Medicaid Reimbursement Restrictions for Hepatitis C Cure in the United States.

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Hepatitis C (HCV) is a blood-borne virus infecting the liver. While people can clear HCV, approximately 75-85% of cases become chronic. It is estimated that approximately 3.2 million people in the United States are living with chronic HCV infection leading to advanced liver disease, cancer, cirrhosis, and death. 

A new, highly effective cure (cure rate >90%) for HCV is available in the form of sofosbuvir-based regimensUnfortunately, these regimens are expensive at a cost of approximately $1000/day for a 12 week course. Because of this, Medicaid has enacted several restrictions on reimbursements.  Most states limit reimbursements for HCV cure to patients in advanced stages of liver disease and/or patients who do not use IV drugs.  Such restrictions do not adhere to treatment guidelines. Curing in advanced fibrosis continues to incur costs to the system due to continuing liver damage post-cure, however curing at moderate stages significantly decreases future costs to the system by halting disease progression. Furthermore, these regimens are effective in past/current IV drug users, and treatment in this population would have the added benefit of preventing further infection. According to Barua et al. “current restrictions seem to violate federal Medicaid law, which requires states to cover drugs consistent with their U.S. Food and Drug Administration labels.” 

There needs to be a strong policy revision by the Centers for Medicare and Medicaid services to use evidence-based guidelines and require state Medicaid programs to reimburse HCV cure at a moderate stage of liver disease and for people with past/current IV drug use.

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3 Responses to “Medicaid Reimbursement Restrictions for Hepatitis C Cure in the United States.”

  1. kucanas Says:

    While I very much agree that it is a tragedy that reimbursement limitations may keep HepC sufferers from accessing a cure, I wonder whether expanding Medicaid coverage adequately addresses the problem. Given the highly cost constrained environment we are in, where healthcare costs rise each year as a result of the aging population, general technological improvements, and increased costs per unit across a variety of services / medicines / devices, it’s clear that CMS has to make a number of difficult choices. You bring up a good point that allowing Hepatitis C to progress can result in even costlier treatments, and not to sound unfeeling, but not all cases do. A Washington Post article (http://www.washingtonpost.com/national/health-science/medicare-spent-45-billion-on-new-hepatitis-c-drugs-last-year-data-shows/2015/03/29/66952dde-d32a-11e4-a62f-ee745911a4ff_story.html) argues that in fact, ongoing HepC treatment frequently does not offset the cost of the drugs. The sad truth is that funds are not limitless and there are always going to be losers. Perhaps another way to approach this issue is to encourage reduced prices set by the drug manufacturers, whose funds and profitability have more room for narrowing than our already strained Medicare / Medicaid funds. That way the funds that would be saved on the cost of drugs could instead go towards expanding Medicaid to cover even more of the population.

  2. canakwe1 Says:

    Great post. These states that restrict access to drug users are assigning value to the life of a human being. I personally do not think that our society has the right to assign value to anyones life. So I wholeheartedly agree with your proposition to allow HCV cure reimbursement at moderate stages of disease and for people with a history of IV drug abuse. But I also understand that this would put a huge strain on state budgets: http://www.courant.com/politics/hc-hepatitis-c-drug-20150430-story.html.
    That being said, we know that the issue of how states will cover this drug arises from the fact that this drug is so expensive. If it were less costly, states would not have to ration HCV cure. The real question is– why are these drugs so expensive and how can we reduce the cost? Because the reality is that if states cannot afford this drug, then they cannot afford it. How can we require states to pay for something that they cannot afford?
    I personally favor increasing coverage of this drug by pressuring the drug companies to reduce the cost of the drug. We have seen this done with other drugs. When Gilead was deciding on the cost of the drug, their conservative estimates were on the order of $150 to $250 per person (http://www.npr.org/sections/health-shots/2013/12/30/256885858/-1-000-pill-for-hepatitis-c-spurs-debate-over-drug-prices) . Instead, they decided to charge nearly a hundred thousand dollars for one course of a drug that costs $1 per gram to make. They can and should offer this drug for a reduced price in the US, as they intend to do in developing countries, and still make a profit.

  3. adiehl9 Says:

    Thank you for writing about this issue. It amazes me how frequently decisions about medical coverage and care are made by people without medical expertise, and disregarding the advice of those that do. It is, of course, a difficult situation to prioritize who should receive what publicly funded care, given the limitation of financial resources. This one seems to be pretty obvious though- if Medicaid is willing to pay for this service for some, it clearly should be covering those in the moderate stages, who will benefit most from this treatment. The above commenter also raises an excellent point that some negotiation should occur with the company to see if they might offer reduced pricing to Medicaid, since they are currently pricing themselves out of the Medicaid population. That would be an intelligent way to use the influence of the federal government, instead of codifying an illogical restriction in Medicaid that will take significant political pressure and time to adjust.

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