like to hear about these supposed rebates being offered to ophthalmologists from drug companies. If there are some kinds of rebates, I've clearly been missing out.


If there were a large outbreak of endophthalmitis from avastin (like what happened with NECC), the discussion (and lawsuits) would be about how cheap doctors blinded their patients by using a non-FDA approved drug.
 
This could only be expected given that almost every piece of this problem is due to government regulatory or government payer or government oversight agencies:

1. FDA (government) won't approve Avastin, a cheaper drug that CATT showed to be near equivocal to Lucentis
2. Medicare (government) is angry about how much money they pay us to buy the expensive Lucentis
3. CMS (government) releases context-less raw data about billing and reimbursement and a media frenzy ensues, not to mention the increased risk that such public data with private identifier information puts practices at given recent increases in fraud
4. FDA (government) also putting pressure on compounding pharmacies, the only place that we can get cheaper Avastin from

And one issue with industry:
1. Genentech won't sell us Avastin in vials suitable for single use intravitreal injections, but can we really vilify them when there wouldn't even be an FDA-approved usage for such a product?



Ultimately, nobody is going to help us with this but ourselves. We may have entered an era where we need to send those patients to buy their own injection drugs as voiced above. "Transparency" in medicine is a joke right now, and until we make patients see the true cost of what we're doing they aren't going to be vocal about change and it will just be us 'greedy doctors' who are voicing complaints. Perhaps we should be telling patients that the government won't approve the cheaper alternative for use in their condition. Being a resident still I have time to think about how I'll do informed consent in my own practice, and I'll definitely be informing patients about the risks of off-label drug usage and contamination from compounding pharmacies and that language will be in bold print on my consent form. It wouldn't protect us from the cost of litigation (the one possible good thing the government could do here but every tort reform discussion quickly), but at least I can say I discussed it specifically with every patient. I'm with Dusn here, one string of a few endophthalmitis cases could really push an issue like this into the public eye in a tragic way. Generally I have trust in the compounding pharmacies that I've seen a couple of practices use, but at the end of the day even if the catastrophic did happen we would be the ones who would be expected to answer for it, right or not.

Another thing that this whole media data dump has brought to light again is the in-fighting about physician reimbursement. There are a lot of doctors out there undoubtedly think this is still 1976 and Ophthalmologists are getting rich off of cataract surgery. When I tell my colleagues in IMED that the job offers they are getting for $250,000/yr for 7 on 7 off hospitalist work or 9-5 clinic work is a lot more than the job offers recent Ophthalmology grads are getting, they literally do not believe me. They also usually don't even realize that glaucoma is a sub-specialty or have any idea what the phrases "anterior ischemic optic neuropathy" or "optical coherence tomography" pertain to. But that doesn't seem to stop them from commenting on our pay, which they know equally little about. For some reason nobody can just say the obvious thing that we all agree on: "PCPs are NOT being paid the value of their work and are greatly underpaid for services." They have to tag a line about how Ophthalmologists and Radiation Oncologists and Dermatologists make too much money, even though the have not one iota of knowledge about how those specialties are reimbursed or the true nature of their daily work. Especially in Ophthalmology.
 
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I was about to post something about this. Just responded to a question on the ASRS forums about the new compounding law. Because patient specific prescriptions are required, unless the pharmacy is an FDA-designated "outsourcing facility," the number of pharmacies that can be used to compound Avastin has decreased substantially. This forces many to fall back on the more expensive options, Lucentis and Eylea, which we are currently being criticized over. The whole thing is ridiculous.
 
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Here's another nugget to chew on, folks. My administrative costs just to get paid for Eylea make it a money loser for me. Avastin is easily approved by any carrier for any indication really, because it's so cheap. You have to ride carriers constantly and jump through all sorts of hoops just to get paid for Eylea, even if they "pre-authorize" it. I have a single person, separate from our coding and billing staff, dedicated to tracking injectables alone. It's ridiculous. That's why I only put patients on Eylea when they've failed Avastin and when I'm "fairly" certain I can get paid for it. I'm really starting to think we should just send our patients out with prescriptions to bring us the drug to inject. Then, let's look at the numbers again. :rolleyes:

I don't disagree with you here. I run a small ophthalmology practice that deals mostly with refractive services, but we also manage most of the ARMD, BRVO/CRVO & DRE cases in the area due to it being reasonably rural. If you didn't come to us for Lucentis/Eylea/Avastin, you'd be driving almost 100 miles one way. That being said, it's an even more interesting balancing game trying to choose which drug to use for people in our case when the clinical data doesn't suggest one treatment over the other. We only do maybe... 20-25 injections per month, and compounded Avastin has to be ordered on a patient specific basis and in minimum quantities to avoid about $160 in shipping (which ins't recouped in reimbursement as you all know). Eylea on the other hand, while grossly expensive, can be ordered in a single dose with 120 day terms from Besse Medical and I can wait until... almost closing time for us to order it and get it the next day if I want. Granted, this kind of model doesn't and wouldn't work for a large retina practice, but for us it's a big deal to perhaps have Avastin arrive a day late because you have to order it by fax and patient Y now has driven 90 miles for their IVI but don't have drugs here to get, etc. We've also found that from more than one compounder, the Avastin doses will begin to stick at about 25 days of storage and on, which leads to an incredibly painful injection for our patients.. My doc just eats the shipping and will only use a dose that's been in our office for 10 days or less, and moves people to Eylea as it's deemed necessary clinically. While we don't use Lucentis and while I don't condone the crazy prices of the two drugs, what I do like about Eylea aside from it being much easier to get/store/etc, is that Regeneron has a really excellent support system in place to make sure that clinics are getting reimbursed. We have one uninsured patient getting the drug for free, we have several others that receive grant money each time they're injected to cover their out of pocket costs, and we have a handful younger patients that still have commercial insurance that have a $10k budget from Regeneron itself that covers all of their out of pocket drug cost minus $5 per injection. On top of that, they do benefits investigations, prior auth assistance, appeals support when we get denials (which, because of this program we never have).. That's pretty neat. I have five employees doing the work of ten and one doctor, so I don't have time or the capital outlay to absorb one of these treatments if it we didn't get paid for it. At LEAST with Eylea there is a program like this that makes sure it can be administered clinically without it being a financial issue. AND, you get to toss aside the woes of using a compounding pharmacy. Double win in my book.
 
I don't disagree with you here. I run a small ophthalmology practice that deals mostly with refractive services, but we also manage most of the ARMD, BRVO/CRVO & DRE cases in the area due to it being reasonably rural. If you didn't come to us for Lucentis/Eylea/Avastin, you'd be driving almost 100 miles one way. That being said, it's an even more interesting balancing game trying to choose which drug to use for people in our case when the clinical data doesn't suggest one treatment over the other. We only do maybe... 20-25 injections per month, and compounded Avastin has to be ordered on a patient specific basis and in minimum quantities to avoid about $160 in shipping (which ins't recouped in reimbursement as you all know). Eylea on the other hand, while grossly expensive, can be ordered in a single dose with 120 day terms from Besse Medical and I can wait until... almost closing time for us to order it and get it the next day if I want. Granted, this kind of model doesn't and wouldn't work for a large retina practice, but for us it's a big deal to perhaps have Avastin arrive a day late because you have to order it by fax and patient Y now has driven 90 miles for their IVI but don't have drugs here to get, etc. We've also found that from more than one compounder, the Avastin doses will begin to stick at about 25 days of storage and on, which leads to an incredibly painful injection for our patients.. My doc just eats the shipping and will only use a dose that's been in our office for 10 days or less, and moves people to Eylea as it's deemed necessary clinically. While we don't use Lucentis and while I don't condone the crazy prices of the two drugs, what I do like about Eylea aside from it being much easier to get/store/etc, is that Regeneron has a really excellent support system in place to make sure that clinics are getting reimbursed. We have one uninsured patient getting the drug for free, we have several others that receive grant money each time they're injected to cover their out of pocket costs, and we have a handful younger patients that still have commercial insurance that have a $10k budget from Regeneron itself that covers all of their out of pocket drug cost minus $5 per injection. On top of that, they do benefits investigations, prior auth assistance, appeals support when we get denials (which, because of this program we never have).. That's pretty neat. I have five employees doing the work of ten and one doctor, so I don't have time or the capital outlay to absorb one of these treatments if it we didn't get paid for it. At LEAST with Eylea there is a program like this that makes sure it can be administered clinically without it being a financial issue. AND, you get to toss aside the woes of using a compounding pharmacy. Double win in my book.
Wow, a lot has changed in the year and a half since I posted that! I was previously the only retina doc in a comprehensive group. About a year ago, I moved to an all-retina group, and being a large group, we have the dedicated manpower to manage large volumes of premium drugs, like Eylea. As a group, we perform well over 100 injections per day, and the majority are Eylea and Lucentis. The financial juggling act is challenging, but we also have a full-time accountant on staff to oversee the cash flow. The support from Regeneron and Genentech has been excellent. All patients, even those receiving Avastin, are pre-authorized or receive sample drug on their first visit. Because we're so careful, our reimbursement loss in negligible.

I still feel the cost of these premium drugs is far too high. There are even studies looking at using drugs like these for treatment of diabetic retinopathy, regardless of DME. Can you imagine how the medical costs would skyrocket, if we started treating all diabetic retinopathy with anti-VEGF?! Something has to give. There are already carriers that are trying to reduce reimbursement costs by requiring Avastin failure prior to using Eylea or Lucentis. I can't blame them, honestly. More recently, we've had a carrier refuse to reimburse Eylea monthly, citing the clinical trial results that demonstrated equivalency for Q8wk dosing! We don't treat patients like clinical trials! I like to tell residents and fellows that the greatest strength of a clinical trial is also its greatest weakness. It gives you a good idea of how your average patient will respond to the treatment. The problem is that if you use that strategy, you will over- and under-treat a significant number of patients. You just can't do that in the real world. You must rely on your clinical judgement.

I don't use premium drugs for the heck of it. I also don't do so for any financial advantage. We have 5 full-time staff that manage the insurance end of these drugs, in addition to the full-time accountant. There's a lot of overhead to using them. The percentage we get pretty well covers that, but it's far from a money-maker. I use Eylea and Lucentis, because I think that in the right situations, they are simply better drugs. Most of the Lucentis I use is the 0.3 mg for DME. I've seen better responses to it than to Avastin, again and again. It's cheaper than Eylea, but I still go with Eylea in severe or resistant DME cases. That's backed up by Protocol T. I always start with Avastin on off-label cases, but even those often need to eventually be enrolled in a program for Lucentis or Eylea, due to suboptimal response. These drugs are not all the same, though they may all affect VEGF.
 
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Wow, a lot has changed in the year and a half since I posted that! I was previously the only retina doc in a comprehensive group. About a year ago, I moved to an all-retina group, and being a large group, we have the dedicated manpower to manage large volumes of premium drugs, like Eylea. As a group, we perform well over 100 injections per day, and the majority are Eylea and Lucentis. The financial juggling act is challenging, but we also have a full-time accountant on staff to oversee the cash flow. The support from Regeneron and Genentech has been excellent. All patients, even those receiving Avastin, are pre-authorized or receive sample drug on their first visit. Because we're so careful, our reimbursement loss in negligible.

I still feel the cost of these premium drugs is far too high. There are even studies looking at using drugs like these for treatment of diabetic retinopathy, regardless of DME. Can you imagine how the medical costs would skyrocket, if we started treating all diabetic retinopathy with anti-VEGF?! Something has to give. There are already carriers that are trying to reduce reimbursement costs by requiring Avastin failure prior to using Eylea or Lucentis. I can't blame them, honestly. More recently, we've had a carrier refuse to reimburse Eylea monthly, citing the clinical trial results that demonstrated equivalency for Q8wk dosing! We don't treat patients like clinical trials! I like to tell residents and fellows that the greatest strength of a clinical trial is also its greatest weakness. It gives you a good idea of how your average patient will respond to the treatment. The problem is that if you use that strategy, you will over- and under-treat a significant number of patients. You just can't do that in the real world. You must rely on your clinical judgement.

I don't use premium drugs for the heck of it. I also don't do so for any financial advantage. We have 5 full-time staff that manage the insurance end of these drugs, in addition to the full-time accountant. There's a lot of overhead to using them. The percentage we get pretty well covers that, but it's far from a money-maker. I use Eylea and Lucentis, because I think that in the right situations, they are simply better drugs. Most of the Lucentis I use is the 0.3 mg for DME. I've seen better responses to it than to Avastin, again and again. It's cheaper than Eylea, but I still go with Eylea in severe or resistant DME cases. That's backed up by Protocol T. I always start with Avastin on off-label cases, but even those often need to eventually be enrolled in a program for Lucentis or Eylea, due to suboptimal response. These drugs are not all the same, though they may all affect VEGF.

Here here. It's a tough game indeed :) I do have a question for you though - I think, overall, we consider Eylea the most effective for nearly all applicable Dx, and from what it sounds like, we use the same approach that you do in your practice. We aren't prescribing any Lucentis at all, however - Should that be something that I should look into? My doc is young (32) so only out on her own a few years. I believe that the people she trained under prescribed Eylea almost exclusively when a case fails on Avastin. Do you have any loose clinical guidelines you'd like to share (in addition to what you have already) that I could pitch her? If Genentech has similar patient support on the cost front, I'd be open to maybe moving a few of our intermediate cases up from Avastin to Lucentis as a first step before going full Eylea. Anything would help :) Thanks for replying!
 
I agree that Eylea seems like the superior drug. The only patients I use Lucentis on are those who have been doing well on it prior to Eylea coming on the scene and those with DME. I don't use it for de novo AMD or RVO any more. For DME, it's effective, but significantly cheaper than either Eylea or the 0.5 mg Lucentis. Of course, you could argue that Protocol T suffered from a floor effect on patients with 20/40 or better vision, so Eylea would be better for them, as well. I do have some patients with that level of vision whom I eventually shift to Eylea. Heh, won't be long and we'll have more options to consider. ;)
 
I think for AMD, the difference between avastin, lucentis and eylea is minimal (see CATT, etc). I prefer lucentis for most treatment navive AMD patients and eylea for non-responders. I only use avastin if it is mandated by insurance which is pretty rare in my area. The VEGF load for vascular disease states such as RVO and DR/DME are so much more pronounced that I think eylea makes more sense in these diseases due to it's higher affinity for VEGF. I do worry about systemic issues associated with these drugs and feel that lucentis has lower risk, although I freely admit that no study has definitively demonstrated a difference. The q8wk dosing of eylea is more of a marketing gimic as I have not really noticed a difference between eylea or lucentis. In fact, HARBOR demonstrated that lucenits dosed PRN was used less frequently than q8wks. Protocol T 2 year data will be out soon so should be interesting to see what that shows. I suspect not much of a difference from 1 year data. All this research in anti-PDGF drugs should be interesting as well.

I think whats more important than the drug used is the dosing regimen. PRN vs treat and extend vs q4wk etc. Keeping the macula dry, no matter what the drug, is the goal and I think in this regard, it's fantastic that we have so many options.
 
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I think for AMD, the difference between avastin, lucentis and eylea is minimal (see CATT, etc). I prefer lucentis for most treatment navive AMD patients and eylea for non-responders. I only use avastin if it is mandated by insurance which is pretty rare in my area. The VEGF load for vascular disease states such as RVO and DR/DME are so much more pronounced that I think eylea makes more sense in these diseases due to it's higher affinity for VEGF. I do worry about systemic issues associated with these drugs and feel that lucentis has lower risk, although I freely admit that no study has definitively demonstrated a difference. The q8wk dosing of eylea is more of a marketing gimic as I have not really noticed a difference between eylea or lucentis. In fact, HARBOR demonstrated that lucenits dosed PRN was used less frequently than q8wks. Protocol T 2 year data will be out soon so should be interesting to see what that shows. I suspect not much of a difference from 1 year data. All this research in anti-PDGF drugs should be interesting as well.

I think whats more important than the drug used is the dosing regimen. PRN vs treat and extend vs q4wk etc. Keeping the macula dry, no matter what the drug, is the goal and I think in this regard, it's fantastic that we have so many options.
I actually disagree. In my experience, Eylea is clearly superior. Why do you use it for non-responders, for instance? ;) I'm saying this as a skeptical late-adopter of Eylea. I don't use Lucentis for any new wet AMD anymore, and my rationale is why would I try Avastin or Lucentis only to have to switch them to Eylea due to suboptimal response? Worse case scenario, I'm over-treating with Eylea and I can potentially get patients off treatment more quickly, using treat and extend. It's what I would choose for my own eye. It's also worth noting that Eylea is actually slightly less expensive than Lucentis. I just see no reason to use Lucentis, outside of the 0.3 mg for DME. Of course, I don't treat per the clinical trial results, and no one should. I'm a treat and extend guy, and I have very few patients that are maintained on Q8wk Eylea. Most of the folks I successfully get to 8 weeks are on their way to 10 weeks. The original idea was that Eylea would have a longer duration of action. I could have told you that wouldn't be the case, as binding affinity has nothing to do with half-life. The reason the Q8wk looked equivalent to Q4wk, in my opinion, is that the drug is good enough that most didn't need to stay on monthly. That said, there are many who do. I must say, however, that I have relatively few who aren't completely dry on monthly Eylea. I can't say that for Lucentis or Avastin, which is why I've ended up switching so many patients over the past couple years.

Regarding systemic risk, I honestly don't believe there is any. We have over a decade of data now without any reliably reproducible safety signal. If it was there, we'd have the evidence. I was talking to Phil Rosenfeld at ASRS last fall, and he made a good point that the most common SAE with systemic Avastin was actually hypertension, and we don't see that with intravitreal treatment. Why, then, would we think that the less common SAEs would be seen? Yes, we can detect the drugs in the blood stream, but we don't know what concentrations are even significant. It's basically a theoretical risk that's never been proven.

I. too, look forward to the anti-PDGF results. We are part of ECLIPSE and CAPELLA. I hope it turns out to be as good as theorized.
 
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