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Community-Level Variation in On-Label Versus Off-Label Anti-VEGF Use and Medicare Part B Spending
Jovany J Franco1, Amy Song2, Warren W Pan1
1Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI.
Purpose:
To examine whether community-level sociodemographic characteristics are associated with differences in on-label versus off-label anti-VEGF agent use under Medicare Part B and to estimate differential spending attributable to variation in community-level agent mix.
Methods:
Part B claims data (2013-2023) were analyzed to identify providers billing for on-label (aflibercept, ranibizumab, faricimab, brolucizumab, and biosimilars) or off-label (bevacizumab) anti-VEGF injections. For each provider year, 15-min drive-time service areas were generated and overlaid on U.S. Census tracts enriched with American Community Survey-derived sociodemographic data. Community-level profiles were generated through population-weighted aggregation of tracts within each service area. Multivariable logistic regression estimated adjusted marginal effects (AMEs) of sociodemographic variables on on-label anti-VEGF proportion. Counterfactual simulations estimated Part B spending under alternative community-level agent mix scenarios.
Results:
From 2013-2023, 5,178 providers billed Part B for 34.5 million anti-VEGF injections. Higher on-label use was associated with greater community-level proportions of Medicare-aged (AME per 10-percentage-point [pp] increase: +6.1 pp [95% CI: 3.1-9.0]), Black/African American (+2.4 [1.5-3.3]), and college-educated residents (+3.2 [1.9-4.5]). An inverse association was observed for proportion very low-income residents (-3.1 [-5.3 to -0.8]), while no association was observed for proportion Hispanic/Latino residents (+0.4 [-0.6-1.3]) or population density (AME per doubling: +0.8 [-0.2-1.8]). Equalizing anti-VEGF mix to that of the highest-poverty quartile would have resulted in approximately $4.2 billion lower spending.
Conclusions:
Despite uniform reimbursement, significant community-level differences exist in on-label anti-VEGF use within Medicare Part B. These gradients produce billions of dollars in differential spending and raise questions of access, equity, and value-based care.
