Cost disparity between anti-VEGF agents raises economic, moral issues

NEW ORLEANS — The substantial difference in cost between ranibizumab, which has U.S. regulatory approval, and off-label bevacizumab presents an economic and moral dilemma for ophthalmologists, according to one retina specialist.

During Retina Subspecialty Day, George A. Williams, MD, presented the economic effect of ranibizumab and bevacizumab on the patient, the physician and Medicare.

Surgeons must weigh the cost difference between bevacizumab (Avastin, Genentech) and its more expensive molecular cousin ranibizumab (Lucentis, Genentech) against a need for assurances of safety and efficacy, said George A. Williams, MD, here during Retina Subspecialty Day preceding the American Academy of Ophthalmology meeting.

To conduct his economic analysis of the two drugs, Dr. Williams started with the assumption that ranibizumab and bevacizumab are equally effective and are used at the same frequencies. On a microeconomic level, he looked at the cost of each medication both to the physician and to the patient. On a macroeconomic level, he evaluated the cost of each drug to Medicare.

For the physician, bevacizumab costs $45 and ranibizumab costs $2,030.92 per injection; for the patient, Medicare co-pays are $9 and $406, respectively. Referring to delayed reimbursements, Dr. Williams called this the "no pay co-pay."

He said the current situation, and the reimbursement delays, have begun to strain the physician-patient relationship. The delays are due to factors such as recent coding updates, claim violations, outdated software and questions over medical necessity.

"We have a low-margin, high-risk business model here that is unacceptable to many providers," he said.

Dr. Williams estimated that ranibizumab is 44 times more expensive than bevacizumab, on a macroeconomic scale.

The disparity raises the question of efficacy vs. cost effectiveness. If put to "the mother test" — referring to which drug surgeons would choose to administer to their mothers — bevacizumab might fail, even though it is cheaper.

He said the upcoming CATT study, the much-anticipated head-to-head comparison of the two drugs funded by the U.S. National Institutes of Health and the National Eye Institute, will hopefully shed more light on the efficacy and safety of both drugs.