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Yang, Shin, Suh, Cho, Tchoe, Kang, and Jee: Final Impact of Anti-Vascular Endothelial Growth Factor Treatment in Age-related Macular Degeneration
Original Article

J Korean Ophthalmol Soc 2018;59(11):1039-1048.

Published online: 25 September 2018

DOI: https://doi.org/10.3341/jkos.2018.59.11.1039

Final Impact of Anti-Vascular Endothelial Growth Factor Treatment in Age-related Macular Degeneration

Jangmi Yang, MD, PhD, MPH1, Sang Jin Shin, MD, PhD1, Jae Kyung Suh, MD, PhD1, Songhee Cho, PhD, MPH1, Hajin Tchoe, MPharm1, Min Joo Kang, MS1, Donghyun Jee, MD, PhD, MPH2,

1Office of Economic Evaluation Research, National Evidence Based Healthcare Collaborating Agency, Seoul, Korea

2Department of Ophthalmology and Visual Science, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Address reprint requests to Donghyun Jee, MD, PhD, MPH Department of Ophthalmology, The Catholic University of Korea St. Vincent's Hospital, #93 Jungbu-daero, Paldal-gu, Suwon 16247, Korea Tel: 82-31-249-7343, Fax: 82-31-249-6225 E-mail: doj087@mail.catholic.ac.kr

Received 3 May 2018       Revised 29 June 2018       Accepted 22 October 2018

Copyright © 2018 Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the effects of anti-vascular endothelial growth factor (VEGF) treatment on the healthcare-related finances of patients with age-related macular degeneration.

Methods

Changes in health care financing due to newly introduced benefit standards were predicted over the coming 5-year period (2018–2022). We also analyzed the financial impact of scenarios in which agents similar to anti-VEGF, such as the over-licensed drug bevacizumab, were introduced. For this purpose, the future number of patients receiving anti-VEGF treatments was estimated for various scenarios based on National Health Insurance Corporation claims data followed by an estimate of the financial burden.

Results

In the case of age-related macular degeneration, the current standard of care (14 times in a lifetime) was maintained in scenario 1. In 2018, the insurance budget for the coming 5-year period was estimated at approximately 440.3 billion won. The insurance cost for that period was estimated at approximately 560.1 billion won under the revised standard of December 2017 (scenario 2). For scenarios wherein, after 2020, similar treatments (scenario 3) and bevacizumab (scenario 4) were introduced, the estimated health insurance costs were 521 billion won and 419.7 billion won, respectively.

Conclusions

Health insurance costs are projected to increase substantially due to the elimination of the 14 time pay standard; however, the actual budget will only moderately increase, due to new limitations of visual acuity ≤ 0.1 or in case of scar-ring/atrophic lesions. Clinically similar agents and bevacizumab could be considered as alternatives to anti-VEGF treatment for age-related macular degeneration.

Keywords: Age-related macular degeneration, Anti-vascular endothelial growth factor, Ranibizumab

References

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Table 1.
Number of patients with anti-vascular endothelial growth factor treatment for age-related macular degeneration in terms of prevalence and incidence (2010–2015)
  2010 2011 2012 2013 2014 2015
Existing patients 14,449 18,063 21,081 24,253 27,392 32,093
New patients 5,099 5,250 4,652 4,725 4,794 5,836
Table 2.
Expectation of number of patients with anti-vascular endothelial growth factor treatment for age-related macular degenertion in terms of prevalence and incidence (2016–2022)
  2016 2017 2018 2019 2020 2021 2022
Existing patients 37,645 44,158 51,797 60,758 71,269 83,598 98,061
New patients 5,994 6,155 6,322 6,492 6,668 6,848 7,032
Table 3.
Number of anti-VEGF injections (2016)
Anti-VEGF Number of injections Proportion (%)
Ranibizumab 27,786 44
Aflibercept 35,329 56

Anti-VEGF = anti-vascular endothelial growth factor.

Table 4.
Scenarios of anti-VEGF treatment for age-related macular degeneration
  Scenario 1 Scenario 2 Scenario 3 Scenario 4
Population change – 10% decrease 10% decrease 10% decrease
Limitation of insurance Ranibizumab, aflibercept maximum 14 times Stop if visual acuity <0.1 after 10 times Stop if visual acuity <0.1 after 10 times Stop if visual acuity <0.1 after 10 times
Anti-VEGF market share (%) Ranibizumab 44 Ranibizumab 44   Bevacizumab 33.3
  Aflibercept 56 Aflibercept 56   Ranibizumab 33.3
        Aflibercept 33.3
2018–2019     Ranibizumab 44  
      Aflibercept 56  
2020–2022     Biosimilar 33.3  
      Ranibizumab 33.3  
      Aflibercept 33.3  

Anti-VEGF = anti-vascular endothelial growth factor.

Table 5.
Dropping rate of patients and the number of injections in age-related macular degeneration
  0–3 years 3–4 years 4–5 years
Drop rate by vision <0.1 in scenario 2–4 (%) 19.0 5.3 5.9
Number of injection for new patients 9.6 2.1 1.6
2018 injections   Average 2.66/year  
Table 6.
Expectation of existing and new patients of age-related macular degeneration (2018)
    2018 2019 2020 2021 2022
Scenario 1 Total patients 51,797        
  New patients 6,322 6,492 6,668 6,848 7,032
  Total-new 45,475        
Scenario 2–4 (10% decrease) Total patients 46,617        
  New patients 5,689 5,843 6,001 6,163 6,329
  Total-new 40,928        
Table 7.
Expectation of new patients of age-related macular degeneration in the future (2018–2022) by scenario 1
    2018 2019 2020 2021 2022
2018 patients (total-new) 2018 patents (total-new) 45,475 45,475 45,475 45,475 45,475
  Drop rate* 0.43 0.50 0.58 0.70 0.84
  Patients (total – drop rate × total) 25,947 22,877 19,218 13,824 7,473
  Injections 69,020 60,854 51,121 36,771 19,878
2018 new patients Patients 6,322 6,322 6,322 6,322 6,322
  Injections 20,229 20,229 20,229 13,275 10,115
2019 new patients Patients   6,492 6,492 6,492 6,492
  Injections   20,775 20,775 20,775 13,634
2020 new patients Patients     6,668 6,668 6,668
  Injections     21,336 21,336 21,336
2021 new patients Patients       6,848 6,848
  Injections       21,912 21,912
2022 new patients Patients         7,032
  Injections         22,504
Total Patients 32,269 35,691 38,700 40,153 40,835
  Injections 89,249 101,858 113,461 114,071 109,379

* Dropping rate after 14 injections = total patients 5 years ago/total patients.

Table 8.
Expectation of new patients of age-related macular degeneration in the future (2018–2022) by scenario 2–4
    2018 2019 2020 2021 2022
2018 patients (total – new) 2018 (total – new) 40,928 40,928 40,928 40,928 40,928
  3rd year drop rate* 0.58 0.70 0.84 1.00 1.00
  3rd year drop patients* 4,490 5,412 6,498 7,776 7,776
  4th year drop rate* 0.50 0.58 0.70 0.84 1.00
  4th year drop patients* 1,078 1,252 1,510 1,813 2,169
  5th year drop rate* 0.43 0.50 0.58 0.70 0.84
  5th year drop patients* 1,037 1,200 1,394 1,681 2,018
  Patients (total-drop)* 34,323 33,063 31,525 29,658 28,964
  Injections 91,299 87,948 83,858 78,891 77,045
2018 new patients Patients 5,689 5,689 5,689 4,608 4,364
  Injections 18,206 18,206 18,206 9,678 6,983
2019 new patients Patients   5,843 5,843 5,843 4,733
  Injections   18,698 18,698 18,698 9,939
2020 new patients Patients     6,001 6,001 6,001
  Injections     19,203 19,203 19,203
2021 new patients Patients       6,163 6,163
  Injections       19,721 19,721
2022 new patients Patients         6,329
  Injections         20,254
Total Patients 40,012 44,596 49,059 52,273 56,554
  Injections 109,505 124,852 139,964 146,190 153,144

* Drop rate at n year = total patients n years ago/total patients.

Table 9.
Cost of anti-vascular endothelial growth factor in age-related macular degeneration
Cost (market share, %) Scenario 1, 2 Scenario 3 Scenario 4
Ranibizumab 828,166 (44.0) 662,533 (33.3) 828,166 (33.3)
Aflibercept 792,163 (56.0) 792,163.0 (33.3) 792,163.0 (33.3)
Ranibizumab, biosimilar   662,533 (33.3)  
Bevacizumab     112,553.7 (33.3)
Injection fee 98,066.0 98,066.0 98,066.0
Doctors fee 15,642.7 15,642.7 15,642.7
Cost of 1 injection 921,713.0 818,745.8 690,758.6
Table 10.
Economic burden of anti-vascular endothelial growth factor treatment by scenario 1
  2018 2019 2020 2021 2022
Number of patients 32,269 35,691 38,700 40,153 40,835
Number of injections 89,249 101,858 113,461 114,071 109,379
Cost/injection (921,713 won) 82,262,071,623 93,884,030,822 104,578,924,437 105,140,366,569 100,816,213,893
Applied discount rate (5%) 82,262,071,623 89,413,362,688 94,856,167,290 90,824,201,766 82,941,748,669
Payer's cost (11%) 9,048,827,879 9,835,469,896 10,434,178,402 9,990,662,194 9,123,592,354
Company's cost (89%) 73,213,243,745 79,577,892,792 84,421,988,888 80,833,539,572 73,818,156,315
Payer's total 48,432,730,724 Company's total 391,864,821,312 Total cost 440,297,552,035
Table 11.
Economic burden of anti-vascular endothelial growth factor treatment by scenario 2
  2018 2019 2020 2021 2022
Number of patients 40,012 44,596 49,059 52,273 56,554
Number of injections 109,505 124,852 139,964 146,190 153,144
Cost/injection (921,713 won) 100,932,593,376 115,077,313,069 129,006,791,287 134,745,049,292 141,155,164,254
Applied discount rate (5%) 100,932,593,376 109,597,441,018 117,012,962,619 116,397,839,794 116,128,702,961
Payer's cost (11%) 11,102,585,271 12,055,718,512 12,871,425,888 12,803,762,377 12,774,157,326
Company's cost (89%) 89,830,008,105 97,541,722,506 104,141,536,731 103,594,077,417 103,354,545,635
Payer's total 61,607,649,374 Company's total 498,461,890,394 Total cost 560,069,539,768
Table 12.
Economic burden of anti-vascular endothelial growth factor treatment by scenario 3
  2018 2019 2020 2021 2022
Number of patients 40,012 44,596 49,059 52,273 56,554
Number of injections 109,505 124,852 139,964 146,190 153,144
Cost/injection (921,713 won) 100,932,593,376 115,077,313,069 114,595,073,082 119,692,293,848 125,386,316,505
Applied discount rate (5%) 100,932,593,376 109,597,441,018 103,941,109,371 103,394,703,680 103,155,632,893
Payer's cost (11%) 11,102,585,271 12,055,718,512 11,433,522,031 11,373,417,405 11,347,119,618
Company's cost (89%) 89,830,008,105 97,541,722,506 92,507,587,341 92,021,286,275 91,808,513,275
Payer's total 57,312,362,837 Company's total 463,709,117,501 Total cost 521,021,480,339
Table 13.
Economic burden of anti-vascular endothelial growth factor treatment by scenario 4
  2018 2019 2020 2021 2022
Number of patients 40,012 44,596 49,059 52,273 56,554
Number of injections 109,505 124,852 139,964 146,190 153,144
Cost/injection (921,713 won) 75,641,830,010 86,242,295,595 96,681,452,941 100,981,870,893 105,785,798,050
Applied discount rate (5%) 75,641,830,010 82,135,519,614 87,692,927,837 87,231,936,848 87,030,237,853
Payer's cost (11%) 8,320,601,301 9,034,907,158 9,646,222,062 9,595,513,053 9,573,326,164
Company's cost (89%) 67,321,228,709 73,100,612,457 78,046,705,775 77,636,423,794 77,456,911,689
Payer's total 46,170,569,738 Company's total 373,561,882,425 Total cost 419,732,452,162
Table 14.
Sensitivity analysis of number of injections in age-related macular degeneration
Scenario Payer's cost Company's cost Total
Scenario 1 48,432,730,724 391,864,821,312 440,297,552,035
Scenario 2 61,607,649,374 498,461,890,394 560,069,539,768
New scenario 2 63,480,465,686 513,614,676,914 577,095,142,600
Table 15.
Sensitivity analysis of the limitation on macular scarring in age-related macular degeneration
Scenario Payer's cost Company's cost Total
Scenario 1 48,432,730,724 391,864,821,312 440,297,552,035
Scenario 2 (20%) 54,762,355,000 443,077,235,905 497,839,590,905
Scenario 2 (15%) 58,185,002,187 470,769,563,149 528,954,565,336
Scenario 2 61,607,649,374 498,461,890,394 560,069,539,768
Scenario 2 (5%) 65,030,296,562 526,154,217,638 591,184,514,200
Table 16.
Sensitivity analysis of the limitation on low vision < 0.1 in age-related macular degeneration
Scenario Payer's cost Company's cost Total
Scenario 1 48,432,730,724 391,864,821,312 440,297,552,035
Scenario 2 (vision <0.1: +10%) 60,413,346,095 488,798,891,136 549,212,237,231
Scenario 2 (vision <0.1: +5%) 61,010,478,619 493,630,236,101 554,640,714,721
Scenario 2 61,607,649,374 498,461,890,394 560,069,539,768
Scenario 2 (vision <0.1: −5%) 62,204,858,361 503,293,854,012 565,498,712,373
Table 17.
Sensitivity analysis of the bevacizumab use in age-related macular degeneration
Scenario Payer's cost Company's cost Total
Scenario 1 48,432,730,724 391,864,821,312 440,297,552,035
Scenario 2 61,607,649,374 498,461,890,394 560,069,539,768
Scenario 4 (price = 1/10) 46,170,569,738 373,561,882,425 419,732,452,162
Scenario 4 (price = 1/4) 49,928,374,468 403,965,938,875 453,894,313,343
Scenario 4 (price = 1/2) 56,191,382,351 454,639,366,294 510,830,748,644
Scenario 4 (market share 60%) 33,774,892,147 273,269,581,914 307,044,474,061
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