An agreement reached with seven major health insurers in New York eliminates a stumbling block that barred hepatitis C treatment for scores of patients with early-stage disease, the state attorney general’s office announced Tuesday.
Eric T. Schneiderman said the new pact ensures that health plans will no longer restrict treatment to people exhibiting only the severest forms of the viral infection. Some companies waited until the disease caused cirrhosis — liver scarring — or other devastating symptoms before coverage kicked in. Beyond cirrhosis, advanced cases of hepatitis C can lead to liver cancer and liver transplantation.
Thousands of new hepatitis C cases are diagnosed in New York annually, according to Schneiderman.
“These agreements will vastly improve access to the medications needed to cure their disease,” he said Tuesday.
New medications have changed the treatment landscape in recent years, making cures more likely. But at $1,000 per pill for the drug Sovaldi, and $1,125 per dose for another called Harvoni, treatment has proved out of reach for patients whose insurers have declined to foot the bill. Harvoni can run close to $190,000 for six months of treatment. Both drugs are products of drugmaker Gilead Sciences.
Health insurers that signed the agreement are: Affinity Health Plan, Empire BlueCross BlueShield, Excellus Health Plan, HealthNow, Independent Health, United Healthcare/Oxford, and MVP Health Plan. The pact means nearly all commercial health insurance plans statewide will cover chronic hepatitis C treatment, Schneiderman said.
The incidence of hepatitis C in New York has risen perilously over the past decade. Statistics reveal an explosive increase among people in their 50s and 60s, the so-called baby boomer demographic. Younger millennials also are a burgeoning age group affected by the virus, mostly the result of injecting opioid-class drugs, experts said Tuesday.
The agreement will mean payment for treatment at an earlier stage of infection, improving chances for long-term survival.
“This is an excellent decision,” said Dr. David Bernstein, chief of hepatology for the Northwell Health system. “Treatment is important for all patients with hepatitis regardless of how much disease they have on biopsy,” he said. “Why wait until someone has advanced disease, which may not be reversible, when you can treat that person early?”
Waiting until advanced disease ensues has become common practice among insurers nationwide, a complaint lodged against the insurance industry by advocacy organizations.
“This situation is unique. It’s the only disease in which you have to get really sick before you’re covered. It would never happen with breast cancer. No one would ever say we aren’t going to cover you because you aren’t sick enough,” said Jill Wolf, a clinical social worker and hepatitis C patient advocate with Caring Ambassadors in Chicago.
Despite costs, Bernstein said doctors have found the newer therapies are far better than the previous generation of medications, which included interferon because of its antiviral capability.
“Studies now show that even with the cost, the new therapies are more cost-effective compared to older treatments because you are curing 98 percent to 99 percent of patients,” Bernstein said.
He noted that with coupons and rebates that are readily available, patients can shave off a significant portion of each drug’s overall expense, which means most people don’t always pay full freight for the medications.
“We use a term called cost per cure: How much it costs to cure someone,” Bernstein said. “These therapies are cheaper in cost per cure than older therapies with cure rates of only 30 to 50 percent.”
Schneiderman, meanwhile, said his office was filing suit against Capital District Health Plan on Tuesday, an insurance carrier representing about 450,000 customers statewide. The lawsuit alleges the insurer failed to cover medically necessary hepatitis C care and deceived members about the scope of coverage.
According to the lawsuit, Capital District Health Plan denied coverage for treatment unless members demonstrated advanced disease, such as moderate to severe liver cirrhosis.
Patients diagnosed with early-stage chronic hepatitis C were required to monitor their disease and wait until they developed cirrhosis or other advanced symptoms before treatment was covered.
CORRECTION: An earlier version of this story contained an incorrect cost per dose for the drug Harvoni.