Who gets new treatment and who decides?

[hepcandme]

Interesting piece in the Chronicle about a vet who is being treated with Sovaldi and the ethics involved in deciding who and what type of treatment are offered to patients

http://www.sfchronicle.com/health/article/1-000-hepatitis-C-pill-a-tough-miracle-to-swallow-5455230.php#/0

[hepcandme]

Agreed that if one takes into consideration the costs associated with treating a decompensated liver and transplant, it is clear that it is less expensive to treat with expensive drugs like Sovaldi.

What has troubled me is how decisions are made about who will have access at all. Some insurance companies are holding out for lower costs while others user older treatments that are much harder on the patient. It's much easier for a faceless insurance company to hold out than for those living with HCV. Prisons and VA hospitals are struggling with limited resources. What if their patients are older? Have other medical issues? In a perfect world, everyone would be treated but this world is not perfect. Sigh...

Some people will never be tested or treated at all and will die when the virus has made their liver unable to do its job

It's a very intriguing ethical question to contemplate

I believe that everyone here has an advantage that is often overlooked - we are smart and resourceful. We are internet savvy and if we don't understand a medical question, we research it and ask questions. That puts us at great advantage to be on the front line for treatment from the outset

So many others do not have this advantage and that makes me sad

[desrt]

As a 'baseline' comparison, consider two geno 3 patients treating with Peg-Intron and riba in 2002. Nominal  probability of SVR  aprox. 80%.

Patient A with no insurance pays roughly $5,000 per month -- about $1,000 for each weekly shot of Peg + riba + helper meds + labs. Tx is open ended since patient is cirrhotic and slow to show response. (Remember this is back in the Dark Ages of HCV tx.)

Patient B with BCBS health insurance has a $50 co-pay for Peg/riba + labs + monthly insurance payment and so forth, still, aprox. 1/10 of what uninsured patient pays. But ....... patient B has only Stage 1 liver damage so is wait-listed until Schering Plough can assure an uninterrupted supply of Peg. (Pegasys was not FDA approved until later that year.)




From the link provided by the OP:

".....Sovaldi is a vexing problem for prisons. One-third of the 2.2 million people in jails and prisons in the U.S. have hepatitis C, according to the Centers for Disease Control and Prevention.

The Federal Bureau of Prisons gets a discount on Sovaldi and another hepatitis C drug, Olysio. But state prisons generally don't receive the same discounts. Although California's prison system has yet to prescribe Sovaldi, a spokeswoman said the state is seeking approval. Now, 260 inmates statewide are being treated for the disease.

"Small jails in particular have big problems with this," said Dr. Michael Puerini, a former president of the Society of Correctional Physicians. "They don't have any funding structure for this kind of treatment."

VA is top provider

In addition to prisoners, veterans represent one of Sovaldi's biggest markets. Almost 190,000 veterans are chronically infected, making the VA the biggest single provider of hepatitis C care in the country, according to a 2010 agency report.

Gilead CEO John Martin told investors in late April that he expected heavy business from the agency. Neither the company nor the federal agency disclosed prices or sales data about Sovaldi for veterans or prisoners
The VA boasts one of the most robust budgets of any federal department: a proposed $60 billion in 2015 for medical care, up nearly $2 billion from this year.

Since the drug just hit the market, Sovaldi's cost is not yet a problem, said Dr. Matthew Goetz, chief of infectious diseases at the VA Greater Los Angeles Healthcare System, which treats 4,000 veterans with hepatitis C.

Long-term costs a concern

But "there are long-term concerns because ... with 4,000 patients and the wholesale cost of $84,000, that's a large sum of money," he said, "which exceeds the total budget of this facility on a yearly basis."

Last month, a VA expert panel recommended that doctors consider new hepatitis C drugs like Sovaldi only for patients with advanced liver disease. The panel, which didn't take finances into account, said patients with less serious conditions should wait for alternative, potentially superior drugs that may hit the market within a year or two.

A California panel made similar recommendations, saying it may be necessary to limit the number of patients treated in part because costs can run from $70,000 to $170,000 per person.

The rationale: Hepatitis C is a slow-working disease that does not have immediate consequences if untreated. "This is not an urgent situation for every patient," said Fox, who was an expert on the VA panel......"


"..... Doctors at the veterans hospital in Los Angeles said 50 of 4,000 hepatitis C patients are getting Sovaldi.

In San Francisco, about 15 of 2,100 hepatitis C patients are undergoing the treatment, a spokeswoman for the veterans hospital said. And in the Palo Alto system, 26 of the 1,295 hepatitis C patients the hospital treated over the past year received the drug.

Doctors cautious

Doctors say they adopt a cautious approach because they must accurately prescribe the drug and monitor patients for signs of improvement.

"We don't want any patients falling through the cracks because of too much haste just to start the medication," Goetz said. "Not surprisingly, some of our patients have been waiting several years for new medications and want it to start instantly. I can understand their frustration when things don't exactly turn on a dime."......."

Who's taking Sovaldi?
Veterans hospitals in California are treating some hepatitis C patients with Sovaldi, but few of their patients are getting the expensive drug. The figures below are approximate as of late April and show how many hepatitis C patients are taking the drug.

Los Angeles: 50 (out of 4,000)

San Francisco: 15 (out of 2,100)

Palo Alto: 26 (out of 1,295)"

[pooh55811]

My insurance company paid about $65,000 for 12 weeks of Incivek for me. They also paid about $1500 per 4 weeks for 48 weeks of Riba and about $2400 per 4 weeks for 48 weeks of Pegasys (total $46,000 for Riba and Pegasys). So the grand total was $111,000 just for meds. Add to that weekly labs and doctor visits for 12 weeks and every 4 week labs and doctor visits following that for the remainder of the 48 weeks. Add to that 48 weeks of treatment for multiple side effects and additional doctor visits and meds for them (cardiaology, dermatology, gastrointestinal problems, and more).

Then, take into consideration that Incivek has an average SVR rate of 75% (much lower in previous  non-responders, partial responders, and  Cirrhotics) while  Sovaldi and Olysio have SVR rates above 90%.

So, while the new treatments are expensive, one might ask,taking all things into  consideration, are they really more expensive than treatment with Incivek and Victrelis. (And this does not even take into consideration the people who failed Triple Tx and have gone onto developing Cirrhosis, HCC, and/or ESRD.

I agree, the new treatment is expensive and it should have a lower price, but denying treatment to people because it is expensive makes no logical sense whatsoever. In addition, arguing that it is so much more expensive than other past treatments also makes no logical sense. There are many costs involved in treatment and if they are going to compare costs, then they need to compare the full cost of treatment, not just the price of one drug.

[dontworry_behappy1]

FYI.....Incivek (triple treatment) was also a very expensive treatment.  Hepatitis C treatment is expensive.   So is liver transplants....which require expensive drugs for the rest of your life.  Makes Hep C treatment look cheap.

The VA treats the sickest first.  Does that seem fair?  It's all how you look at this practice.  

[JimmyMose]

No subscriber or registration link needed  

$1,000 hepatitis C pill a tough miracle to swallow
Stephanie M. Lee Updated 6:27 am, Tuesday, May 6, 2014

http://www.sfgate.com/health/article/1-000-hepatitis-C-pill-a-tough-miracle-to-swallow-5455230.php

[Sarah1949]

You have to be a subscriber to read the article. Oh well.