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The Dark Side of Letting Insurance Payers Dictate Hepatitis C Treatment

Here's what it comes down to for me: How many people have to die or be injured before medical decisions will be returned to licensed medical providers? When are we going to let doctors write the prescriptions rather than insurance payers?
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Imagine that you have a disease and you have two choices of treatment. Both treatments are highly effective at treating your condition. Medication A has mild side effects. Medication B has lots of side effects including, fatigue, nausea, itching, insomnia, and weakness. Pretty much everyone who takes medication B has side effects. Medication A is a pill a day; medication B uses two pills in the morning and one at night, and sometimes additional pills are prescribed that must be taken twice daily. Medication B has the potential to interact with more drugs than medication A does. Which would you pick? I assume you'd pick medication A.

Your doctor would likely recommend medication A. Drug regimens with many side effects means that you are more likely to need assistance from your health care team, perhaps needing additional laboratory tests to monitor your safety. If your doctor has more patients on medication B, then your doctor's schedule will use appointment slots for side effect management, rather than for seeing other patients who also need to be treated.

So, it seems like medication A is the obvious choice. Unfortunately, for many people with hepatitis C, it isn't. In this case, medication A represents Gilead Sciences' Harvoni; medication B represents AbbVie's Viekira Pak or Technivie. Harvoni is not covered under all insurance plans, such as those using Express Scripts. In short, your doctor may want to treat you with Harvoni, but your insurance may not carry it on its drug formulary. Your hep C treatment may be limited to medication B.

To make matters worse, the FDA announced on October 22 that at least 26 people had serious liver injuries from Viekira Pak or Technivie, including at least 10 cases ending in liver transplantation or death due to liver failure. Contrast this to Harvoni, which so far carries only one serious risk, a severe slowing of the heart rate (bradycardia) in patients taking the drug, amiodarone.

Given these dramatic differences, how can Express Scripts and other payers deny coverage for Harvoni but include coverage for Viekira Pak or Technivie? It's simply and appallingly about money. The wholesale acquisition cost (WAC) for a 12-week treatment using Harvoni is $94,500. Twelve weeks of Viekira Pak costs roughly $83,300. For patients needing ribavirin, a drug often added to Viekira Pak, the cost would increase by as much as $850. The side effects would also increase, often rather substantially.

For the record, insurance companies don't pay the full drug price. Express Scripts cut a deal with AbbVie, the manufacturer of Viekira Pak and Technivie, and likely pays less than the WAC. However, even if we used the WAC, Viekira Pak costs $10,000 less than 12 weeks of Harvoni. Number crunchers are going to like that, and aren't going to be thinking about the side effects, the drug interactions or the complicated pill regimen.

Unfortunately, now accounting departments have to think about the FDA warnings, of the 26 people who were seriously injured while taking Viekira Pak or Technivie, 10 of whom are now dead or living with a transplanted liver. When thinking about this versus the cost of hepatitis C treatment, one wonders what the wholesale acquisition cost of a human life is.

Stated like this, the choice seems so simple, but there is a further complication. Express Scripts' decision to carry AbbVie's hepatitis C drugs had an upside. Express Scripts stepped up to the plate and agreed to treat patients who had early stages of liver disease, patients who might not otherwise get treated by insurance plans restricted to Harvoni. So, my scenario using medication A versus medication B was a bit simplistic. For hep C patients with minor liver damage, the choice often is medication B versus no treatment. This makes Viekira Pak and Technivie look much more appealing, at least until you think about those 26 serious injuries.

Here's what it comes down to for me: How many people have to die or be injured before medical decisions will be returned to licensed medical providers? When are we going to let doctors write the prescriptions rather than insurance payers? When are we going to stop this nonsense?