Insurance Companies Continue to Deny Payment for Life-Saving Treatments

When infected with the virus hepatitis C, serious and life-threatening damage to the liver can develop, resulting in some nasty symptoms and shortening life expectancy. Treating hepatitis C early prevents this damage, and luckily we now have a daily pill that treats the infection within a matter of weeks.

So what’s the worry?

Despite the availability of these drugs, private insurance companies and even public payers like Medicaid and Medicare are still refusing to pay for it. A study published in Open Forum Infectious Diseases has revealed, through a prospective analysis of over 9,000 prescriptions submitted to a national specialty pharmacy between January 2016 and April 2017 that private insurers had the highest denial rates, with 52.4% of patients denied coverage, while Medicaid denied 34.5% of patients and Medicare denied 14.7%.

These highly effective daily pills, known as direct-acting antiviral drugs (DAAs), became available in the United States back in 2014. With limited side effects for patients and a 95% cure rate, they’re pretty much the perfect treatment. The only problem is they cost between $40,000 and $100,000 – quite a hefty bill for private and public insurers…

From Retirement to the Front Lines of Hepatitis C Treatment

As a result of the costs, access restrictions to the medication were put in place whereby only for patients with evidence of advanced liver fibrosis and/or abstinence from alcohol or illicit drug use, for example, were given approval.

Recently, some of those restrictions had been relaxed because of vocal stakeholders and leaders, class action lawsuits, and greater drug price competition that experts believed would help increase the overall approvals by insurers. However, analysis of the data carried out by researchers at University of Pennsylvania School of Medicine suggests otherwise.

“Despite the availability of these newer drugs and changes in restrictions in some areas, insurers continue to deny coverage at alarmingly high rates, particularly in the private sector,” said study senior author Vincent Lo Re III, MD, MSCE, an associate professor of Infectious Disease and Epidemiology. “It warrants continued attention from a public health standpoint to have more transparency about the criteria for reimbursement of these drugs and fewer restrictions, particularly in private insurance and certainly to continue the push in public insurance, if we want to improve hepatitis C drug access across all states.”

The reason for the higher than expected denial rate is unclear, the authors said, but may be due to the varying restrictions on reimbursements that exist among the states. It’s likely there were more attempts to treat patients who have less advanced liver fibrosis, have not met sobriety restrictions, or have not had consultation with a specialist, they wrote.

“From a clinical standpoint, patients with chronic hepatitis C who are denied therapy can have continued progression of their liver fibrosis and remain at risk for the development of liver complications, like cirrhosis, hepatic decompensation, and liver cancer,” Lo Re said. “In addition, chronic hepatitis C promotes not only liver inflammation, but systematic inflammation, which can lead to adverse consequences on organ systems outside of the liver, such as bone, cardiovascular, and kidney disease. Further, untreated patients can continue to transmit infection to others.”

FDA Approves Hepatitis C Drug Treatment

The drugs offer a chance for a world free of hepatitis C infection, with a 2016 report estimating that the disease could be fully eradicated in the US by 2030, as long as 260,000 people are treated successfully every year. To reach this goal, it was recommended that public and private insurers remove restrictions to the hepatitis C drugs that are not medically indicated and offer treatment to all chronic hepatitis C-infected patients; recommendations that are also consistent with guidelines from the American Association for the Study of Liver Diseases and Infectious Diseases Society of America.

“Here’s a disease that’s curable, that can be eliminated as a public health problem, but we don’t have the will to do it,” said Lo Re.