Oregon Health Plan ends ration of life-saving pills
Falling prices are prompting the Oregon Health Plan to stop rationing the use of drugs that can cure hepatitis C but cost $1,000 per pill.
Currently, most patients must already have liver damage in order to qualify for the hepatitis C cure.
But in March 2019, the Oregon Health Authority expects to lift that requirement — opening up treatment to people before they suffer liver damage.
The Oregon Health Plan covers one-in-four Oregonians statewide, and one-in-three residents in Jackson and Josephine counties.
Hepatitis C is spread mainly through contact with infected blood, putting injection drug users, health care workers and those who received blood transfusions before 1992 most at risk. But the disease can also spread through the sharing of razors or toothbrushes, to babies born to mothers with the disease and from improperly sanitized medical, dental and tattoo equipment.
Although hepatitis C often lies dormant for decades, the disease can scar the liver — reducing its ability to function — and eventually lead to liver cancer, liver failure and death.
Hepatitis C is most common in baby boomers born between 1945 and 1965, although infection rates are rising in younger age groups due largely to injection drug use, according to health experts.
Widespread use of the antiviral treatment could eliminate the virus from the bodies of most patients — preventing liver damage and stopping the spread of the virus to others.
“Oregon has the highest mortality rate associated with hepatitis C in the country,” said OHA Director Patrick Allen. “We have an opportunity to eliminate hepatitis C in our state, and this is a key strategy to get us there.”
OHA estimates 95,000 Oregonians have hepatitis C, although half don’t know it.
Health care providers and hepatitis C patients were excited by the release of new drugs in 2013 and 2014 that cured most cases of the previously incurable disease. But that excitement soon turned to dismay when they saw the prices.
“It was a pretty revolutionary breakthrough. The problem was that it was $1,000 a pill,” said Josh Balloch, vice president of government affairs for AllCare Health, a provider of Oregon Health Plan coverage in Southern Oregon.
Pharmaceutical giant Gilead Sciences charged $84,000 for a 12-week course of Sovaldi, or $1,000 a pill. It priced Harvoni at $94,500 — $1,125 per pill.
Most private and government-funded insurance plans responded by restricting the cure to those who were already sick.
Treating everyone with hepatitis C would have bankrupted the Oregon Health Plan and driven the cost of employer-provided insurance so high workers and businesses would no longer have been able to afford premiums, doctors and pharmacists said.
“It was a complete bank-breaker. There was no way individual insurance plans or governments could afford the pill where it was priced,” said Jennifer Lind, chief executive officer for Jackson Care Connect, another local provider of Oregon Health Plan coverage.
But with more hepatitis C drugs on the market and generics being released, prices are falling.
Gilead Sciences announced in September it will release a generic version of Harvoni in January 2019 with a list price of $24,000.
“As those prices have gone down, you’ve seen people getting more and more access to the drug,” Balloch said.
Even with the price drop, OHA is requesting $107 million for the upcoming biennium to fund the cost of the treatment expansion. That amount includes $10 million in state general fund dollars, plus an infusion of federal money.
Gov. Kate Brown’s proposed budget includes the request for added money. The Oregon Legislature, which convenes in January 2019, must approve the state budget.
“I’m actually really excited about it,” Lind said of the move by Brown and the Oregon Health Authority to expand hepatitis C coverage.
When prices were high and coverage had to be restricted, Lind said the state provided extra funding to help ensure coordinated care organizations like Jackson Care Connect weren’t bankrupted as they treated the highest priority patients with liver damage.
Falling prices and the new investment of state and federal dollars could help save Oregon money in the long run, even though the drugs are still relatively expensive, Lind said.
She noted hepatitis C infection is the leading cause of serious complications from liver disease.
“If we go upstream and invest more in treating it through what is a relatively expensive course of treatment, then we will be saving money by not having to treat the cirrhosis, liver failure, cancer, liver transplant and so forth,” Lind said. “So I do believe there’s a solid math equation there that makes this not only good policy, but good business.”
Beginning in January 2019, OHA is introducing another change to hepatitis C coverage requirements.
People with addiction will no longer be required to be abstinent from substances or in a substance abuse treatment program.
The fear was people would go through the costly cure regime, but then continue to damage their livers with substances or become reinfected with hepatitis C through injection drug use.
Lind said Jackson Care Connect worked hard to support members through substance abuse treatment so they could become eligible for the hepatitis C medication.
“They were likely headed toward liver failure. We were able to get them into drug or alcohol treatment in order that they could then treat their ultimate disease. So it served as an incentive for some and there are remarkable stories of lives that have been turned around as a result of that,” she said.
However, some people were suffering so many medical complications from hepatitis C they weren’t able to focus on substance abuse treatment, Lind said.
Allowing those people to have the hepatitis C treatment will improve their health, boosting their chances of successfully tackling their addiction, she said.
The pharmaceutical industry has said the high cost of the hepatitis C cure was justified because it prevents spending on even costlier medical intervention.
A liver transplant, for example, cost an estimated average of $812,500 in America in 2017, according to the international insurance risk statistics firm Milliman.
Gilead Sciences acquired the first hepatitis C blockbuster drug Sovaldi by paying $11.2 billion for the company that developed it. Research and development costs for Sovaldi were $62.4 million and the original company had planned to sell it profitably for $36,000 for a course of treatment, according to the U.S. Senate Committee on Finance, which investigated the pricing issue.
Once Gilead had control of Sovaldi, it raised the price to $84,000 for a course of treatment, according to the committee.
In the first three quarters of 2014, Gilead made $11.4 billion off sales of Sovaldi, recouping its acquisition costs in less than a year, according to quarterly earnings reports.
If Jackson Care Connect had taken the money it spends for all prescription drugs — including birth control and medication for diabetes, cancer and heart disease — and spent that money just on hepatitis C drugs, it would only have been able to treat 25 percent of its hepatitis C patients, parent organization CareOregon said in 2015.
AllCare reported at the time it would have been cheaper to fly its hepatitis C-positive members to India for treatment — where the drugs cost pennies on the dollar compared to America — than to pay for the drugs here. Federal regulations bar that practice, or letting an AllCare employee travel abroad and come back with a suitcase full of Sovaldi.
Lind said she has no doubt people suffered liver damage and even died while the American health care system waited for the cost of hepatitis C medication to fall.
“Every day that it is not treated the disease worsens, so that absolutely has occurred,” she said.
Although coverage is expanding, the federal Centers for Disease Control and Prevention doesn’t recommend hepatitis C testing for the general population.
Adults born between 1945 and 1965 should be tested once if they don’t have other risk factors.
Testing is recommended for those who inject or have ever injected drugs, babies born to hepatitis C-positive women, people who received clotting factor concentrates before 1987, people who received a blood transfusion or organ transplant before 1992, those who were on long-term hemodialysis, people with persistently abnormal alanine amionotransferase levels and those with human immunodeficiency virus (HIV.)
Testing is also recommended for health care, emergency medical and public safety workers after sticks with needles or other sharp equipment, or after hepatitis C-infected blood contact with mucous membranes, including those of the eyes, nose and mouth.
Testing may sometimes be recommended for those who have received transplanted tissue, users of illegal intranasal drugs like cocaine, long-term sexual partners of those with hepatitis C and people with a history of tattooing, body piercing, multiple sexual partners or sexually transmitted disease.
Reach Mail Tribune reporter Vickie Aldous at 541-776-4486 or firstname.lastname@example.org. Follow her on Twitter @VickieAldous.