By: Marcus J. Hopkins, Blogger
Since the introduction of Sovaldi (Gilead) and Olysio (Janssen) in 2013, Hepatitis C (HCV) advocates have argued several points: (1.) that the price for these drugs was/is too high; (2.) that Medicaid is required to pay for these treatments by law; (3.) that ensuring that HCV-infected patients achieve a Sustained Virologic Response (SVR – “cure”) will reduce the cost of care over time. This last point was the subject of a recent report published in the American Journal of Managed Care (AJMC).
The argument goes like this: HCV is a deadly virus that results in liver cirrhosis, eventual liver failure, and ultimately death; it is also can result in a number of co-morbidities that are costly to treat, including cancer, liver disease, connective tissue disease, abdominal pain, and upper and lower respiratory infections. That said, state Medicaid programs consistently place incredibly stringent Prior Authorization (PA) prerequisites on patients in order for their treatment to be covered, that can include mandatory enrollment in a drug or alcohol recovery program or treatment facility, a mandatory period of abstinence from all drugs or alcohol, failure of other, less easily tolerated treatment regimens, and meeting a certain stage of liver fibrosis (F-Score). These prerequisites are put in place in order to defray the high cost of treatment, ultimately resulting fewer patients being approved and less money being spent.
Advocates and economists, alike, have been arguing for years that the long-term costs associated with leaving HCV patients either untreated, or treated with older Pegylated Interferon-based regimens rather than with newer Direct Acting Agents (DAA) that are more easily tolerated and have a higher SVR rate will ultimately cost Medicaid and other government agencies (as well as private payers) more over time. Medicaid officials from several states have argued that treating every patient on their rosters would not just outstrip their existing pharmacy budgets, but do so four-times over, thus bankrupting the program. Drug manufacturers – Gilead Sciences, in particular – have argued that the cost of one-time treatment for a cure is less expensive than the cost of treating other serious conditions, whose cure rate is far lower, and takes far longer, ranging a period of years, to end in a positive result. The reality is that none of these parties are wrong.
The report in the AJMC, “Treating Medicaid Patients With Hepatitis C: Clinical and Economic Impact,” does an excellent job of outlining all the various consequence related to allowing HCV to go untreated until liver decomposition reaches a certain stage and concludes that adopting a “treat all” strategy will ultimately result in a 39.4% ($3.8 billion) savings and decrease the proportion of total costs attributable to downstream costs of care to 18.3% (Younossi, 2017). It also looks at how Medicaid programs arrived at the current “wait for treatment” model that prevents many patients from being approved for newer DAA regimens.
In next week’s post, HEAL Blog will get into the details of their analysis, their methodology, and their recommendation, as well as look into the feasibility of their proposal – that all state Medicaid programs adopt a “treat all” approach to approving HCV regimens.
- Younossi, Z., Gordon, S., Ahmed, A., Dietrich, D., et al. (2017, February 16). Treating Medicaid Patients With Hepatitis C: Clinical and Economic Impact. Cranbury, NJ: American Journal of Managed Care. Retrieved from: http://www.ajmc.com/journals/issue/2017/2017-vol23-n2/Treating-Medicaid-Patients-With-Hepatitis-C-Clinical-and-Economic-Impact – sthash.s7NKnsGH.dpuf
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.