Comparison of Ophthalmic Medication Prices Between the United States and Australia

Key Points

Question  Are relatively expensive prices for adalimumab, ranibizumab, or aflibercept changing in different ways in high-income nations with the highest and lowest spending on health care?

Findings  In this comparison of prices paid by government entities in the United States and Australia for ophthalmic medicines, the estimated annual decrease in price from 2013 to 2017 for adalimumab, ranibizumab, or aflibercept was greater in Australia than in the United States. For example, the decrease in price for aflibercept was −1.5% in the United States compared with −16.9% in Australia, a difference of 15.4%.

Meaning  The prices of adalimumab, ranibizumab, and aflibercept had larger declines from 2013 to 2017 in Australia than the United States despite similar or higher initial prices.

Importance  Health care prices may drive differences in health care costs across high-income nations. Adalimumab, ranibizumab, and aflibercept are high-cost medications in the United States and Australia. A comparison of their prices over time may elucidate how ophthalmic medication prices contribute to health care costs.

Objective  To compare changes in the prices of adalimumab, ranibizumab, and aflibercept in the United States and Australia, the highest and lowest spenders on health care, respectively, among high-income nations.

Design, Setting, and Participants  This retrospective price comparison study examined prices paid by government entities in the United States (Medicare) and Australia (Pharmaceuticals and Benefits Scheme). The analysis and data collection were conducted from March 28 to May 4, 2018, in accordance with guidelines set by the International Society for Pharmacoeconomics and Outcomes Research Task Force on Good Research Practices and prior published studies. No human participants or related data were included in this study.

Exposures  The change in mean prices of adalimumab, ranibizumab, and aflibercept in the United States and Australia.

Main Outcomes and Measures  Initial, final, and change in medication price annually from 2013 to 2017 in inflation-adjusted 2017 US dollars.

Results  The mean prices (US dollar prices unadjusted for inflation) in 2013 and 2017 in the United States were $1114 ($1053) and $1818 ($1818), respectively, for adalimumab; $2102 ($1988) and $1904 ($1904), respectively, for ranibizumab; and $2074 ($1961) and $1956 ($1956), respectively, for aflibercept. The mean (Australian dollar prices unadjusted for inflation) 2013 and 2017 prices in Australia were $1854 (A $1797) and $1206 (A $1574), respectively, for adalimumab; $2157 (A $2090) and $972 (A $1268), respectively, for ranibizumab; and $2030 (A $1967) and $996 (A $1300), respectively, for aflibercept. The estimated annual change in price for adalimumab was +12.8% (95% CI, 9.1%-16.5%) in the United States compared with −11.1% (95% CI, −15.0% to −7.1%) in Australia, a difference of 23.9% per year (95% CI, 19.7%-28.0%; P < .001). The annual change in price for ranibizumab was −2.6% (95% CI, −3.9% to −1.3%) in the United States compared with −18.5% (95% CI, −29.3% to −7.8%) in Australia, a difference of 15.9% per year (95% CI, 7.6%-24.2%; P = .003). The annual change in price for aflibercept was −1.5% (95% CI, −2.2% to −0.7%) in the United States compared with −16.9% (95% CI, −25.1% to −8.6%) in Australia, a difference of 15.4% (95% CI, 9.1%-21.8%; P = .001).

Conclusions and Relevance  Results of this study indicate that the prices of adalimumab, ranibizumab, and aflibercept significantly decreased during the past 5 years in Australia compared with the United States. These data do not indicate why these differences are noted or what actions might affect future pricing in either country.

Increasing health care costs have long been cited as a major concern in the United States and other high-income nations, with spending in the United States exceeding that of other nations.¹ Conventional wisdom has pointed to a fee-for-service system incentivizing higher use of health care resources and driving higher health care spending in the United States.² However, a study in JAMA^1(p1024) has implicated prices of “labor and goods, including pharmaceuticals and devices, and administrative costs” as the main drivers of higher US health care spending when compared with other high-income nations. From 2005 to 2014, ophthalmologic medications accounted for the largest annual spending growth but lagged behind oncologic, urologic, primary care, and rheumatologic medications for overall US Medicare Part B drug spending.³

Quiz Ref IDAustralia is another high-income nation with parallel practice patterns to the United States in that most medical professionals are self-employed in private practice and compensated by fee-for-service, with some movement toward group practice and alternative payment models.⁴ In addition, Australia has been noted to have a similar overall burden of disease and demographics compared with the United States.^1,5,6 Unlike the United States, however, the Australian government-run Pharmaceutical Benefits Scheme (PBS) provides most prescription drugs with a highly subsidized patient copayment.⁷ Despite fee-for-service billing, Australia had the lowest health care spending among the 10 highest-income nations at 9.6% of its gross domestic product, whereas the United States spent 17.8% of its gross domestic product on health care according to the most recently available estimates from a 2018 study.¹ In Australia, 3 of the 6 overall highest-cost medications to the PBS are used for ophthalmic disease: adalimumab (Humira; Abbvie, Inc), aflibercept (Eylea; Regeneron Pharmaceuticals), and ranibizumab (Lucentis; Genentech), which were the third, fifth, and sixth highest-cost medications, respectively, for the fiscal year 2016-2017.⁸ Although adalimumab has a variety of indications and noninfectious uveitis has only been a recent addition, aflibercept and ranibizumab are exclusively used for ophthalmic indications.^9-11

Because prices have been identified as the main driver of higher US health care spending, we aimed to examine how the prices of aflibercept, ranibizumab, and adalimumab changed from 2013 to 2017 in the United States and Australia. Both countries have fee-for-service billing and a high cost of ophthalmic medications but a large disparity in overall health care costs. Our study aims to assess how medication prices have changed for aflibercept, ranibizumab, and adalimumab in each country to provide further information on how ophthalmic care may contribute to overall rising health care costs.

Data for this price comparison came from publicly available information, and this study did not involve any human participants or related data. Therefore, institutional review board approval and informed consent were waived.

Prices in the United States were collected from the publicly available Medicare Part B Drug and Biological Average Sales Price Index quarterly payment files.¹² The prices in these files represent the dollar amounts used to pay for Part B–covered drugs for a given quarter of a given year and are calculated based on manufacturer reporting of the mean sales price. The data were collected and analyzed from March 28 to May 4, 2018. For aflibercept, ranibizumab, and adalimumab, we collected prices from the July files from 2013 to 2017 with the exception of the 2017 price for adalimumab, which came from the January file because no price was listed for adalimumab in the July file. The prices were based on a dosage of 0.5 mg of ranibizumab, 2 mg of aflibercept, and 40 mg of adalimumab. We must note that the 0.3-mg dosage of ranibizumab is unique to the United States and was not included in this analysis because it is not used abroad, prohibiting an equivalent international price comparison.

Australian prices in Australian dollars were collected from the government PBS Expenditure and Prescription report for the years 2013 to 2017, each of which cite the price in July of that year.¹³ Prices for aflibercept, ranibizumab, and adalimumab were collected from the table listing drugs sorted by highest government cost. Per the PBS report, these prices were calculated by dividing the total cost of the drug (ie, the cost to the patient plus the cost to the government) by the total prescription volume for a given year.

In accordance with guidelines set by the International Society for Pharmacoeconomics and Outcomes Research Task Force on Good Research Practices and prior published studies,^14-17 all prices used in this study were adjusted for inflation using consumer price indices and converted into US dollars based on annual exchange rates obtained from the X-rates currency calculator.¹³ To compare how the costs and the rate of increase in costs varied between identical drugs in Australia and the United States, we used a simple linear model with an interaction term between year and country. Inflation adjustments were based on Australian and US consumer price indices from the Australian Bureau of Statistics and US Bureau of Labor Statistics, respectively, and calculated in local currencies. The mean daily exchange rate for each year was applied to corresponding Australian annual price data (for example, the annual exchange rate across all days in 2013 was applied to 2013 data), and all analyses were performed in 2017 US dollars. We compared how the price change within each country varied between Australia and the United States for identical drugs and dosages. To do so, a linear regression model with a log link and interaction term between year and country was used. This method has been previously used to compare trends in medication prices.¹⁵ All analyses were performed in Excel (version 15.34; Microsoft Corporation) and R (version 3.1.0; R Project for Statistical Computing); P < .05 indicated significance.

The mean prices in 2013 and 2017 (values in parentheses are unadjusted for inflation and in local currencies and without inflation or exchange rate adjustments) for adalimumab were $1114 ($1053) and $1818 ($1818), respectively; for ranibizumab, $2102 ($1988) and $1904 ($1904), respectively; and for aflibercept, $2074 ($1961) and $1956 ($1956), respectively, in the United States. The 2013 and 2017 prices in Australia for adalimumab were US $1854 (A $1797) and US $1206 (A $1574), respectively; for ranibizumab, US $2157 (A $2090) and US $972 (A $1268), respectively; and for aflibercept, US $2030 (A $1967) and US $996 (A $1300), respectively. The estimated annual change in price for adalimumab was +12.8% (95% CI, 9.1%-16.5%) in the United States compared with −11.1% (95% CI, −15.0% to 7.1%) in Australia (P < .001). The US price of adalimumab was $740 dollars cheaper in 2013 and $612 more expensive in 2017 compared with the Australian price (Table and Figure, A). Compared with Australia, the percentage change in price per year was 23.9% greater in the United States during this period (95% CI, 19.7%-28.0%; P < .001).

Quiz Ref IDThe estimated percentage change per year for ranibizumab when accounting for inflation was −2.6% (95% CI, −3.9% to −1.3%) in the United States compared with −18.5% (95% CI, −29.3% to −7.8%) in Australia (P = .003). The difference in price of ranibizumab between the 2 nations was $55 less in the United States in 2013 and annually rising to $933 more in the United States in 2017. Compared with Australia, the percentage change in price per year was 15.9% greater in the United States during this period (95% CI, 7.6%-24.2%; P = .003).

Quiz Ref IDThe estimated percentage change for aflibercept per year was −1.5% (95% CI, −2.2% to −0.7%) in the United States compared with −16.9% (95% CI, −25.1% to −8.6%) in Australia (P = .001). The difference in aflibercept price was $44 more expensive in the United States in 2013 and increased to $960 more expensive in the United States in 2017 (P = .001) (Table and Figure, C). The percentage change in price per year was 15.4% greater in the United States compared with Australia during this period (95% CI, 9.1%-21.8%; P = .001).

The price of adalimumab, ranibizumab, and aflibercept decreased during the past 5 years in Australia compared with the United States. The prices of ranibizumab and aflibercept remained relatively stable throughout the United States from 2013 to 2017 but declined in Australia. Although the price of adalimumab was initially higher in Australia compared with the United States, an inverse price change occurred from 2013 to 2017 with a progressively increasing price in the United States and a progressively decreasing price in Australia. The increase in adalimumab price in the United States may coincide with its 2014 approval by the US Food and Drug Administration for noninfectious uveitis, leading to the US inflation-adjusted price in 2014 of $1290 to increase to $1734 in 2016. However, further study is needed to assess this change in price.

Quiz Ref IDThe strengths of our study are that we used published citable prices from the largest payers for medications in the United States and Australia, the Centers for Medicare & Medicaid Services and the PBS. The medications studied are not only high cost for ophthalmology but among the overall highest-cost medications in all of health care to the Centers for Medicare & Medicaid Services and PBS. Further, the authors used the guidelines of the International Society for Pharmacoeconomics and Outcomes Research to have come to an accurate comparison of prices between changes in inflation and currency exchange rates to ensure a proper price comparison. Limitations of this study include the difficulty in estimating costs and prices, both of which can often be variable even within each country. A comparison of only 3 medications between 2 nations may also be a limitation. Further study will be important when assessing the changes in medication price across nations.

Ranibizumab, adalimumab, and aflibercept each have the potential to provide tremendous benefit to patients globally. The prices of adalimumab, ranibizumab, and aflibercept significantly decreased during the past 5 years in Australia compared with the United States. These data, however, do not indicate why these differences are noted or what actions might affect future pricing in either country.

Accepted for Publication: October 2, 2018.

Published Online: January 10, 2019. doi:10.1001/jamaophthalmol.2018.6395

Correction: This article was corrected on May 9, 2019, to fix inconsistently notated currency in the Abstract and incorrect 2017 prices for aflibercept in the Results.

Corresponding Author: Yasha S. Modi, MD, New York University Ophthalmology Associates, 222 E 41st St, New York, NY 10017 (yasha.modi@gmail.com).

Author Contributions: Drs Parikh and Modi had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Parikh, Feng, Tainsh, Hemmati.

Acquisition, analysis, or interpretation of data: Parikh, Feng, Tainsh, Sakurada, Balaratnasingam, Khurana, Modi.

Drafting of the manuscript: Parikh, Feng, Tainsh, Balaratnasingam, Modi.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Feng, Sakurada.

Obtained funding: Sakurada.

Administrative, technical, or material support: Parikh, Tainsh, Balaratnasingam, Modi.

Supervision: Parikh, Sakurada, Balaratnasingam, Hemmati, Khurana.

Conflict of Interest Disclosures: Dr Sakurada reported serving as a paid speaker for Bayer and Novartis. Dr Khurana reported grant support from Allergan, Clearside Biomedical, Inc, Genentech, Regeneron Pharmaceuticals, Inc, and Santen Pharmaceutical; consulting for Allergan, Genentech, Regeneron Pharmaceuticals, Inc, and Santen Pharmaceutical; and serving as a speaker for Genentech and Regeneron Pharmaceuticals, Inc. Dr Hemmati reported being a shareholder of Allergan, Noveome Biotherapeutics, Cell Care Therapeutics, Inc, Optigo Biopharmaceuticals, and Levation Pharma; being an employee and cofounder of Levation Pharma and Optigo Biopharmaceuticals; and consulting for Cell Care Therapeutics, Inc, Sienna Biopharmaceuticals, Novateur Ventures, Inc, Sanguine Biosciences, and ViewPoint Therapeutics. Dr Modi reported consulting for Genentech, Allergan, and Alimera Sciences. No other disclosures were reported.