Purpose
To analyze anti–vascular endothelial growth factor (anti-VEGF) agent–associated industry payments to ophthalmologists using the Centers for Medicare and Medicaid Services (CMS) Open Payments and Provider Utilization and Payment data.
Design
Retrospective database review using 2 national databases.
Methods
Payments from 2013 to 2014 were analyzed by anti-VEGF agent, payment category, and dollar amount. Ranibizumab and aflibercept usage was correlated by performing log-ratio analysis.
Results
A total of 3207 ophthalmologists received 13 449 payments totaling $4 454 325 associated with ranibizumab and aflibercept. As 7% of ophthalmologists received 90% of payments, the Gini index was 0.92, demonstrating unequal distribution of payments. Consulting fees and speaker fees were associated with highest payment amounts to fewest providers. For 2383 providers (74%), greater than 90% of the anti-VEGF payments were associated exclusively with either ranibizumab or aflibercept. A total of 1382 ophthalmologists were matched in both databases. Providers receiving >90% of payments from ranibizumab were more likely to use ranibizumab, and those receiving >90% of payments from aflibercept were more likely to use aflibercept over bevacizumab as compared to those who received no payments.
Conclusions
The distribution of all anti-VEGF payments is unequal. Ophthalmologists who received aflibercept or ranibizumab payments were more likely to receive the majority of payments from one source or the other, but not both. Those who received anti-VEGF payments were more likely to use ranibizumab or aflibercept, as compared to off-label bevacizumab, than those who did not receive any payment.
In 2014, the Centers for Medicare and Medicaid Services (CMS) released payment records from drug and device manufacturers to physicians in the Open Payments database. Payments or transfers of value from industry to physicians from August 2013 to December 2014 have been reported. The publicly available dataset entitled “General Payment Data” includes payments associated with such categories as consulting, services other than consulting (such as serving as a speaker at a non–continuing medical education event), gifts, honoraria, food and beverage, travel, and education. The database contained some limitations, as some potential conflicts of interest such as sample medications, educational materials for patients, trial loans of devices, discounts, rebates, and dividends were excluded.
Interpretation and utility of these data remains controversial. Supporters have argued that the information promotes transparency and could result in more cost-effective practice patterns. Others have questioned the data’s accuracy and pointed out that information presented without context has the potential to mislead patients. A common question is whether these data demonstrate how industry payments affect physician behavior. CMS also publishes a database of Provider Utilization and Payments (PUP), and by correlating the payment and utilization patterns of physicians in the 2 databases, we may develop a greater understanding of the interactions between physicians, industry, and patients.
Over the last 10 years, anti–vascular endothelial growth factor (anti-VEGF) agents have played an increasing and significant role in ophthalmology patient management for diabetic macular edema (DME), neovascular age-related macular degeneration (AMD), and macular edema associated with retinal vein occlusion (RVO). Currently the 3 most common agents used are ranibizumab (Lucentis; Genentech, Inc, San Francisco, California, USA), aflibercept (Eylea; Regeneron, Tarrytown, New York, USA), and off-label bevacizumab (Avastin; Genentech, Inc).
The current study examined the payments made to ophthalmologists related to ranibizumab and aflibercept and correlated those payments to provider usage of these medications.
Methods
The study is an analysis of publicly accessible databases and is therefore exempt from Institutional Review Board approval. The Open Payments General Payment dataset from August 31, 2013 to December 31, 2014 was reviewed ( https://www.cms.gov/OpenPayments/Explore-the-Data/Dataset-Downloads.html ). Payments to ophthalmologists associated with ranibizumab or aflibercept were identified by examining the entries to physicians with taxonomy of ophthalmology and specifically associated with ranibizumab or aflibercept in the Open Payments database. If a single payment listed several medications, of which ranibizumab or aflibercept was one, the whole payment was said to be associated with the anti-VEGF agent. For each instance of payment, 98% of ranibizumab-associated payments and 100% of aflibercept payments were not associated with any other medication or device. Payments to hospitals were similarly classified.
In the database, each medication-related payment is attributed to 1 of the categories specified by CMS. The categories include the following: (1) education, (2) consulting fee, (3) food and beverage, (4) travel and lodging, (5) compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program (called “compensation for other services” throughout the manuscript), (6) gifts, (7) honoraria, (8) charitable contribution, (9) compensation for serving as faculty or as a speaker for a nonaccredited and noncertified continuing education program, (10) compensation for serving as faculty or as a speaker for an accredited or certified continuing education program, (11) current or prospective ownership or investment interest, (12) entertainment, (13) grant, (14) space rental or facility fees, (15) royalty or license. Research payments are not included the Open Payments General Payment database.
For each ophthalmologist and hospital, the following were calculated: total payments associated with all anti-VEGF agents, total payments associated with each anti-VEGF agent, and total payments by anti-VEGF agent and category of payment. For ophthalmologists, total payments in the Open Payments database received by an individual was also calculated.
The Gini index, a measure of the concentration of resources within a population, used to measure inequality, was also calculated for the distribution of anti-VEGF payments. The formula for the Gini index is the following:
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