Experts say the common brand-name products used for IV iron infusions are, in many cases, medically interchangeable—yet providers are increasingly administering the most expensive products, leaving patients facing unexpectedly high bills, Shefali Luthra reports for Kaiser Health News.

What patients want along their financial journey

A nearly $3,000 medical bill (and a growing trend)

In spring 2018, Shannon Rothenberg learned she had iron-deficiency anemia. The condition ran in her family, and her doctor began treatment with over-the-counter iron pills. But after two months with no improvement, her doctor sent her to a hematologist at a hospital-operated cancer center to receive two infusions of Injectafer, an iron solution.

When Rothenberg received the bill for the infusions, she and her husband were "floored," Luthra reports. According to Luthra, the hospital had charged more than $14,000 per vial for Injectafer—an amount that was negotiated down to about $1,600 per vial because the hospital was in her insurer's network. Still, she owed the hospital $2,733, since her family hadn't yet met their $9,000 deductible.

Rothenberg isn't alone, Luthra reports. Millions of patients receive iron infusions each year, and the prices of these infusions can vary dramatically. According to an analysis by the Health Care Cost Institute (HCCI), the prices paid by private health plans for several branded IV iron products in 2017 averaged:

• $412 per visit for Ferrlecit;
• $825 per visit for Venofer;
• $1,502 per visit for Infed;
• $3,087 per visit for Feraheme; and
• $4,316 per visit for Injectafer, the drug Rothenberg received.

Of these products, Injectafer and Feraheme are becoming more commonly prescribed, Luthra reports. According to HCCI's data, 23% of privately billed iron infusion visits used Injectafer or Feraheme in 2017, compared with just 13% in 2015. Further, an analysis by KHN found that more than half of all IV iron infusions under Medicare in 2017 used Injectafer or Feraheme, up from less than a third in 2014.

Why are costly iron infusions becoming more common?

While the iron infusion products on the market do have different chemical formulations, they are generally considered medically interchangeable, Luthra reports. According to Richard Pollock, a health economist at Covalence Research in London, "There's not a huge amount of difference in the efficacy of iron formulations."

But some critics say U.S. providers have a financial incentive to prescribe the more expensive formulations, Luthra reports. For instance, Medicare calculates a doctor's payment in part based on the average sales price of a prescribed drug. For patients with private insurance, prices can be marked up even more before being negotiated down with the insurer, Luthra writes.

And some experts question whether IV iron infusions are even necessary in many cases, rather than lower-cost, in-home options such as pill-based supplements or skin injections. For example, Pollock said "it would be extremely unlikely that IV iron would be administered" to an otherwise healthy patient in Great Britain.

However, Walid Gellad, an associate health policy professor at the University of Pittsburgh, notes that in some cases there's a medical need for a more costly iron option. He said some formulations of iron infusions may be more convenient for patients and may require fewer doses or take less time to use. Further, it's possible a patient could have a specific profile that would make one drug a better fit than another, Gellad added.

'A big mental shift'

Rothenberg said she was never informed that cheaper options for her iron infusion may exist. "If they had said, 'This is going to cost you $3,000,' I would have said, 'Oh, never mind,'" Rothenberg said. "It's a big mental shift for me to say, 'I'm supposed to weigh the costs against the health benefits. I'm not supposed to necessarily do what the doctor says.'"  

The hematologist who treated Rothenberg did not respond to Luthra's request for comment.

However, Alan Miller, chief medical director of oncology for SCL, the umbrella organization for the cancer center Rothenberg was treated at, said the hospital stopped using Injectafer a month after Rothenberg's treatment, and now instead uses Venofer and Feraheme (Luthra, "Shots," NPR/Kaiser Health News, 8/1).