By: Marcus J. Hopkins, Blogger
Last week, HEAL Blog discussed some of the thinking behind a “Treatment for All” paradigm for dealing with America’s burgeoning Hepatitis C (HCV) problem. The argument put forth in the study released in the American Journal of Managed Care (AJMC; Younossi et al, 2017) suggests that adopting a policy of treating every HCV-infected client on government-funded healthcare rosters will ultimately lead to long-term cost savings by reducing the incidence of multiple co-morbidities, such as cirrhosis, hepatocellular carcinoma, and the number of liver transplants. This is a position that advocates (including HEAL Blog) have been arguing for years – since the release of Sovaldi (Gilead) and Olysio (Janssen) in 2013. The pharmaceutical companies who manufacture Direct Acting Agents (DAAs) to treat HCV have been arguing this position, as well.
Read Part 1, “Data Analyses Indicate HCV Treatment for All Saves Money“
All of these parties are coming up against the stark reality of the budgetary process. Rather than being calculated based on long-term expenditures, they are calculated using estimated yearly expenditures using the amount of money given to them by the Federal and state governments – resources that are limited, and unlikely to increase without significant increases in tax revenues generated by tax hikes (business, corporate, and personal) or some unexpected increase in profits that comes out of nowhere. Medicaid directors and drug purchasing officials have repeatedly made the claim that treating everyone on their rosters infected with HCV will outstrip their pharmacy budgets several times over. Tom Burns, head of drug purchase for the Oregon Health Authority in 2014, said in an interview that “…Oregon can afford to wait” to see how other HCV drugs develop, and that “…the vast majority [of the 5,600 clients infected with HCV] could wait while we figure out a policy that doesn’t bankrupt this state” (Millman, 2014).
This line of thinking has been echoed by virtually every state’s Medicaid program. The Centers for Medicare and Medicaid Services (CMS), however, didn’t buy that line, and in 2015 issued an official guidance that reminded Medicaid programs that they are required by law to cover these drugs under section 1927(b) of the Social Security Act (CMS, 2015). Furthermore, states facing litigation related to treating HCV patients have found little sympathy from the Judicial Branch. In May 2016, Federal U.S. District Court Judge John C. Coughenour ordered Washington state’s Medicaid provider to cover HCV drugs for all patients by granting a preliminary injunction that forced the state Health Care Authority (HCA) to halt a 2015 policy that restricted access to the drugs based on a fibrosis score (Aleccia, 2016). This injunction was in response to a class action lawsuit against Apple Health, Washington’s Medicaid program, on behalf of two clients and 28,000 other enrollees. Another Federal U.S. District Judge, Robert Mariani, ordered the Pennsylvania Department of Corrections (DOC) to provide HCV treatment to well-known inmate, Mumia Abu-Jamal (Moran, 2017). While his ruling applied only to Abu-Jamal, the judge went on record, stating that the DOC’s interim protocol for treating HCV “…presents deliberate indifference to the known risks which follow from untreated chronic Hepatitis C.”
The report in the AJCM found that if Medicaid in the U.S. continues its use of restrictions to treatment, the estimated total cost of treating the HCV cohort will come to $9.7 billion, with the majority of costs (50.4%) attributable to downstream costs of care (i.e. – hospitalization costs, outpatient costs, and non-Harvoni pharmacy costs). Conversely, treating all Medicaid patients with Chronic HCV using Harvoni led to a 39.4% savings – $3.8 billion – over the model time horizon and decreased the relative proportion of total costs attributable to downstream costs of care to 18.3% (Younossi).
While most of the cost savings were related to downstream medical cost offsets, even the pharmacy costs attributed to Harvoni treatment over non-Harvoni treatment decreased 2%, from $4.84 billion to $4.75 billion. This is due in part to the 9,618 patients in the cohort potentially eligible for an 8-week regimen of Harvoni to achieve a Sustained Virologic Response (SVR), rather than the traditional 12-week regimen. Treating all Medicaid patients with Harvoni led to a 19.8% savings per SVR, given that earlier treatment of HCV resulted in better health and cost outcomes (Younossi).
Though this analysis is a fantastic tool, another harsh reality is the [potential] repeal and replacement of the Affordable Care Act (ACA). It was announced, last week, that the Fiscal Year 2018 budget resolution has been put on hold, pending the repeal of the ACA (Shutt, 2017). This means that any type of Federal budgeting process for Medicaid (as well as the Centers for Disease Control, and other domestic spending programs) has stalled for the foreseeable future, leaving virtually everyone involved in those organizations in the lurch, waiting for their fates to be handed down to them. Most HIV and HCV advocates, however, are heartened by Tom Cole (R-OK) saying, “We thought it was wrong when Democrats said for every increased dollar on defense, you had to increase domestic. It’s just as wrong to say for every increase on defense you have to cut domestic.” He finished that statement, however, by saying that he believes those increases should be offset on “…the entitlement side of the ledger.” That statement is considerably LESS heartening.
- Aleccia, J. (2016, May 28). Judge orders Washington Medicaid to provide lifesaving hepatitis C drugs for all. Seattle, WA: The Seattle Times: Health: Local News. Retrieved from: http://www.seattletimes.com/seattle-news/health/judge-orders-apple-health-to-cover-hepatitis-c-drugs-for-all/
- Centers for Medicare and Medicaid Services. (2015, November 05). MEDICAID DRUG REBATE PROGRAM NOTICE [Release No. 172]. Baltimore, MD: Department of Health and Human Services: Centers for Medicare and Medicaid Services: Center for Medicaid and CHIP Services. Retrieved from: https://www.medicaid.gov/medicaid-chip-program-information/by-topics/prescription-drugs/downloads/rx-releases/state-releases/state-rel-172.pdf
- Millman, J. (2014, July 18). Why one state wants to slow down use of a new hepatitis C cure. Washington, DC: The Washington Post: Wonkblog. Retrieved from: https://www.washingtonpost.com/news/wonk/wp/2014/07/18/why-one-state-wants-to-slow-down-use-of-a-new-hepatitis-c-cure/
- Moran, R. (2017, January 04). Federal judge orders state to provide Mumia Abu-Jamal with hepatitis C treatment. Philadelphia, PA: Philly (dot) com. Retrieved from: http://www.philly.com/philly/news/20170104_Federal_judge_orders_state_to_provide_Mumia_Abu-Jamal_with_hepatitis_C_treatment.html
- Schutt, J. (2017, March 09). Work on Fiscal 2018 Budget On Hold. Washington, DC: CQ Roll Call: Politics. Retrieved from: http://www.rollcall.com/news/politics/health-care-bill-fiscal-2018-budget
- 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.