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Friday Jun 09, 2017

Sorry, You're Not Sick Enough: Approach to Hep C Defies Logic

You've never heard Randy's story before, but you probably have patients just like him.

Randy tested positive for hepatitis C two years ago, just one of roughly 34,000 Americans diagnosed with the disease in 2015(www.cdc.gov). That year, the number of new hepatitis C virus infections reported to the CDC reached a 15-year high, nearly triple the number from 2010.

The CDC attributes that spike, in part, to increased use of injection drugs, and the agency estimates that 3.5 million Americans are infected with hepatitis C virus(www.cdc.gov).  That staggering number makes it the most common bloodborne infection in the country. At least 75 percent of those patients will develop chronic infection, which can lead to cirrhosis or liver cancer.

This story doesn't have to be tragic. Safe and effective medications are available. In fact, new direct-acting antiviral agents such as sofosbuvir, daclatasvir and the combination medication sofosbuvir/ledipasvir can cure more than 90 percent of infections(www.who.int). These newer medications are better tolerated and safer than older drugs.

But unfortunately for Randy and others like him, tragedy is exactly what's unfolding. Despite the availability of medications that can cure infection -- thus avoiding complications such as cirrhosis and liver cancer -- and prevent spread of the disease, the pharmaceutical industry's single-minded focus on maximizing revenues(www.finance.senate.gov)  and short-sighted coverage decisions by payers have put treatment beyond the reach of many patients.

The price tag for treatment is often more than $100,000. Instead of covering that exorbitant amount, payers are declining coverage until patients develop complications(www.npr.org)

That was the case with Randy, who initially had a low viral load and a low liver fibrosis score. Two years later, his insurance is willing to cover Randy's treatment because he now has liver tumors that could have been prevented. Instead of covering his medications immediately after diagnosis, the payer -- and Randy -- now face the much higher costs of invasive treatment and, potentially, chemotherapy and/or a liver transplant.

As physicians, we have the opportunity to educate our state legislators about this issue and encourage them to ensure greater access to treatment, which will also address the spread of the disease.

Under the threat of a class action lawsuit from advocacy groups, Pennsylvania recently announced it would expand Medicaid coverage of hepatitis C treatment(www.philly.com). A spokeswoman for the state's Department of Human Services told the Philadelphia Inquirer that the fiscal impact of expanding coverage to 3,750 patients with hepatitis C infection would be less than one-half of 1 percent of the state's Medicaid program budget. Similar lawsuits have been filed in federal courts in at least three other states.

Meanwhile, Louisiana health secretary Rebekah Gee, M.D., M.P.H., recently proposed a strategy to combat high drug prices(khn.org). A 1910 patent law could allow the federal government to contract with a generic manufacturer to produce low-cost versions of antiviral drugs.

What else can we do? Screen. In 2013, the U.S. Preventive Services Task Force and the AAFP recommended screening baby boomers (patients born between 1945 and 1965) regardless of apparent risk, as well as those at increased risk, including patients on long-term hemodialysis, those born to a mother who is infected with hepatitis C, incarcerated individuals and those who use injection drugs.

Without adequate screening and treatment, this disease will continue to spread, more people will suffer and the long-term cost of care will continue to climb. Let's prevent more cases like Randy's.

Ada Stewart, M.D., is a member of the AAFP Board of Directors.

Posted at 02:37PM Jun 09, 2017 by Ada Stewart, M.D.

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