History has many instances in which an idea seemed logical and beneficial on paper but failed spectacularly when put into practice.
One famous example of this is Prohibition in the United States. On the surface, the idea of curbing the availability of “demon rum” would lead to a more stable, law-abiding society. But when Prohibition went into effect, it had almost the exact opposite effect: it led to a huge increase in organized crime as criminals profited off of the illegal production and distribution of alcohol; many citizens started drinking homemade alcohol, leading to a rise in cases of alcohol poisoning; corruption in law enforcement increased; and the alcohol industry was severely damaged, leading to mass layoffs and depriving the government of tax revenue from alcohol sales, which wound up stinging even more during the Great Depression.1
Similarly, the blind allegiance health insurers have for “step therapy” is an idea that seems useful on the surface but, as was pointed out at the 2024 American Academy of Ophthalmology meeting during a presentation on physician reimbursement, is actually counterproductive.
In the presentation, New Jersey retina specialist and chair of the American Society of Retina Specialists’ Research and Safety in Therapeutics Committee, Paul Hahn, outlined how step therapy misses the mark.
In the context of retina care, step therapy involves starting a patient with diabetic macular edema on the lower-cost Avastin first, followed by a switch to Eylea due to lack of response. The idea, of course, is to try to save money by using the cheaper option initially, and Protocol AC from the Diabetic Retinopathy Clinical Research network seemed to bear that out.2 However, as Dr. Hahn pointed out, that’s not what actually happens, since he notes that Protocol AC used treatment regimens that exceed real-world utilization.
In Dr. Hahn’s presentation, he describes a cost-effectiveness analysis he co-authored that identified “40 percent greater direct medical cost in the Protocol AC bevacizumab-first arm compared to real-world treatment over two years. Although clinical trial vision outcomes were greater, a subcohort of real-world patients whose vision outcomes were matched still demonstrated 19 percent lower cost.”3 They also found that, when societal costs were analyzed, the step therapy used in Protocol AC would result in 25 percent greater costs.
At the podium, Dr. Hahn said that if these differences were applied to the 1.1 million patients with DME in the U.S., the additional societal costs associated with Protocol AC Avastin-first treatment would total $12 billion over two-years compared to real-world regimens.
Dr. Hahn’s ultimate point is that physicians should be allowed to use whichever drug they feel is appropriate for a particular patient presentation, rather than have an insurance company dictate their choice. This not only results in better patient care, but it actually saves money too—an idea that works on paper, and also in practice.
— Walter Bethke
Editor in Chief
1. Okrent, Daniel. Last Call: The Rise and Fall of Prohibition. Scribner, 2010.
2. Jhaveri CD, Glassman AR, Ferris FL, et al. Aflibercept-monotherapy versus bevacizumab-first for diabetic macular edema. N Engl J Med. 2022; 387(8):692-703.
3. Grewal DS, Leung EH, Busquets M, et al. Bevacizumab-first in DRCR Protocol AC versus real-world physician treatment choice for diabetic macular edema: A two year cost analysis. J Vitreoretin Dis 2024. In press.
