Many states restrict DAA coverage to the sickest of hep C patients
by Larry Buhl
[dropcap]W[/dropcap]hen direct-acting antiretrovirals (DAAs) for hepatitis C were new, some private insurers limited access to them, citing cost as a reason for rationing coverage. While many private payers have expanded their DAA reimbursement in the past two years, that’s not the case with Medicaid. And that’s a problem because many of the people with hepatitis C are Medicaid patients.
In December, the U.S. Senate Finance Committee issued a report identifying some trends in coverage for hepatitis C. It showed that more than $1.3 billion was spent by Medicaid programs for Sovaldi in 2014, but only 2.4 percent of Medicaid patients with hepatitis C were treated with Sovaldi. The report also showed that nearly half of the states limited treatment to patients at stage three and four of liver disease.
There’s increasing pressure being put on states to include DAA reimbursement for all of their Medicaid beneficiaries with hepatitis C, not just the sickest patients. It’s not clear whether this pressure will have much affect.
Early last year the American Association for the Study of Liver Diseases (AASLD) put out clinical guidelines for when these meds should be prescribed. In that iteration the AASLD suggested that because of the cost of treatment, payers might prioritize the people who are the sickest. But the AASLD’s latest iteration of clinical guidelines backs off on that initial suggestion and now recommends treatment for everyone, regardless of the stage of that disease.
Many states either haven’t gotten the message or are digging in their heels to avoid broader reimbursement for DAAs, even at a discounted price of around $40,000 per regimen, per patient.
“So far we aren’t seeing much movement from states to change their Medicaid policies on giving greater access to these medications,” says Abbi Coursolle, a staff attorney at the National Health Law Program (NHeLP). Coursolle says the practice of rationing drugs for only the sickest patients is a violation of the Medicaid Act.
In March NHeLP sent a letter to Senators Ron Wyden and Chuck Grassley, the leaders of the Senate Finance Committee, asking them for urgent action to reduce costs for public payers.
Colorado has one of the most restrictive prior authorization criteria in the country. Medicaid patients need a fibrosis score of three or four and be abstinent from marijuana—which is legal in Colorado—and alcohol for one year prior to treatment.
Nancy Steinfurth, executive director of Liver Health Connection in Denver, says Colorado Medicaid isn’t even familiar with their hepatitis C population.
“The state says there are 8,500 Coloradans with hepatitis C among the 1 million registered for Medicaid. But they don’t know anything more about them. They don’t know their co-morbidities or their fibrosis scores.”
Steinfurth says that not only is the state immoral to let people’s health deteriorate significantly before they can access DAAs, it’s penny-wise and pound foolish.
“We commissioned a study showing the state would save money the next year [after hep C treatment]. When someone clears the hepatitis C virus at any stage, there are higher costs that are avoided related to the virus. It can make their heart disease less significant or their diabetes or other ailments.”
David Higginbotham is a fifty-four-year-old plumber from Canon City, Colorado, who has had hepatitis C for many years and doesn’t know how he contracted it. He’s on Medicaid due to a few lean years and some ailments that sideline him from time to time. Because his F-score (fibrosis level) is 1, and Colorado Medicaid covers DAAs only for patients with F3 or F4, he can’t get the new meds that his doctor prescribed.
“The doctor said I was covered for interferon treatment but not the new medication. I declined to do it because I was sick enough with pains in my back and throughout my body and the last thing I needed was what sounded like a brutal [interferon] regimen on top of that.”
He hopes that his liver remains relatively healthy until Medicaid decides to pay for DAA for all hepatitis patients or until he can afford private insurance that covers DAAs.
The Centers for Medicare and Medicaid Services (CMS) sent a Medicaid Drug Rebate Notice to the states, saying some state Medicaid programs may be violating the law by subjecting DAA HCV drugs to “conditions for coverage that may unreasonably restrict access.”
But for now there’s no evidence that the federal government will try and force the states to let all Medicaid beneficiaries with hepatitis C to access DAAs.
CMS could threaten to take some of the state Medicaid dollars away, but historically it’s not a stick that’s used often. Threatening to take away funding would be a high stakes game of chicken, Coursolle says.
Larry Buhl is a radio news reporter, screenwriter, and novelist living in Los Angeles.