November 2017

NEWS & OPINION

Research highlight
Study shows eyecare providers prescribe more
brand medications than any other specialty


by Vanessa Caceres EyeWorld Contributing Writer

Glaucoma, dry eye agents ratcheted up claims in analysis of Medicare Part D claims

Compared with other specialties, eyecare providers prescribe more brand medications by volume, according to a recently published study that analyzed eyecare providers’ Medicare Part D prescribing patterns.1
Led by Paula Anne Newman- Casey, MD, University of Michigan Kellogg Eye Center, Ann Arbor, the authors conducted a retrospective cross-sectional study to analyze Medicare Part D prescriptions in 2013. Prescriber public use and summary files enabled researchers to calculate medication costs by physician specialty and drug. They then estimated savings from generic or therapeutic drug substitutions in place of brand drugs.
Researchers separated prescribed medications into disease-specific drug groups: glaucoma, dry eye, ocular inflammation, ocular infection, allergic conjunctivitis, mydriatics, other ophthalmic, and other non-ophthalmic.
Researchers also estimated potential savings from price negotiation using drug prices that are negotiated by the U.S. Veterans Administration.
There was a total of 1,049,381 providers or facilities in the Medicare Part D summary file, of which 1.9% were ophthalmologists and 2.4% were optometrists.
Researchers found that the total Medicare Part D payment for drugs eyecare providers prescribed was $2.4 billion, or 2.3% of all Medicare Part D payments.
“Brand medications accounted for a significantly higher proportion of monthly supplies by volume, and therefore also by total cost for eyecare providers compared with other providers,” according to the researchers. The total was 38% by volume for eyecare compared with 23% for other provider types.
“Ophthalmologists had the highest percentage of claims for brand name drugs (71%) when compared with all other medical specialties with at least 1,000 providers,” according to the study.
About 67% of the claims from optometrists were for brand name medications.
Following ophthalmology and optometry, specialties with the largest number of brand name claims were pulmonary disease, endocrinology, infectious disease, allergy/immunology, obstetrics/gynecology, diagnostic radiology, radiation oncology, and gastroenterology.
The highest total costs of a single category of ophthalmic medications was for glaucoma medications at $1.2 billion. “Glaucoma medications accounted for 8 of the top 15 drugs by total cost and 9 of the 15 drugs prescribed by total volume,” the researchers wrote. Although brand medications made up 75% of the total glaucoma medication cost, they were only 35% of the total glaucoma medication volume.
The next category for total eye medication cost was dry eye, for a total of $376 million—even though this was only the fourth highest by volume of prescriptions. Almost 99% of the total cost of dry eye medications was attributable to cyclosporine ophthalmic emulsion (Restasis, Allergan, Dublin, Ireland).
The next two areas within ophthalmology that had the highest costs were in ocular inflammation and ocular infection.
Researchers also considered cost savings if generics were substituted for brand names and calculated that such a move could generate $882 million in Medicare savings, or a 42% reduction of 2013 costs.
Further negotiation by Medicare to obtain drug rates similar to those negotiated by the U.S. Veterans Association would decrease expenditures by 53%, or a savings of $1.09 billion.

Weighing in

The debate between branded and generic drugs is often forefront in the minds of ophthalmologists, as they consider drug effectiveness versus cost savings and medication adherence. EyeWorld asked several sources to review the study’s findings and weigh in. Here is an edited version of their comments.

Lindsey De Lott, MD, assistant professor, Departments of Ophthalmology & Visual Sciences, and Neurology, University of Michigan Kellogg Eye Center, and study coauthor

It’s difficult to know exactly why ophthalmologists had the highest proportion of claims for brand name drugs, but I think there are a few possibilities:
1. There is concern among eyecare providers that generic eye medications might not be as effective.
2. There is a lack of comparative effectiveness research. It’s difficult to switch from a proprietary preparation of a drug tested in a clinical trial to a generic preparation that hasn’t been proven to be as effective.
3. For some common eye conditions, like dry eye, there are not many prescription drug choices that are generic. In 2013, the primary drug for dry eye was Restasis, for which no generic was available. Often, ophthalmologists just don’t have other options.
My colleagues and I are currently looking at geographical variation in prescribing brand and generic medications. We’re also interested in exploring other policy questions relevant to the practice of ophthalmology such as how reimbursement policies place value on various aspects of clinical and surgical care.

Donald Gagliano, MD, principal, Global Medical Innovation, and president, Prevention of Blindness Society of Metropolitan Washington, Washington, D.C.

When it comes to vision care, patients expect high quality anatomic and functional outcomes. Ophthalmology is a specialty care field requiring precise measures of effectiveness for both procedures and pharmaceutical interventions. I tend to use branded drugs for chronic diseases that need precise measures of effectiveness for small determinations of change and generics for more generalized purposes, such as post-procedure or post-exposure prevention.
An attempt to control costs for medications of equivalent potency is a noble and meaningful effort. However, as we learn more about these costs through studies like this, the value of other means of intervention may become even more meaningful by eliminating the need for continued use of daily medications for chronic disease through improved prevention, surgical intervention, and gene-based therapy.

Alan Mendelsohn, MD, Eye Surgeons & Consultants, Hollywood, Florida

The vast majority of my colleagues and I heavily utilize branded ocular medications. At national meetings, the topic of branded versus generic is discussed over and over. The majority of experts explain that due to issues of bioavailability, the precise inactive ingredients, and the bottle utilized, among other factors, there may be a profound difference between topical and ocular branded medications and generics. The take-home message is that ophthalmologists do what they think is in the best interest of the quality of care of their patients. For the majority of topical ophthalmic medications, I think the branded options are superior. Interestingly, with coupons and discount codes that are provided by manufacturers, frequently there is a minimal cost differential between branded and generic medications.

Tania Tai, MD, assistant professor of ophthalmology, co-director of the Glaucoma Clinic, and director of the Microsurgical Laboratory, New York Eye and Ear Infirmary of Mount Sinai, Icahn School of Medicine at Mount Sinai, New York

Not all eye medications have generic equivalents, and thus branded eye drops are used when necessary. For some eye drops, the branded versions may be less likely to induce an allergic response due to their preservative constitution, even though the active ingredient is the same. Occasionally, patients will insist on taking a branded form of the medication. I prescribe generics when I think the difference in efficacy and possibility of adverse reaction for the respective patient is non-significant as compared to the branded medications. I also rely on generics for patients who cannot afford the branded versions.

Jeffrey Whitman, MD, Key-Whitman Eye Center, Dallas

If all generics were as efficacious as brand names, it’d be a better world. I’m suspect of the cost savings the study came up with. They say at the end it was all Medicare Part D. It’s an interesting sub-study, but it’s not all-comers.
If we could put it in the majority of patients, I’d do intravitreal steroids. That would save frustration with patients getting in drops and would save Medicare and insurance companies a huge amount of money.
The industry has to do a better job of studying generic efficacy compared to brand name.

Patrick Gless, MS, associate director, graduate programs in healthcare decision analysis, adjunct professor of pharmaceutical and health economics, University of Southern California School of Pharmacy and Schaeffer Center for Health Policy & Economics, Los Angeles

If asked which provided specialty prescribed the most brand medications, I would have guessed infectious disease or immunology. The leading autoimmune and virology drugs are biologics, and the nascent U.S. biosimilar market is only beginning to develop generic alternatives. However, it makes sense that eyecare providers are large prescribers of brand drugs given the unique nature of their specialty.
Physicians may select branded medications when they trust the manufacturing quality of a particular brand. Allergan, for example, produces several eye products. They are an established and trusted brand in this therapeutic area. Just as patients tend to prefer their specialist to primary care practitioners, physicians have their preferences with the quality of certain brand manufacturers, particularly in higher risk conditions.
The article correctly discusses that generic products may vary in the ease of use of the bottle. Any encumbrance to the administration of medicine from packaging to the delivery method to the frequency of dosing increases the likelihood that a patient will not take the medication as prescribed.
Payers may adjust their drug formularies based on Dr. Newman-Casey’s study findings or use the study to negotiate lower prices from brand eye medication manufacturers. Formulary adjustments would incentivize patients to select generics over brand medications when available and may eventually have a spillover effect on ophthalmologist prescribing patterns.

Reference

1. Newman-Casey PA, et al. Branded medications and Medicare Part D: How eye care providers’ prescribing patterns influence costs. Ophthalmology. 2017 Jun 16. Epub ahead of print.

Editors’ note: The physicians have no financial interests related to their comments.

Contact information

DeLott: ldelott@med.umich.edu
Gagliano: nfarano@youreyes.org
Gless: andrew@coastprgroup.com
Mendelsohn: karensuedennis@gmail.com
Tai: losak@optonline.net
Whitman: whitman@keywhitman.com

Study shows eyecare providers prescribe more brand medications than any other specialty Study shows eyecare providers prescribe more brand medications than any other specialty
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