ANN ARBOR, Mich. -- 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 Veterans Administration could save $1.09 billion in total annual ophthalmic drug costs.
“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 Kellogg neuro-ophthalmology specialist Lindsey De Lott, M.D., M.S., who is a member of the U-M Institute for Healthcare Policy and Innovation.
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.
The work, with senior author and Kellogg glaucoma specialist Paula Anne Newman-Casey, M.D., M.S., earned best poster honors for the Kellogg team at the 2016 American Academy of Ophthalmology national meeting in Chicago before it was published in Ophthalmology.
The study 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 was 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.
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.
“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,” De Lott says. “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.”
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.) Study authors described some barriers to 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.
- 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: With any infectious disease of the eye, there’s concern that it might get worse. Bacterial culturing of eye infections is limited to a subset of cases leading physicians to give prophylactic coverage, just in case. But doctors tend to provide that coverage with medications that are much stronger than needed for prevention.
- Optimizing care: If a patient is optimized with a medication, it can be challenging to switch to something else.
If patients are having trouble affording their medication, authors suggest asking their doctor about effective lower cost medications. For glaucoma treatment, there are generic options and therapeutic substitutions, meaning a medication in the same therapeutic class.
Although health care providers prescribing more generic medication as first-line therapy would contribute to significant savings for Medicare, authors say there are times when only policy change will help.
“If the cost of generic medications increase, 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,” says senior author and Kellogg cornea specialist Maria Woodward, M.D., M.S. “A policy change, such as allowing Medicare to negotiate drug prices, would lead to more substantial savings.”
Newman Casey and Woodward are also U-M IHPI members. Researchers were supported by the National Eye Institute (K23EY023596, K23EY025320-01A1, and K12EY022299-04); Research to Prevent Blindness and the Centers for Disease Control and Prevention.