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BLOG: When costly drugs are standard of care
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Let’s say you’re going to the hardware store to buy a wrench. Naturally, the store sells more than one product that can do the same job, but let’s pretend that one wrench is, say, 10% better than another. Maybe it requires 10% less effort to turn the bolt or maybe it turns the bolt 10% tighter. How much more would you pay for that wrench?
Some of us would choose the less expensive wrench regardless of price, figuring that either product gets the job done, so why not save a little? Some might spring for the better tool regardless of price, always wanting to “own the best.” Most of us, though, would consider the price difference in relation to how much we expect to use the wrench, and we’ll judge whether the price differential is worth it.
Now, which wrench would you buy if someone else were paying? The better one? But what if it cost twice as much and was still only 10% better? Five times as much? Ten times as much? How about 30 times as much? At what point would you say, “That’s too much to pay, regardless of who is paying!”
As doctors, we regularly face this “wrench dilemma” when choosing between medications for our patients. While some products offer marginal benefits over others, their costs can be dramatically higher, and this is exactly the case that retina specialists face in treating diabetic macular edema.
Compounded Avastin (bevacizumab, Genentech) in the Protocol T study was shown to achieve visual acuity on the ETDRS chart within two letters of the more expensive compounds, Eylea (aflibercept, Regeneron) and Lucentis (ranibizumab, Genentech). But the price of these two products, according to wholesale acquisition costs, differed by a factor of –30. That’s an expensive wrench! This small difference was found among patients whose vision was better than 20/50 with diabetic macular edema requiring treatment. (Among the group with greater vision loss, a significantly greater difference was found between Avastin and the two more expensive products.)
Like the rest of us, retina specialists are a cost-conscious group, particularly since the use of these costly drugs has become standard of care. Still, the collective cost of injected retinal drugs in the U.S. is approaching one-third the total cost of all ophthalmic care. This is a cost we simply can’t ignore.
How do we, as doctors, address the “wrench dilemma,” which arises again and again with medications and even surgical implants? It’s easy to say we’ll treat each patient like a family member but very hard to afford. With family, we tend to choose the best wrench regardless of price because someone else is paying. On a population basis, that’s not particularly responsible. What we really need are more products to choose from, at varying prices. We also need more studies like the Protocol T to help clarify where and how different products offer their benefit. Meanwhile, using our best judgment to pick the “wrench” we would buy with our own money seems like the most valid approach to this nagging, constantly growing challenge.