Medicaid programs grappling with cost of new hep C drugs

Like a growing number of Medicaid programs around the country, Rhode Island’s Medicaid program has quietly posted its first guidelines for approving coverage of a new drug for chronic hepatitis C.

If you are enrolled in Medicaid, have hepatitis C, and you’ve been waiting for these new drugs, you might be jumping for joy. If not, you might be asking, "Huh?" or "Who cares?"

Here’s what this means and why it matters, whether you have hepatitis C or not.

First, the new drug. It’s called a direct acting antiviral, and it’s going to change everything for people in treatment for hepatitis C.

Until recently, one of the only options for treating this disease — which attacks the liver over time and can lead to cirrhosis or liver cancer — was a drug called interferon. By most accounts, it was an awful treatment. Several weekly injections for an entire year, major side effects, about a 50 percent cure rate. It felt, some said, like chemotherapy. The new drug, called sofosbuvir (trade name Sovaldi) comes in pill form. It takes 12 weeks. And it’s reported to have about a 90 percent cure rate, with no major side effects (so far — it’s still pretty new).

The rub? Sovaldi can cost up to $84,000. State Medicaid agencies have been, understandably, busy trying to come up with a policy that outlines who gets the treatment and who has to wait. If we treated everyone who has chronic hepatitis C with this new drug, we’d go bankrupt. Rhode Island has just come out with its policy.

The good news is that people who have been waiting for this drug may now be able to get it. The bad news is that they may not.

The policy requires something called a “pre-authorization,” which is a bunch of paperwork you and your doctor have to fill out documenting your need for the drug, how bad your liver disease is, and the fact that you can’t tolerate other treatments very well. Many drugs and treatments require some kind of pre-authorization, so this isn’t completely unheard of. But this particular pre-authorization has some doctors scratching their heads about some of the extra hoops patients have to jump through. Rhode Island’s Medicaid director, Diedre Gifford, says the idea is to ensure patients can comply with the treatment regimen, and understand the risks of getting re-infected (most often through injection drug use).

Why does any of this matter to people who don't have Medicaid or hepatitis C? Well, for starters, Medicaid is taxpayer money. Second, this new drug is a harbinger, I think, of more to come. It's considered a specialty drug, and these often expensive drugs are becoming more common. How insurers - whether Medicaid or a private carrier like United Healthcare - decide to cover them could affect all of us. And third, you or someone you know could have hepatitis C and not know it. In fact, most people don't know they're infected. The CDC recently came out with the recommendation that everyone born between the years 1945 and 1965 (boomers) get tested. You could have become infected with hepatitis C by a single use of injection or snortable drugs, a blood transfusion before 1992, or even an accidental needle stick in a health care setting. There are a few other ways, but those are the most common.

I’ll be reporting more about hepatitis C in Rhode Island and beyond, and the changing treatment landscape, in the months to come.

Photo by r. nial bradshaw via Flickr.