Going Dutch

Peter K. Kaiser, MD

At a recent meeting in Amsterdam, a Dutch working group presented its country’s plan to treat patients with exudative MD in the most efficacious, but more importantly, most cost-effective manner.

In their plan, AMD patients are treated with bevacizumab on an as-needed basis after a monthly loading phase. Only if they lose vision or do poorly on bevacizumab are they switched to another anti-VEGF agent. With this plan, the hope is that the Dutch population will be best served with the limited resources available to pay for AMD care.

The working group is carefully monitoring outcomes before and after the plan is enacted, and it hopes to make changes to the plan to ensure optimal visual gains. It is important to note that the Dutch had some of the best visual outcomes in AMD in a very large, recently completed patient registry.

This plan is eerily similar to what insurance companies and large hospital systems are starting to demand of retina physicians across the United States: bevacizumab first — before anything else. Unlike the Dutch working group, they do not care about outcomes, but rather the bottom line.

Of course, all of these plans are based on the numerous comparison studies demonstrating that bevacizumab and ranibizumab have similar efficacy, and aflibercept is similar to ranibizumab. Moreover, discounting the compounding issue, in which the safety problem cannot be denied (see page 42 of this issue), the drugs have also shown relatively similar safety.

Now, I am not trying to defend the comparison studies or discuss the many issues they have raised, nor am I saying anything about these treatment plans for AMD. Instead, I’m trying to describe the problem our profession will face when episodic care begins due to the Affordable Care Act.

When episodic care starts, we will all be faced with the same dilemma as the insurance companies because we will decide how the dollars are spent. In a fee-for-service world, using monthly ranibizumab is very reasonable, especially if you are in a practice that receives Genentech’s rebate. This is not the case with episodic care.

At that time, will starting everyone with AMD on bevacizumab PRN be reasonable? One could argue yes, in that many people will do well with this regimen, and without starting them on it, we will never know. Others could argue that any loss of vision from the wrong regimen will never be regained.

So is preventing vision loss in a few worth the expense to society of on-label treatment for the many? Clearly, we will find out, as outcomes are also going to be tracked. The government has shifted the risk to us.

I hope that it will be a while before Washington figures out how to administer the ACA. By then, maybe we will have a new delivery system or drugs that may make this mental exercise moot, but it is something that many organizations, including the Cleveland Clinic, has taken up as a priority over the next year.

Like speed skating, the Dutch are far ahead of the rest of us.