New, Expensive Treatments for Chronic Hepatitis C: Insuring Good Outcomes?

The advent of new treatments for chronic hepatitis C virus (HCV) in the USA presents a rare opportunity but also poses substantial challenges. These highly effective treatment regimens improve sustained virologic response rates to well over 90 % among chronically HCV-infected patients, though their price can exceed $50,000 per patient. Despite findings that such treatments offer good value [1– 3], their high price challenges the affordability of their delivery to all eligible patients. It is estimated that there are more than 3 million free-living people in the USA with chronic HCV infections as well as nearly 1 million incarcerated or institutionalized people with such infections [1, 4]. In this issue of Digestive Diseases and Sciences, Stepanova and Younossi describe important characteristic of large segments of the HCV-infected population in the USA, using data from the 2005–2012 National Health and Nutrition Examination Survey (NHANES) [5]. Though NHANES does not cover incarcerated or institutionalized individuals, the study findings are directly relevant to the vast majority ([80 %) of those with chronic HCV infections in the USA. The authors reported two principal findings: The first is that the number of individuals eligible for treatment has increased substantially, which they note is due primarily to the safety of the newer, interferon-free regimens that have far fewer contraindications, enabling treatment for those who were ineligible for the prior regimens. The second is that, as of 2012, HCV-infected individuals had relatively low levels of insurance coverage compared to otherwise similar uninfected individuals. Combining these findings, the authors conclude that although the potential for broad population health benefits from treatment has expanded, the lack of insurance poses a serious barrier to achieving these benefits. The first point—that the massive pool of individuals who can benefit from treatment has expanded with the commensurate challenge of paying for care—is well taken and of prime importance. Combined with the higher perpatient costs, the total potential expenditures to treat all eligible individuals are now estimated in the hundreds of billions of dollars [1, 2]. Who is likely to pay? The traditional mechanism for paying for medical care, especially expensive care, in the USA is via health insurance; yet, in the USA, insurance is split across many payers. A substantial fraction of the potential burden falls on public payers such as Medicaid, prison healthcare systems, the VA Healthcare System, and increasingly on Medicare as the birth cohorts with the highest HCV prevalence reach the age of Medicare eligibility. Likewise, private commercial insurers shoulder a substantial share [2]. The total burden of paying for HCV treatment depends on treatment price, and in the world of prescription drugs, there is not one price for all. Both public payers such as VA and private pharmacy benefit managers such as Express Scripts and CVS/Caremark are able to garner substantial drug price discounts, given their formularies, market power, and the arrival of multiple competitor treatments [6, 7]. Yet, other payers, particularly Medicare, remain statutorily hobbled in their inability to negotiate drug prices. It seems strikingly irrational that Congress would demand testimony from drug manufacturers about high prices, as it did with Gilead Sciences, Inc., makers of one of the new & Jeremy D. Goldhaber-Fiebert jeremygf@stanford.edu