When Independent Health sent a letter informing eye specialists that using the $2,000-a-dose brand name drugs to treat age-related macular degeneration would be met with consequences, the insurer struck a nerve. Doctors were told to use off-label Avastin, instead. It runs about $50 a dose.
It was the right move. Now Congress needs to act.
Independent Health’s CEO, Dr. Michael Cropp, has been vocal about the high cost of health care, penning several opinion pieces for this newspaper. The decision to begin crunching data five years ago to “weigh quality and cost of care provided by specialists” falls in line with the maverick approach by the insurer. As News staff reporter Scott Scanlon wrote, its letter to eye specialists about a “potential fee schedule reduction” was the first time an insurer in this region, and perhaps the nation, raised the possibility of financial penalties to doctors who ignore a median standard of care determined by data comparisons.
The insurer revised the potential policy for 2019 after getting feedback from eye doctors. Instead, the company asks doctors to take a measured approach — one that should already be employed — by starting all treatment regimens with Avastin. If it does not work well, then go to the more expensive drugs.
Independent Health is taking a strong stand, one necessary against the backdrop of an industry that has set exorbitant prices for some drugs.
Still, not everyone is pleased. Dr. Gareth Lema told The News: “They’re asking us to play God.” Lema is a Buffalo eye surgeon whose two-doctor practice received one of the letters informing Lema that the office was not meeting the preferred threshold for Avastin use.
It is not the case here, but some specialists elsewhere prescribing the higher-cost medication are also reimbursed at higher rates. Independent Health raised the reimbursement for Avastin to bring it more in line with the expensive drugs.
Dr. John Thompson, past president and chairman of health policy with the American Society of Retina Specialists, said most ophthalmologists and retina specialists start macular degeneration patients on Avastin for “three to six months” but move on to costlier drugs, if necessary. He also raised the specter of more frequent injections with the Independent Health policy and questioned whether doctors with patients in poorer communities and those with higher risk of blood clots and stroke would be adversely affected. These are good points but, under the circumstances, must be measured against the backdrop of out-of-control drug costs that threaten American health care.
Congress must act. The outgoing GOP-controlled House wasted precious time trying to dismantle the Affordable Care Act. The Democrats must make health care costs its priority and the should start by leveraging vast buying power to secure bulk discounts for expensive drugs.
Independent Health’s bold move should be a wake-up call to doctors who do a disservice to patients and the taxpaying public by choosing the higher-cost path when there is a less expensive alternative.