Why comparative effectiveness won’t matter to Avastin and Lucentis

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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    Here’s the real deal. I use this stuff. Let me give it to you from my perspective.

    Lucentis and Avastin are both very good agents for the treatment of wet macula degeneration. We pay between $20 and $50 for our Avastin depending on vendor. We pay $1997 for a single dose of Lucentis. The drugs seem to have very comparable safety and efficacy. Avastin has a longer half life and may allow a longer interval between injections.

    Reimbursement is a wash as it is driven mostly by the injection reimbursement fee. Many docs fear having $30,000 worth of perishable meds in a $100 office refrigerator for many reasons which should be obvious.

    CMS study is set up as an inferiority study and will not determine if one drug is more efficacious than the other. It hopes to prove that Avastin is not inferior to Lucentis. If this is supported by the data the hope is that more docs would buck the idea that if there are two comparable meds to be used and one is FDA approved and OFF label and the other is FDA approved and ON label, the On label drug should be used unless there are compelling reasons to use the OFF label choice.

    Our office uses Avastin about 4:1 to Lucentis for wet AMD and Avastin exclusively for other anti-angiogenic indications such as diabetes and vein occlusions. My patients that cast clues to being litigious all get Lucentis regardless of co-pay etc. Sorry. On paper it still may be more defensible should there be a bad outcome.

    Some patients request the ON label more expensive perceived “top shelf” Lucentis. Most patients don’t care. I, personally, would use either of these products on myself.

    The Genentec detailers have two great products and they know them very well. There is no money for them in the use of Avastin for the OFF label ocular purposes mentioned.

    There was an effort on their part to make Avastin unavailable to ophthalmologists by banning the sale of Avastin to compounding pharmacies. This was ultimately stopped and Avastin continues to be readily available.

    The use of these agents have been a breakthrough for patients and reasons as to which agent gets used are multidimensional.

    What I’m saying is that it ain’t all about the money.

  • http://nostrums.blogspot.com Doc D

    No need to engage the nanny state.

    Just make sure patients have the information by publishing it widely. They’re perfectly capable of judging value. They do it every day with homes, cars, and refrigerators.

    And if their doctor won’t switch to Avastin, they should find another doctor. That’ll do the trick.

    Unless you want Uncle Sam to regulate refrigerator purchases, too.

    • twicker

      You’re forgetting something:
      a) Unlike homes, cars, and refrigerators, Medicare subsidizes this, and is specifically prohibited by Republican-written law from using comparative-effectiveness trial data to use pricing to differentiate between the two. So: no, patients having the information will absolutely not drive the same degree of change in behavior that you’d see with cars, homes, and refrigerators. Unless, of course, you think that somehow pricing doesn’t actually affect behavior.

      b) Now, admittedly, the patient does see some price differential — just not the full price differential. And the patient does see that one is on-label, and the other is off-label. So, if the patient is a normal person, more-expensive = better (isn’t the $2MM house better than the $50K house?) and on-label = better — so, combine the obvious signals that scream (to the layperson) that ranibizumab is “better” with the fact that the price differential is NOT $1,997 to $50, and — hey presto — you absolutely won’t see the level of shift you seem to be predicting. Unless, of course, you don’t believe that people can be influenced by things like perception.

      So, if you happen to hit a bunch of people who are just so altruistic that they won’t let the government pay more for them to have “more,” you’ll see a shift — but not much of one, and certainly nothing coming close to the shift you’d see with houses, cars, and refrigerators.

      (As an aside: why is it that some doctors seem to assume that patients see fundamental health issues — like eyesight — as though people think they’re mere materialist goods like cars and refrigerators? Are these doctors somehow clamoring to give up their eyesight for an off-season weekend at the beach [roughly the cost differential between a mediocre refrigerator and a good-quality refrigerator -- both of which still keep everything nice and cold]?)

      Given that the AMD patients who were most likely to be clamoring against Obama’s health reform were also wanting to keep the government away from their Medicare or VA benefits, and keep the government out of their Social Security checks, I’m not sanguine about this happening.

      As to “engag[ing] the nanny state” — Doc D, what on Earth does this mean? That you don’t want something funded by tax dollars to make sure those tax dollars are being used effectively? You want it just to spend tax money like it’s water — why? Because it’s for healthcare, and you’re a doctor, and, thus, you make more money? It’s in your economic best interest, and the rest of us need to suck up and deal?

      Now — first, NO, I don’t for an instant believe that you think that tax dollars should be spent like water. Quite the contrary, from your posts, I’m suspecting you’d like to pay less, not more, in taxes — and would like the same for everyone else.

      That said, I don’t see how having the comparative effectiveness information available would somehow trigger the “nanny state.” Yes, it would likely lead to a shift in what’s funded by the taxpayer — but not what a private individual can purchase on the free market. After all, Roche/Genentech isn’t exactly clamoring to get the AMD use put on-label for Avastin (they’re trying to make profits, and that would dramatically hurt profits, no matter how many people it would help — free market and all that), and, in the past, Roche/Genentech was actually trying to restrict the off-label use of Avastin (again, it’s all about the profit motive — that’s part and parcel of the “invisible hand”). Thus, we should expect that Roche/Genentech will continue to try to push people to use the more-expensive drug, since that protects their profits. Shouldn’t our tax money be protected, too?

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    I’m with Doc D here. Do the research and publish the information widely. Write guidelines too so Paul MD doesn’t have to worry about litigation. But that’s about it. Let patients and doctors figure it out.
    Right now CMS and congress time would be better spent in addressing the reimbursement model.


    Thank you. Many of us are looking forward to the results.

  • twicker

    BTW, the comments section of the original GoozNews article includes information on how the comparative effectiveness research is, in fact, used by Medicare now (just not in exclusion from other information):

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