By Megan Liz Smith, Michelle Stoddart, Meg Cunningham and Cecilia Cao
For Missouri Medicaid beneficiaries with hepatitis C, getting treated can be tricky. The state will only cover the treatment if a patient’s condition has reached a certain level of severity. They claim the cost of providing treatment is too high to treat everyone who has the disease. Three Missourians under Medicaid who have hepatitis C, are suing the Missouri Department of Social Services for refusing to provide treatment. The plaintiffs say that withholding treatment costs more because of what it leads to, like cirrhosis, liver transplants, cancer and even death.
In the United States, up to 3.9 million people are infected with chronic hepatitis C, according to the Centers for Disease Control and Protection. Fortunately, there are now drug treatments available with an almost 100 percent cure rate. In the past five years alone, new drugs have come to the market that treat all six types of the virus.
While more treatment options are becoming available, they come at a price of upwards of $95,000. A single pill of Harvoni, a leading hepatitis C treatment, costs $1,125. Competition
is slowly driving prices down, but states are still having trouble affording the lifesaving treatment. In 2015, Missouri entered an agreement with Sovaldi, which reduced the price of the drug by 30 to 40 percent, according to the Department of Social Services.
Although the lower prices make the drug easier to afford, the Medicaid budget is tight.
“No one has an extra five or 10 percent of their budget just lying around,” Matt Salo, executive director of the National Association of Medicaid Directors, said.
Because of this, states set requirements for who they can and cannot treat. They do this by grading the severity of liver scarring.
“It’s called a Fibrosis Score, or F Score,” said Ghassan Hammoud, a hepatologist and gastroenterologist at the University of Missouri Hospital. “If you have a higher score, like F3 or F4, you’re on the verge of having your liver fail, getting liver disease, or even cancer. If the scarring is still in its early stages, like F0 or F1, that means there’s not much damage.”
The state tries to save money by only treating those with advanced scores. In Missouri,
treatment is withheld until a patient has reached a score of F3, at which point severe liver damage has already occurred.
The Missouri Department of Social Services is being sued by three patients waiting for treatment under Medicaid. The plaintiffs argue that the state has an obligation to cover the cost of their treatment.
John Ammann, the attorney representing the plaintiffs, said it is proven that follow-up care is cheaper for the state if the disease is addressed early on. A recent study from Gilead Sciences, Inc. looked at this issue from a national level. They produce the hepatitis C drugs, Harvoni and Sovaldi, and wanted to find whether a “treat all” method really was cheaper. What they found was treating all eligible Medicaid patients with hepatitis C, regardless of the fibrotic stage, would result in 16,173 fewer hepatitis C related deaths and $3.8 billion in national savings.
“Collectively, most states are definitely relaxing their criteria. Some of that is in response to lawsuits, some of it is in response to the fact that prices are coming down,” Salo said.
The trial is set for February 2018. Many advocates hope the outcome of this case could change the status of thousands of patients waiting for treatment.