Advancing Safe Cost-Effective Treatment of Chronic Eye Conditions

Independent Health Brief: Advancing Safe, Cost-Effective Treatment of Chronic Eye Conditions

(December 13, 2018) - Independent Health has a long history of collaborating with physicians to achieve the triple aim of better health, better care and lower health care costs for our community. Through partnerships with cardiologists and urologists, Independent Health has been able to decrease variation in care and move toward consistency in adhering to evidence-based medicine. We have also partnered with local pharmacists to improve medication adherence among members with chronic conditions.

One area of particular focus has been on the different available medications used to treat macular degeneration and other related serious eye conditions related to chronic illness.

Ophthalmologists and retinal specialists have three medication options to treat these conditions, with significant cost differences: Avastin, which costs $60 per dose, and Lucentis and Eylea, which each cost about $2,000 per dose.

Independent Health has implemented a new policy to reduce variation among ophthalmologists and retinal specialists to meet a 60% threshold for using the drug Avastin as opposed to Lucentis and Eylea in an effort to rein in skyrocketing pharmaceutical costs and reduce variations in care.

The current average for Avastin use among our participating ophthalmologists and retinal specialists is 65%, so we are seeking to encourage certain physicians to examine their practice patterns and consider bringing them to a level closer to their peers. As with all of our medical policies, and coverage and medication decisions, we made this determination on Avastin based first and foremost on safety and efficacy, followed by its cost efficiency.

In keeping with our collaborative approach with physicians, we continue to have productive conversations with the ophthalmologists and retinal specialists on how, together, we can control costs without sacrificing quality. Encouraged by these follow-up conversations, we have, on a case-by-case basis, exempted practices from the proposed fee adjustments based on their plans to address clinical variances and issues related to the overall cost-effectiveness of care. All along, we have advocated using the more expensive drugs when Avastin is not effective for an individual patient and therefore these situations will not be factored into the threshold calculation.

Independent Health will continue our ongoing efforts to work with local retinal specialists and ophthalmologists to better prepare them for the new value-based care environment, promoting concepts of professional fiscal stewardship and assisting our community in achieving long-term solutions to more cost effective, high quality care.