Community-Level Variation in On-Label Versus Off-Label Anti-VEGF Use and Medicare Part B Spending.
Document Type
Article
Publication Date
7-21-2026
Publication Title
Retina (Philadelphia, Pa.)
Abstract
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.
Recommended Citation
Franco JJ, Song A, Pan WW, Williams GA, Johnson MW, Wubben TJ. Community-level variation in on-label versus off-label anti-vegf use and medicare part b spending. Retina. 2026 Jul 21. doi: 10.1097/IAE.0000000000004920. Epub ahead of print. PMID: 42479493.
DOI
10.1097/IAE.0000000000004920
ISSN
1539-2864
PubMed ID
42479493