Tag Archives: California

Three States Expand Access to Hepatitis C Treatment

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

In the past two months, three states – California, New Jersey (Hester, 2018), and Rhode Island (Miller, 2018) – have moved or plan to move to drastically reduce the number of prerequisites to gain access to Direct-Acting Agents (DAAs)to treat and cure Hepatitis C (HCV). Here, at HEAL Blog, we have been advocating for such a change since our inception, though it would be hubristic to suggest that a single blog post could account for any change to state Medicaid policies.

As discussed in the previous blog linked above, California’s efforts to expand access likely relate to a couple of Class-Action lawsuits they’ve been facing over the past few years, both from Medicaid clients and incarcerated citizens. Rather than wait to end up paying exponentially more by way of settling or outright losing in court, the state wisely chose to expand access by providing more money through the budgeting process. This additional $176 million will allow the state to open treatment to more lower-income Medi-Cal recipients, as well as those incarcerated.

New Jersey has also broadened coverage for HCV DAAs to cover all Medicaid enrollees in the state once someone is diagnosed with the virus. This policy change was also facilitated by increased funding in the FY2019 budget to the tune of $10m. (Stainton, 2018).

New Jersey’s Medicaid program, however, is run a bit differently. Since 1995, the state’s Medicaid program has been administered by way of Managed Care Organizations (MCOs) – private companies who are contracted to provide and disburse benefits and payments to Medicaid recipients in exchange for a per member per month capitation payment. Currently, there are five private insurers who offer these services: Aetna, Amerigroup NJ, Horizon NJ Health, UnitedHealthcare Community Plan NJ, and WellCare. MCOs are designed to save state’s money by outsourcing the work to private companies for cheaper than the state itself would spend on salaries, pensions, and benefits to administer the program. Of the five MCOs in New Jersey, all but oneplan (Amerigroup NJ) provide drug coverage only for Mavyret (AbbVie), the newest pangenotpyic DAA drug on the market (which is conveniently also the cheapest). Amerigroup alone provides coverage to virtually every other DAA still on the market.

The problem with MCOs is that, because they are private companies providing this service, they are not always quick to adapt to new rules and regulations. There are several states which employ MCOs alongside traditional Fee-For-Service (FFS) Medicaid programs. The rub is that MCOs are required by law to provide the same coverage for clients as the FFS program, meaning that, if the FFS Program covers all available DAA drugs, the MCOs must also offer the same drug coverage. This is rarely the case, and few people, either from the state governments, or individuals who enroll in these plans, ever really push the point hard enough to ensure that MCOs are meeting this requirement. In the case of New Jersey, there is no FFS Medicaid programs; it’s entirely operated via MCOs, which essentially means that it will be difficult for New Jersey’s government to ensure that clients in all five MCOs are receiving access to this expanded treatment.

Finally, Rhode Island has also broadened coverage for HCV treatments. This was accomplished as a result of persistent lobbying by the Rhode Island Center for Justice, the Center for Health Law and Policy Innovation of Harvard Law School, and community activists and lawyers (Miller).

The ball got rolling on this change when a state resident receiving legal representation after being denied treatment by the state’s Medicaid program. The Center for Health Law and Policy Innovation has been tireless in its efforts to expand access to treatment of chronic illnesses both by government-funded programs, and by private insurers. Over the past three years, the Center has repeatedly stepped in on behalf of Medicaid recipients and privately insured individuals to use public pressure and threat of legal action to ensure that patients receive the coverage to which they are entitled, either by Federal law, or by state mandate. They have worked with several states to create HCV medication pilot programs that allow state AIDS Drug Assistance Programs (ADAPs) to offer coverage for HCV drugs that they might otherwise never receive.

All three of these states are moving in the right direction. Hopefully, we will see more forward momentum from other states in the coming months.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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California Plans to Allocate $176 Million to Hepatitis C

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

The state of California has revised its 2018-2019 state budget to include $176 million to expand Hepatitis C (HCV) treatment to low-income citizens (Bartolone, 2018).

For low-income recipients of Medi-Cal (California’s version of Medicaid) and inmates in state prisons, access to the Direct-Acting Antivirals (DAAs) that cure HCV by allowing a patient to achieve Sustained Virologic Response – SVR – has been extremely limited. For recipients of Medi-Cal, there were several prior authorization requirements that served as barriers to treatment (Department of Health Care Services, 2015). For patients incarcerated in California state prisons, access has been so difficult that inmates have had to file a Class-Action lawsuit in an effort to force the state to provide the Constitutionally guaranteed access to treatment they should be receiving (Bayse, et al. v. California Department of Corrections and Rehabilitation, et al.).

Medi-Cal

Photo Source: Kaiser Health News

The newly allocated funds – $106m – will primarily go to the correctional system, as the rate of HCV infection is much higher in correctional settings than in the general population (Holzer, 2018). In speaking with colleagues at the National Viral Hepatitis Roundtable, the scuttlebutt around California is that this revision to increase HCV funding is a preemptive step to resolve the pending Class-Action suit against the state. The thinking seems to be that it will be cheaper to pony up the money to treat inmates, now, rather than to wind up paying a potentially much higher amount to accomplish the same goal, as well as potential damages awarded for failing to provide access to treatment.

While these funds are a fantastic development, history has shown that, even when the money is there, changing course is often difficult to implement with any immediacy. We’ve seen, before, that there will always be bugs in the system. Though Medi-Cal hasn’t yet moved to alter the existing prior authorization restrictions, it is highly anticipated that the agency will do so within the coming months (Bartolone). The $70m in additional funds designated to pay for treatment of approximately 2,090 patients. Let’s see if that comes to fruition.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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“OC” Shut Down the County’s Only Syringe Services Program

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

Last week, HEAL Blog covered San Francisco’s multi-pronged approach to dealing with public health among People Who Inject Drugs (PWIDs) and health concerns related to Injection Drug Use (IDU). This week, we’ll visit the southern part of the state – Orange County.

Photo Cover of the OC Weekly

Photo Source: OC Weekly

For those unfamiliar with Orange County, either from the salacious Bravo “reality” series involving housewives, or from Disneyland, the OC is virtually the opposite of all things San Francisco. Long considered a Conservative bastion for the rich and ridiculous, Orange County is home to some of the most ludicrous local regulations and laws – regulating that street lights be turned off by 10 PM to avoid “light pollution;” regulating the length of grass and the design of doors on houses; one town attempted to ban flip-flops. The county has long been the butt of jokes, and deservedly so.

It should, then, come as no surprise, then, that Orange County recently shut down the county’s only Syringe Services Program (SSP) in Santa Ana in January 2018 by denying it a permit (Graham, 2018). This move came after a massive Hepatitis A (HAV) outbreak spanning the southern California coast from San Diego to Los Angeles (between which Orange County lies) primarily within homeless and PWID communities in 2016-2017. At the time, Orange County officials failed to follow the leads of San Diego, Santa Cruz, and Los Angeles Counties in declaring a public health emergency, deciding instead to continue with their protocol of vaccinating and educating their homeless population…which many cities within the county have criminalized (Vo, 2017). Not only did they fail to recognize that the HAV outbreak in surrounding counties could spread to them, they failed to enact any of the proactive sanitation recommendations put forth by the California Health and Human Services that were instituted in San Diego County.

Following this regressive trend, a permit request that would allow the establishment of a mobile SSP in Costa Mesa’s Westside is currently attempting to raise botoxed eyebrows. The justification used by Santa Ana to January permit denial was an “increased number of discarded syringes in the area.” Costa Mesa officials called the proposed mobile SSP a “magnet for drug users” (Fry, 2018).

…because there are no drug users originating from Orange County…

The proposed mobile SSP would serve four Orange County cities – Santa Ana, Anaheim, Orange, and Costa Mesa. These cities were chosen because the Orange County Health Care Agency depicted them as being hotspots for HIV and drug overdoses (Brazil, 2018). Anaheim had the highest number of opioid-related overdose deaths between 2011-2015, followed by Huntington Beach, Santa Ana, Costa Mesa, and Orange. Santa Ana has the highest rate of HIV cases, while Costa Mesa and Orange also have high rates.

Syringe Exchange Program worker providing assistance

Photo Source: LA Times

As for Hepatitis C (HCV) and Hepatitis B (HBV), California, as a whole, has relatively low rates of both – 0.2 and 0.3, respectively. Moreover, the state consistently runs behind on issuing annual reports and epidemiological profiles – the most recent HCV report was issued in 2016, and counts only Chronic HCV cases, which is counter to how the Centers for Disease Control and Prevention (CDC) accounts for HCV counts and rates in the U.S. (they count Acute HCV cases, as Chronic HCV is a long-term disease that is hard to track and may take years to develop). When states account for Chronic HCV cases in their reporting, rather than Acute infections, the data tends to skew toward patients within the Birth Cohort – Baby Boomers born between 1945-1965. This inevitably will wind up excluding PWID and homeless populations, as they are less likely to be screening for HCV, and data from virtually every state in the U.S. indicate that PWID who contract HCV trend younger – 15-45.

The justification in Costa Mesa for denying permits to the Orange County Needle Exchange Program – that it will attract drug users to their fair cities – is ludicrous on several fronts, not the least of which is the simple issue of distance. Anyone who’s ever lived in southern California can tell you that it will likely take you an hour or more to get somewhere during the daytime, and that’s if you’re driving. The suggestion that a mobile SSP will somehow draw PWID from neighboring counties – from Los Angeles, San Bernardino, San Diego, or Riverside, all of which are wellout of walking distance – is just ridiculous.

If the Real Housewives of Orange County taught us anything, it’s that keeping up appearances in Orange County is more highly regarded than adequately addressing serious issues. Orange County, rather than being proactive and attempting to directly confront HIV, HBV, and HCV, are instead trying to maintain the façade of a Pleasantville-esque paradise, where the homeless are invisible and drug users mustbe coming from othercounties. It’s a shortsighted approach, destined to produce lackluster results.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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San Francisco: A Case Study in Multi-Pronged Approaches

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

One of the most frequent drums HEAL Blog likes to bang is that epidemics do not occur in siloes. As we learned in Scott County, Indiana, an uptick in new HIV and Hepatitis C (HCV) cases was largely the result of the Injection Drug Use (IDU) of the now-removed-from-the-market prescription opioid drug, Opana. The HIV community has been banging this drum since the 1980s; unfortunately, the politics around IDU were such that Syringe Services Programs (SSPs, or needle exchanges) simply weren’t a politically feasible reality in most of the United States. In other parts of the country, like San Francisco, underground exchanges began in the late-80s, and legalization was relatively quick to follow.

Needle exchange program with volunteers working with injection drug users

Photo Source: 5KPIX CBS

San Francisco’s first underground needle exchange – Prevention Point –  began in 1988 when a group of friends realized that something needed to be done to stop the spread of HIV among People Who Inject Drugs (PWIDs). Against California law, the organizers and volunteers went to great lengths to provide sterile syringes to PWIDs and also partnered with researchers, collecting data to document the positive health benefits programs like theirs could achieve (San Francisco AIDS Foundation, n.d.). Prevention Point operated for four years underground until 1992, when then-mayor Frank Jordan declared a public health emergency in the city of San Francisco and committed $138,000 to Prevention Point. This bold step went a long way to ensuring that SSPs were legalized within the state of California.

Fast-forward to 2018, and again, IDU is again a serious issue in San Francisco. This time, however, the San Francisco Department of Public Health is leading the charge using a variety of integrated initiatives involving:

opioid overdose prevention, education, and the distribution of Naloxone [an opioid overdose reversal drug]; access to and distribution of [sterile] syringes; prevention, screening, and treatment of HIV and HCV; alcohol prevention; and the creation of a Harm Reduction training institute (Chaverneff, 2018).

This multi-pronged approach to dealing with these intertwined epidemics using community-based methods, including peer education and testing models that have proven effective in other settings around the world.

More importantly, their model also includes taking HCV treatment outside of traditional healthcare settings, and helps to provide treatment at an Opiate Treatment Outpatient Program (at University of California San Francisco), at the San Francisco County Jail, at the SF AIDS Foundation Syringe Exchange program, at Magnet (a gay men’s sexual health clinic), at shelters, and in street settings (mobile setups). Of these, the most notable success was that the 10 patients who began HCV therapy in shelters all completed treatment; conversely, less than half of the 100 inmates who began HCV therapy completed treatment (Burk, 2018).

This model has been working for San Francisco, and it has the potential to work around the country, as well.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Class Action Correctional Malpractice

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

Inmates in Oklahoma prisons must have advanced liver disease before they become eligible for treatment for Hepatitis C (HCV). This means that their livers must manifest significant scarring before they’re even allowed to receive the curative treatment that will prevent further damage (Botkin, 2018).

A class action lawsuit has been filed in the state of California alleging that doctors within the prison system have denied them treatment because their liver disease isn’t advanced enough, that their disease is too advanced, and/or the drugs are too expensive (Locke, 2018).

A class action lawsuit in Missouri alleges that only five out of thousands of Missouri inmates have received treatment for HCV, desite between 10-15% of the incarcerated population being infected with HCV (Margolies & Smith, 2017).

Idaho says that nearly 1/3 of its prisoners have HCV, and it needs $3M to treat them (Boone, 2018). An inmate diagnosed with HCV while in a Mississippi prison has filed a suit alleging they’ve refused him treatment on at least nine separate occasions (Wolfe, 2018).

Inmate looking out window with bars on it

Photo Source: thedenverchannel.com

Each of these instances is indicative of a few major points: (1.) We have a growing number of prisoners within our justice system who are infected with HCV; (2.) Prison systems and/or state Departments of Corrections (DOCs) are refusing or delaying treatment; (3.) This is unconstitutional.

In last week’s HEAL Blog (“Cruel and Unusual” Neglect in Prisons), we introduced the concept of “deliberate indifference,” a measure introduced by Estelle v. Gamble (1976). This week, there’s another take – does being literally unable to afford the cost of treating inmates qualify as deliberate indifference?

The answer to that question really depends on the judge who hears the case. In 2017, U.S. District Court Judge Mark Walker in Tallahassee, Florida ruled in favor of three inmates who filed a class action lawsuit against the state of Florida, requiring the state to treat a significant portion of its 98,000 inmates (total population; not HCV-infected population) for HCV (Klas, 2017). Similarly, in Pennsylvania, a U.S. District Court Judge Robert D. Mariani ruled in favor of Mumia Abu-Jamal, an inmate who gained notoriety for his shooting of an officer who had stopped his younger brother in a traffic stop (Mayberry, 2017). Both Federal judges found that prisons are required to provide treatment for HCV, regardless of the cost.

Make no mistake, however – these rulings are few and far between; the primary issue is that it’s difficult to prove “deliberate indifference” without detailed and voluminous documentation. Even then, the measure is specifically designed to be difficult to prove (as are all burdens of proof). And the primary reason why prisons refuse or delay treatment has little to do with indifference, so much as the cost. HCV Direct-Acting Antivirals are prohibitively expensive for regular consumers; prisons, however, have even less wiggle room, as they are largely unable to negotiate on drug prices.

Where we are, at the moment, seems to be a holding point: until the drugs to treat HCV get exponentially cheaper to purchase (right now, the least expensive 8-week treatment regimen – Mavyret (AbbVie) – goes for $26,400, roughly 1/3 the cost of the cheapest drug in 2013), prison systems are unlikely to make any substantive efforts to treat HCV-infected inmate. Moreover, until the Federal government requires states to both screen and treat inmates for infectious diseases, it’s likely that HCV will continue to spread among inmates and the general population.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Pre-Requisite Treatment Standards Still Abound

By: Marcus J. Hopkins, Blogger

Remember that time when county health officials refused medical treatment coverage to people living with HIV if they were drug users and openly admitted it in a radio interview? Yeah…me, either. This was, however, the case on August 24th, 2016, when Dr. Hal Lee, Los Angeles County Health Services’ Chief Medical Officer and liver specialist, freely admitted to the practice with the following statement:

It’s our obligation to offer treatment in a manner that’s rational and logical. We identify the individuals for initial treatment right now, based on how we can offer the most care to the most people, who are going to benefit from it the most now. We believe it is likely that patients who are not using drugs are more likely to complete the treatment than people who are actively using illicit drugs (Plevin, 2016).

This policy is in direct conflict with the Medi-Cal – California’s Medicaid program – Treatment Policy for the Management of Chronic Hepatitis C, a set of guidelines that went into effect on July 1st, 2015, well over a year prior to the date of this interview (State of California, 2015). What makes Yee’s statement ironic is that Medi-Cal is very likely the agency that would be paying for the services that his office is failing to provide.

In this interview, the reporter states that Yee has developed a checklist of criteria to determine if patients are eligible for treatment – one that apparently disregards the very specific checklist put forth by the State of California. One of the criteria requires patients to be free of drug use for six months prior to receiving Hepatitis C medications.

To bring this further into focus, Health Services, which provides health care for about a half-million low-income Los Angelinos, has approved treatment for only 160 people, as of the beginning of August. By comparison, San Francisco Health Network, which serves only 65,000 people overall, treated 631 people by late June 2016. This is a stark difference in treatment approaches, and speaks, I believe, to the social and socioeconomic stratification that exists in Los Angeles County.

My own experiences with L.A. County’s Health Department left much to be desired. As someone who has relocated to several states and been the beneficiary of their respective health agencies, my experiences within L.A.’s low-income health care programs presented a stark and sad reflection of how L.A. treats its residents who don’t reside in the best zip codes.

Hospitals were run essentially like prisons, with barred windows, numerous metal detectors, and employees who behaved more like judgmental prison workers, rather than health care professionals. Facilities were overcrowded, parking was nearly impossible to find, and locations were so far-flung that taking public transportation to them would take hours. After enduring hours-long commutes on the 5 and 405 freeways just to get to an appointment, I finally gave up on the County program and switched my treatment facility to the AIDS Healthcare Foundation in Van Nuys.

Just beyond the Sepulveda Pass in “The Valley” (San Fernando, that is), this facility that catered to low-income patients was in the right zip code. Though small, it was rarely crowded, focused solely on patients with HIV, and the employees treated everyone, regardless of their mental or physical state, without judgment. There were no metal detectors or barred windows; just good healthcare providers.

Dr. Hal Lee

Photo Source: L.A. Care Consult

What makes me sad about the interview with Dr. Yee is the following quote:

If 70 percent of individuals would live out their lives without any consequences of their hepatitis C infection, none of those people will benefit from treatment. I know that if you come talk to me in one year, in five years, in ten years, you’re going to see these numbers climb, because we’ve put in infrastructure that I know allows us to provide the kind of care that other counties can’t even begin to think about.

Make no mistake – Yee’s approach to treatment is not only outside of California’s long-established treatment guidelines, they are also part of a greater issue: the belief that not everyone is deserving of treatment; that some patients are just “better” than others; that one’s station in life makes them more deserving of quality healthcare.

This interview with not just a county healthcare employee, but the Chief Medical Officer, is a sad reminder of how some doctors fail to live up to their obligations to their patients in a nation where healthcare is not considered a human right. Opponents of Universal/Single-Payer Healthcare love to bandy about the boogieman of “Death Panels,” failing to see that those types of panels already exist, right here in our United States.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

 

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Litigation and Legislation May Force Lower Prices

By: Marcus J. Hopkins, Blogger

The past three years have brought many great tidings for those living with Hepatitis C (HCV): a total of seven new HCV-specific Direct Acting Agent (DAA) regimens have been released onto the market, all of which are far more easily tolerated than the ribavirin and Pegylated interferon-based treatments, and all of which sport Sustained Virologic Response (SVR) rates of above 90% in most HCV patients. We’re now looking at the release of at least one more drug from Gilead, this year, that will be pan-genotypic – it can be used in the treatment of any genotype of HCV – as well as the possibility of injectable treatments that can be used on a regular basis, and reduce reliance upon pills.

Image of a stethoscope wrapped around a $20 bill , laying next to an open medication bottle

Affordable Healthcare

But, the reality is that these medical and technological breakthroughs cost money. Lots of money, really; and there seems to be no one willing to accept responsibility for their part in creating a market where a Wholesale Acquisition Cost (WAC) – the “baseline” for a drug’s price, before discounts and rebates – of $54,000 for twelve weeks of treatment is seen as a welcome reprieve.

Since Sovaldi (Gilead) and Olysio (Janssen) hit the market in 2013, virtually every payer and patient in the medical field has had a beef with the cost of the medications. Public and private payers, both, have essentially gone out of their way to restrict access to these medications to only the sickest of the sick, creating moral and legal arguments that may force those payers to pony up, regardless of whether or not they can “afford” the price.

On the legislative front, both California and Ohio are considering similar pieces of legislation that would require all state-run health agencies to purchase drugs at the lowest price paid by the Veteran’s Affairs (VA), which would mean that the “private” contract between manufacturers and the VA would have to become transparent. This could be either a boon or a bust, as VA prices may not be the cheapest of all the prices being paid, or in some cases, could be significantly less than one agency is paying for treating a large swath of people. Essentially, all public payers would have to pay the same price, whether or not the pharmaceutical company likes it, which could mean both a decrease in profits for them, as well as either an increase or decrease in spending for the payers.

These legislative efforts, both of which are sponsored by the AIDS Healthcare Foundation (AHF), are essentially an effort to force pharmaceutical companies to show their hand on pricing. If they’re giving a significantly lower price to one agency over another, they risk their ability to haggle for higher payments from other agencies. It’s an attempt to essentially level the playing field, and to do away with the “trade secret” nonsense that prevents publicly-funded agencies from openly discussing and publishing the exact details of these agreements.

On the litigation front, two new class action lawsuits have been filed in Washington state, aimed at forcing both private and public payers to provide HCV drugs to patients, regardless of the prices set by the manufacturers. Since Sovaldi and Olysio hit the market in 2013, payers have consistently been accused of establishing and maintaining overly and intrusively strict pre-requisites before providing HCV drugs to patients. The restrictions became so rampant that Gilead effectively severed access to its once very generous Support Path Patient Assistance Program (PAP) in response to private and public insurers refusing to pay for the drugs (despite having reached a pricing agreement with Gilead), and instructing patients to “…just go get it for free from Gilead.”

Private insurers have never been the bastion of ethical business practices; it has long been conventional wisdom that insurance companies will do their best to refuse coverage, just to save a buck, all while jacking up premiums, deductibles, and out-of-pocket costs in the process. It, therefore, comes as no surprise that they would refuse to pay for drugs.

State Medicaid programs face a particularly tough road in this legal battle, as the Centers for Medicare and Medicaid Services (CMS) issued guidance in November 2015 specifically stating that Federal law requires them to provide these drugs regardless of the price. This came after several complaints were filed stating the state Medicaid programs were violating the law by refusing to provide access to these medications on the basis of cost, alone. Arizona’s Medicaid program has reportedly stated that they will not be complying with the CMS guidance. While Washington state’s Medicaid program, Apple Care, has not released any similar responses, it’s not unlikely that they are simply refusing (or unable) to act on it.

The reality is that the high cost of these medications honestly restricts payers from providing access to these medications. In the case of Washington state, were the program to cover treatment for every Medicaid patient with HCV, the cost is estimated to be triple the total pharmacy budget for Fiscal Year 2016 ($1 billion). So, while covering the cost of treatment for everyone is the goal, that goal may simply be unfeasible if current pricing structures remain the same.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

 

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