It’s Time to End Insurance Restrictions on Life-Saving Hepatitis C Treatments

As consensus on the shortsightedness of insurance restrictions on life-saving hepatitis C treatments continues to build, it’s time for private insurers and Medicaid programs to give all Americans suffering from this devastating disease a chance at a cure.
Published Online: May 03, 2016
Ryan Clary
Am J Manag Care. 2016;22(5 Spec Issue No. 6):SP185-SP187
Take-Away Points
Many private insurers and Medicaid programs across the country have placed onerous restrictions on life-saving treatments for hepatitis C virus (HCV), even though public health officials, researchers, and medical authorities agree that these restrictions needlessly put patient lives at risk, contribute to the spread of disease, and drive up healthcare costs in the long term. As consensus on the futility and shortsighted nature of these insurance restrictions continues to build, it is time for private insurers and Medicaid programs to give all Americans suffering from HCV a chance at a cure. In doing so, commercial and public payers will not only be at the helm of eliminating a life-threatening virus from our borders, but they will help raise the standard of healthcare for generations to come.
Healthcare media coverage over the past year has focused on the costs of breakthrough hepatitis C virus (HCV) treatments, rather than the lives they would save or the insurance roadblocks that are keeping them out of reach for millions of Americans. With little fanfare, many private insurers and Medicaid programs across the country have placed onerous restrictions on these life-saving treatments, ostensibly oblivious to what public health officials, researchers, and medical authorities have categorically accepted: preventing patients with HCV from accessing the safest and most effective treatments needlessly puts patient lives at risk, contributes to the spread of disease, and drives up healthcare costs in the long term.
More deadly, and 10 times more infectious than HIV/AIDS,1 HCV affects more than 3.5 million Americans,2 and it is also a leading cause of liver failure and liver cancer3—the fastest-rising cause of all cancer-related deaths.4 For the past several decades, HCV treatment regimens revolved around painful interferon injections, which carried a high cost per-cure—often higher than innovative treatments—and were vastly ineffective at managing the disease. In fact, in large part due to the debilitating side effects endured during the course of treatment, as many as 85% of patients discontinued traditional HCV therapies.5 In contrast, breakthrough treatments offer cure rates of near 100% with minimal side effects,5 providing patients with HCV with an unprecedented chance to live virus-free, and avoid liver failure, cancer-causing cirrhosis, liver transplants, and other health complications.
Insurers Seek to Ration a Cure
Still, despite this unparalleled progress in treating the nation’s deadliest blood-borne disease, many state Medicaid programs and private insurance plans across the country are rationing care, such as barring those with current or recent substance use issues, forcing patients to “fail first” on debilitating and far less effective treatments, and requiring patients to develop deadly liver complications before being covered for HCV treatment. According to new research by the University of Pennsylvania, these policies have become so pervasive among state Medicaid programs that nearly half of Medicaid recipients with HCV are being denied access to a cure.6 And these restrictions may even be illegal; the Center for Health Law and Policy at Harvard Law School recently found that 42 state Medicaid programs with stringent limitations on who can access a cure could be violating federal Medicaid law, which requires states to cover drugs consistent with their FDA labels.7
The Growing Case for Curing HCV
Thankfully, the tide may finally be turning—if insurers will just pay attention to the facts. Several studies are now coming out that prove the case for curing HCV from both a public health and cost-savings perspective. For example, one recent study, published in the Annals of Internal Medicine and funded by the National Institutes of Health, suggests that innovative treatments are cost-effective in 83% of new patients and in 81% of previously treated patients.8 Another study, published in Clinical Infectious Diseases, suggests that immediately treating patients with HCV with new treatments is cost-effective, even for those with only moderate disease progression.9 Any remaining doubt about the cost effectiveness of treating the virus early should be put to rest by a new Avalere Health study, which found that the true calculated value of HCV treatments to payers is likely even greater than previously thought, due to the growing number of HCV treatments entering into the marketplace and other pricing offsets, such as discounts and rebates.10
However, although studies such as these are essential to underscoring the futility of onerous HCV treatment restrictions for patients seeking to access a cure, a true shift in public discourse on this issue will likely require firm objection by medical community leaders. Fortunately, key organizations are now starting to publicly speak out against unchecked insurance policies. Recognizing the severity of the problem within state Medicaid programs across the country, CMS recently issued a letter advising states against unreasonable restrictions on HCV treatments. CMS warned that HCV treatment restrictions should not result in the denial of access to “effective, clinically appropriate, and medically necessary treatments” for Medicaid recipients, and urged states to carefully monitor HCV drug-coverage policies of their Medicaid Managed Care Programs (MCOs) to ensure that all enrollees have appropriate access to treatment.

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