Ranibizumab rebate spawns ethical debate

South San Francisco, CA-A rebate Genentech offers large-volume purchasers of its ranibizumab (Lucentis) has stirred debate over the propriety of rewarding physicians for treating their patients with expensive drugs.

The rebate, introduced last fall, provides a financial incentive for ophthalmologists who use large volumes of the drug, which costs as much as $2,000 per injection. The company also manufactures bevacizumab (Avastin), which is commonly used off-label as a much less-expensive alternative to ranibizumab, and the two drugs are the subject of a clinical trial comparing their safety and efficacy.

John Snisarenko, Genentech's vice president of Lucentis sales and marketing, said the program is similar to other rebates the company offers in other medical specialty areas. It was designed to encourage physicians to use ranibizumab to treat patients with age-related macular degeneration and its more recently approved indication, macular edema following retinal vein occlusion (RVO).

"Our feeling is that any information that [patients] would want to know that would affect their decision-making should be disclosed," she said. "All conflicts-financial or otherwise-certainly need to be managed, and disclosure is the golden rule of managing conflicts of interest."

Disclosure can be written or verbal, but she encouraged dialogue with the patient so that "informed consent is more than a signature." She urged AAO members to consult the code of ethics, advisory opinions, and policy statements on the academy's Web site ( http://www.aao.org/).

"Our ethics perspective is that, if physicians are doing something they would be uncomfortable if their patients found out about, then it's probably a good idea to take a step back and examine the motive for doing that," she said.

In a statement, the AAO noted that physician-industry collaborations have advanced medical care, and that pricing incentives such as rebates are legal under the Physicians Payment Sunshine Act, part of the Patient Protection and Affordable Care Act, the segment of health-care reform that President Obama signed into law March 23, 2010.