An analysis of Medicare Part D data reveals that a preference among eye care providers for name-brand medication has systemwide cost implications.
Treating glaucoma, chronic dry eye, ocular inflammation and eye infections among the elderly comes at a price — perhaps a higher price than necessary.
Eye care providers prescribe more brand medications by volume than any other provider group, data show, making them big influencers of prescription drug spending in the United States.
University of Michigan Kellogg Eye Center researchers analyzed the prescribing patterns behind the $2.4 billion in annual Medicare Part D prescription costs generated by eye care providers. A switch to lower-cost generics could save $882 million a year. Negotiating prices like the deals afforded the United States Department of Veterans Affairs could save $1.09 billion in total annual ophthalmic drug costs.
Brand medications can cost triple or quadruple the cost of generics. Medication adherence is at stake, researchers say, if patients don't fill a brand medication prescription because it costs too much.
"Lawmakers are currently looking for ways to reduce federal spending for health care, and policies that favor generics over brand medications or allow Medicare to negotiate drug prices may lead to cost savings," says senior author and neuro-ophthalmology specialist Lindsey De Lott, M.D., M.S., who is a member of the U-M Institute for Healthcare Policy and Innovation.
The work is published in Ophthalmology. It also was presented at the American Academy of Ophthalmology national meeting in Chicago, earning the Kellogg team, that includes lead study author and IHPI member Paula Anne Newman-Casey, M.D., M.S., a Kellogg glaucoma specialist, best poster honors.
The analysis of 2013 data, which became available in 2015, ranks the kinds of medications eye care providers prescribed. There were obvious goliaths: Glaucoma medications made up half of prescription ophthalmic drugs prescribed at a cost of $1.2 billion.
The second costliest category, dry eye medications, was attributable mostly to a single drug. With no generic equivalent, cyclosporine (Restasis) eye drops accounted for $371 million in spending and were the most-used eye medication among Medicare Part D beneficiaries. These two categories, plus ocular inflammation and infection medications, made up 96 percent of drugs prescribed.
Researchers note that eye conditions and drugs prescribed may differ for non-Medicare populations, meaning the results may not apply across different insurance types. For example, glaucoma is more common among the elderly age 65 and older who qualify for Medicare Part D.
As the health care cost debate roars on, De Lott and study co-lead author Maria Woodward, M.D., M.S., a cornea specialist at Kellogg and IHPI member, describe the systemwide implications of the preference for brand medications.
Why are brand medications used so often in ophthalmology?
De Lott: Eye care providers turned to brand medications for 79 percent of the total Medicare Part D payment claims. (Compared to one-third of claims among nearly all other specialties.) Physicians face some barriers in using generics, including:
Familiarity: Even when generics become available, clinicians can get comfortable prescribing what's first on the market.
Lack of data: There are very few comparative effectiveness trials between brand and generic medications. It's a huge weakness.
Industry influence: Physician acceptance of industry money, speaking and consulting fees, rebates, gifts and drug company samples (which are not accepted at Michigan Medicine) can influence prescribing patterns, even if doctors think they don't.
Medical worries: Infectious diseases are a good example. With any infectious disease of the eye, there's concern that it might get worse. Bacterial culturing is limited to a subset of cases so physicians give prophylactic coverage, just in case. But doctors tend to provide that coverage with medications that are much stronger than needed for prevention.
Optimized care: If a patient is optimized with a medication, it can be challenging to switch to something else.
Using a brand medication for a single patient may not seem like a big deal, but ultimately, these higher costs are paid by all of us.Lindsey De Lott, M.D., M.S.
How can price negotiation help?
Woodward: Although providers prescribing more generic medication as first-line therapy would enable significant savings for Medicare, there are times when only policy change will help. If the cost of generic medications increases, such as what occurred in 2014 when the price of generic prednisolone acetate and generic phenylephrine soared, changing providers' prescription patterns would not help to reduce costs. A policy change, such as allowing Medicare to negotiate drug prices, would lead to more substantial savings.
What's the risk of using brand-name medications?
De Lott: Using a brand medication for a single patient may not seem like a big deal, but ultimately, these higher costs are paid by all of us. In the case of Medicare, taxpayers are spending the money and most of the time there is no evidence to suggest that brand medications are superior to generics.
Woodward: Also, when costs are high, patients don't buy their medications because they can't afford them, which is a more severe adherence problem than forgetting to administer an occasional drop. For many Americans, even a $10 copay versus a $25 copay can make a difference in affordability.
Are there ways patients can ask for help or reminders for doctors to look at cost?
De Lott: It depends on the condition. For example, for glaucoma, there are many options and therapeutic substitutions, meaning a medication in the same therapeutic class is available, but the medication was a different chemical compound. Patients should be encouraged to ask their doctors about less costly alternatives that may be available. Sometimes we get stuck in a prescribing pattern, but when a patient brings cost to our attention, we're reminded that there are often other options available.
Woodward: But for other conditions like a severe infection there are only a few options and they are brand medications.
De Lott: There have been some studies in the general medical literature where costs are presented to physicians at the point of care to see if it changes prescribing patterns, but unfortunately, it's not resulted in great savings. In ophthalmology, where we prescribe so many brands versus generics, that type of intervention may be an effective lever.
What was the response from physicians at the AAO meeting?
Woodward: Physicians were as curious as we were about why eye care providers deviate so sharply from other doctors and health care providers. There was a lot of interest in our future work in which we'll look at regional variations and how it might apply to them. They also wanted to know more about cost differences in classes of medications and what will happen as the cost of generics goes up. It's an important conversation to have about how we define drug safety and what it means for health care spending.
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