Prior Authorizations, Care Rationing Block Hepatitis Patients’ Access to Cure
January 23, 2015
by Amanda Conschafter, blog editor
Will a cure for hepatitis remain a pipe dream for patients – despite new medical therapies? Unprecedented cures for the debilitating disease can carry extravagant price tags. And as state and federal governments struggle to balance the limits of their budget with the needs of their patient population, hepatitis patients are fighting for access – with varied success.
In Tennessee, the state’s TennCare Medicaid program has introduced prior authorization requirements to limit the number of patients approved for expensive hepatitis cures. One Tennessee liver specialist reported that the agency is granting access for only patients with “very advanced disease.”
Some physicians, however, find fault with rationing care to only the sickest patients. As one Pennsylvania physician specializing in hepatitis C noted, “”We know that people who are treated earlier respond better to treatment.”
Despite this type of physician input, a September analysis reported that 35 states have erected barriers to access for hepatitis therapies. In addition to gauging the state of disease, some states inquire about patients’ success with prior treatments, monitor their adherence, and demand drug and alcohol tests to prove sobriety.
Notwithstanding impediments to access, states have already spent significantly on these therapies. TennCare reported paying $27 million for hepatitis cures in the first 10 months of 2014. And with an estimated 3.2 million Americans battling hepatitis, these costs are poised to rise. Yet, as some analysts point out, medication costs may still provide long-term savings over treating hepatitis-related conditions with options such as liver transplants, roughly $577,000 each.
Meanwhile, hepatitis patients’ struggles aren’t confined to the United States. Earlier this month, patients in Spain marched in protest for better access to hepatitis C cures. Protest leaders accused the government of using a “confused and selective” approach to rationing these therapies.
But treatment costs, amplified by a vast patient population, pose significant challenges for the European Union. An estimated 85 percent of hepatitis C patients live in low- and middle-income countries, where limited public health budgets sometimes require patients to pay for medications out-of-pocket.
As both domestic and international policymakers grapple with hepatitis therapies’ cost, patients turn to appeal processes and even legal aid to access the medication their physicians prescribe. Some succeed. But for many patients, health care decisions lie not with their physicians but with their policymakers, who face increasing budgetary pressures.
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