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New HCV Guidance Section - Cost, Reimburse. & Cost-Effect. Considerations

"New Guidance Section
Thursday, August 20, 2015
The following new section of the HCV Guidance has been released, Overview of Cost, Reimbursement, and Cost-Effectiveness Considerations for Hepatitis C Treatment Regimens."
(Haven't had time to read yet but wanted to let you know - see hot linked topics - Title abbreviated to fit)

Accessed August 22, 2015

FYI This is a link I use now to quickly check if there are new updates. - bookmark link.  The updated sections have direct links to the updated pages.  Plus the updated text is highlighted in Yellow for at least 30 days after the date of the update.

Previous most recent update

"Guidance Sections Updated
Friday, August 7, 2015
The Initial, Retreatment, Monitoring, and Unique Populations (HIV/HCV Coinfection, Decompensated Cirrhosis, Post-Liver Transplantation, and Renal Impairment) sections have been revised based on newly available therapies and data."
2 Responses
Avatar universal
I saw this yesterday, printed it out and have read it several times.  And I'll probably have to read it several more before I can completely wrap my head around it.  

The good news, as I see it, is the clarity it brings to the subject of actual cost of new medications to payers.  "The $1000 dollar pill" or the "$1125 pill" has gotten so much play in the media.  (Doctors aren't immune to this nor are many who work in the insurance industry.)  It's great that they laid out, in no uncertain terms, the reality of rebates and discounts that are negotiated with those in the "pharmaceutical supply chain."

And when your average citizen reads that treating HCV requires a course of treatment totally $94,500 an expected response would be: "that's undoable!  It'll bankrupt the insurance companies, Medicare, the VA!  Sorry guys, but obviously only the very sickest patients are going to be able to do this."

Saying there is a cure for a deadly virus that costs $51,030 doesn't pack nearly the sensational wallop.  In fact, you'd more likely hear, "oh, that's about what my hip replacement cost."

But we don't really know that exactly.  Why?  More good news - they made clear that price negotiations are confidential and highlighted the lack of financial transparency in the insurance industry.

So when an insurance company responds to an appeal with "Given the high cost of the drug, it is appropriate and necessary to prioritize treatment..." maybe reviewers might take a second glance.  What's that cost again?

Avatar universal
I am curious if you have any idea how this new information would be interpreted by an independent review organization.  Specifically, if it does or does not support the decision of insurance companies to deny treatment based primarily on Metavir scores or narrowly defined co-morbid conditions.
My earlier post mentions that "doctors aren't immune" to the media blitz of the "$1000 pill".  
From the above link:
"Prioritization based on liver disease and comorbid conditions, while controversial to some, is intended to acknowledge the strain that widespread treatment will place on the health care system. A 12-week course of direct-acting antivirals for HCV treatment currently costs roughly $100,000 per patient, and there are an estimated 2.7 million people in the United States with chronic HCV infection."
"The cost of the new HCV medications is always on my mind when I’m considering treatment for a patient."
This doctor treats a preponderance of patients covered under Medicaid yet has clearly been misled or misinformed on true treatment costs since this new HCV guideline update specifically says that Medicaid plans receive the lowest price offered to any other payer.  In other words, clearly NOT 12 wks @ $100,000 per patient.
I'm still wading through the multi-layered appeals process(es) and am trying to figure out if this newest update is a positive or a negative for patients with not "highest priority" status.
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