The Center for Medicare and Medicaid Services could save a half billion dollars a year by switching its beneficiaries with macular degeneration to Genetench’s Avastin instead of Genentech’s Lucentis, the Wall Street Journal reported recently. The two drugs are variations of the same molecule.
Many eye doctors across the country have been switching to the less expensive Avastin ($42 a dose compared to $1593 for Lucentis) to save their elderly patients with the sight-robbing condition from expensive co-pays. Medicare at first said it wouldn’t pay for the off-label use of Avastin for macular degeneration, but reversed itself last year after pressure from Capitol Hill.
Four years ago, the National Institutes of Health funded a $16 million trial comparing the two to provide definitive clinical evidence that the two drugs have the same effect. The trial results are due next year. Numerous smaller studies have already shown the two drugs are comparable.
According to the Journal story, CMS sought to suppress this latest cost savings analysis, whose authors included three CMS employees. When Journal reporter Alicia Mundy called, CMS chief medical officer Barry Straube claimed there was no effort to suppress the data and saw no reason why it couldn’t be published quickly.
What’s the difference? Everyone already knows you can save a bundle for Medicare and for patients by using Avastin off-label instead of Lucentis. I suspect the main reason many eye doctors still use Lucentis is that they make a small mark-up for drugs administered in their own offices (the treatment is given with a shot in the eye). Six percent on $1593 beats the hell out of six percent on $42.
The NIH comparative effectiveness trial will not change that core incentive. CMS will still cover Lucentis after the “definitive” trial results are published because it is prohibited by law from using comparative effectiveness research or cost-benefit analysis to make coverage decisions.
Until Congress gives CMS the power to make coverage determinations based on the relative cost of treatments that have been proven to be equally effective, many doctors with well-off Medicare beneficiaries who can afford the co-pays (and the Genentech detailers who cater to them) will feel free to ignore the results of comparative effectiveness studies like the forthcoming Avastin-Lucentis trial.
Merrill Goozner is a freelance writer, independent researcher and consultant who blogs at Gooznews on Health.
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