Disparities in Access to Intravitreal Anti-VEGF Therapies Among Medicare Advantage Versus Fee-for-Service Beneficiaries

Highlight

• Medicare Advantage (MA) beneficiaries are less likely to receive higher-cost intravitreal anti-VEGF drugs than Medicare Fee-For-Service (FFS) patients.
• Lower-cost repackaged bevacizumab is more frequently used in the MA population compared to FFS.
• This utilization pattern raises concerns about access barriers to newer, expensive anti-VEGF agents among MA enrollees.

Study Background

Intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents are cornerstone treatments for retinal diseases such as neovascular age-related macular degeneration, diabetic macular edema, and retinal vein occlusion. Currently available agents include bevacizumab, aflibercept, ranibizumab, brolucizumab, and the recently approved faricimab, varying widely in cost and approval status. Widespread disparities in drug utilization, especially among older adults covered by Medicare, have implications for clinical outcomes and healthcare resource allocation.

Medicare beneficiaries are typically enrolled in either the traditional Fee-For-Service (FFS) Medicare program or Medicare Advantage (MA), a managed care alternative. MA plans often have different reimbursement policies, formulary restrictions, and utilization management strategies that could influence access to costly therapies, such as the newer anti-VEGF agents. Understanding differences in anti-VEGF drug use between these groups is critical in assessing equitable access to retinal care under Medicare.

Study Design

This retrospective, cross-sectional analysis utilized de-identified data from the American Academy of Ophthalmology’s IRIS® Registry, spanning patient encounters between January 2017 and December 2022. The study population comprised Medicare beneficiaries aged 65 years or older with continuous enrollment in either FFS or MA for at least 12 months. Patients were included if they received intravitreal anti-VEGF injections.

Anti-VEGF drug use was categorized based on the predominant drug (>50% of injections) administered over at least 12 months per patient. The study compared proportions of beneficiaries predominantly treated with each anti-VEGF drug across FFS and MA groups. Statistical analyses evaluated differences in utilization patterns with 95% confidence intervals and significance testing.

Key Findings

A total of 930,411 Medicare beneficiaries underwent 12,942,057 intravitreal injections during the study period.

In the FFS group, drug use distribution was as follows: aflibercept 2 mg (43.8%), bevacizumab (34.7%), ranibizumab (20.6%), brolucizumab (0.6%), and faricimab (0.4%). In contrast, the MA group showed bevacizumab as the most used agent (45.1%), followed by aflibercept 2 mg (37.8%), ranibizumab (6.5%), brolucizumab (0.4%), and faricimab (0.2%).

Repackaged bevacizumab, which represents the lower-cost drug option, was administered more frequently to MA beneficiaries than their FFS counterparts (60.0% vs. 47.0%; difference 13.0%, 95% CI: 12.8% to 13.3%, P<.001).

Conversely, higher-cost anti-VEGF drugs were significantly less utilized among MA enrollees compared with FFS beneficiaries:

• Aflibercept 2 mg: 28.9% vs. 36.6% (difference -7.7%, 95% CI: -7.9% to -7.4%, P<.001)
• Ranibizumab: 11.9% vs. 16.8% (difference -4.9%, 95% CI: -5.03% to -4.7%, P<.001)
• Faricimab: 0.06% vs. 0.24% (difference -0.18%, 95% CI: -0.19% to -0.16%, P<.001)
• Brolucizumab: 0.12% vs. 0.19% (difference -0.07%, 95% CI: -0.09% to -0.05%, P<.001)

Expert Commentary

These data elucidate a pronounced discrepancy in anti-VEGF drug utilization between MA and FFS Medicare patients. The preference for lower-cost repackaged bevacizumab in MA could stem from cost containment incentives inherent to managed care plans, including preferred formularies and prior authorization requirements. Given that bevacizumab is off-label but widely used due to substantial cost savings, MA plans may preferentially encourage its use over expensive biologics.

While bevacizumab demonstrates efficacy comparable to approved agents, certain newer drugs like faricimab offer potential benefits such as extended dosing intervals and dual VEGF and Angiopoietin-2 inhibition, which might improve outcomes or reduce treatment burden. Restricting access to these agents due to cost considerations could impact patient care quality.

It is necessary to evaluate whether utilization differences translate into disparate visual outcomes or patient satisfaction across Medicare populations. Limitations of the study include its observational nature and reliance on registry data that might not capture clinical nuance or reasons for drug selection.

Conclusion

The study reveals that Medicare Advantage beneficiaries are less likely to receive higher-cost intravitreal anti-VEGF therapies compared with those in the Fee-for-Service program, with a marked preference for repackaged bevacizumab in the MA group. This pattern underscores potential access disparities possibly driven by cost containment policies in managed care settings.

Further research is warranted to assess the clinical impact of these differences and to guide policy decisions ensuring equitable access to emerging, potentially superior anti-VEGF treatments for all Medicare beneficiaries.

Funding and Clinical Trials

The article does not specify funding sources or registered clinical trials related to this work.

References

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