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Oregon Sovaldi Decision Tabled
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from Jules: Oregon officials acknowledge they "have to cover" Sovaldi, that's because the SSA medicaid rebate law provides state medicaid's with a discount/rebate of at least 23% & in return the state medicaid is required to cover FDA approved drugs. But this state medicaid has constructed resections that may not be legal. The SSA law does not say anything providing that a state can construct restrictions, read the law for yourself, these medicaid's should be legally challenged, a lawsuit, a discussion with CMS & the federal govt, to see if these restrictions are legal. The law appears to say the state gets a rebate & in return they provide drugs. In addition, this state claims, as it says below, they have 24,000 on medicaid who have HCV, then they project a cost of $480 mill to treat all Hep-C patients on medicaid, these numbers should also be challenged, do they really have 24,000? would they all be treated in 1 year? we know usually it takes time to treat patients, it could take several years? And what about the discount/rebate, are they factoring in the rebate in the total cost they project? And have they tried negotiating for a larger discount? The law says rebate is negotiable and be higher then the 23% standard medicaid rebate.
Section 1927 of the Social Security Act (actual text of the law establishing the Medicaid drug rebate program):
http://www.ssa.gov/OP_Home/ssact/title19/1927.htm
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Aug 15, 2014, 1:44pm PDT
State committee tables decision on $1K hep-C pill, as CCOs raise concerns
Elizabeth Hayes
Staff Reporter- Portland Business Journal
http://www.bizjournals.com/portland/blog/health-care-inc/2014/08/oregon-health-plan-inches-closer-to-limiting-1k-a.html?page=all
The committee in charge of prioritizing Medicaid services decided to postpone a decision on coverage of Sovaldi, the pricey, but effective, new hepatitis-C drug.
The Health Evidence Review Committee tabled a decision, in response to concerns from the Coordinated Care Organizations, which deliver Medicaid services.
Public payers across the country have raised a hue and cry in recent months about the drug's price tag, $1,000 per pill or $84,000 for a full course of treatment.
Last week, a subcommittee recommended that the Health Evidence Review Committee limit the pill to those patients whose conditions would worsen without immediate treatment.
If adopted, the restrictions would save the state millions of dollars. It would mean a cost of $40 million to treat the known Medicaid population that would qualify, versus $480 million to treat all hep-C patients on Medicaid. The entire pharmacy budget was $377 million last year.
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Aug 12, 2014
Oregon Health Plan inches closer to limiting $1K-a-pill hep-C drug
The Oregon Health Authority is a step closer to limiting prescriptions of a pricey, new hepatitis-C drug to only those patients whose conditions would worsen without immediate treatment.
The OHA's Value-Based Benefits Subcommittee's Friday recommendation on Sovaldi, which costs $1,000 per pill, goes later this week to the Health Evidence Review Committee, which has the final say.
If adopted, the restrictions would save the state millions of dollars. It would mean a cost of $40 million to treat the known Medicaid population that would qualify, versus $480 million to treat all hep-C patients on Medicaid. The entire pharmacy budget was $377 million last year.
An estimated 24,000 patients on the Oregon Health Plan (Medicaid) may have hepatitis-C. Under the recommendations, not all would qualify for Sovaldi, however.
"The Medicaid program has to cover it," said Mark Gibson, a member of the Value-Based subcommittee. "The question is under what circumstances?"
The recommendation is that patients be covered if they have:
· Advanced liver disease (late-stage fibrosis) or proof of cirrhosis and expected survival of more than five years.
· A prescription from a liver specialist.
· One of five other conditions, which include lymphoma, HIV and pre- and post-liver transplant.
· No marijuana use, alcohol abuse or IV drug use in the prior six months or significant mental impairment.
The Health Evidence Review Committee provides guidance on prioritizing health services and drug treatments for the state's 16 Coordinated Care Organizations, which deliver Medicaid services to more than 900,000 Oregonians. The Sovaldi recommendation has been much anticipated in light of the drug's price tag, which has public health programs up in arms all over the U.S. and sparked a Congressional investigation.
"On a population health basis, we'd want to treat everyone and eradicate the virus," said Dr. David Labby, chief medical officer for Portland-based Health Share of Oregon, the largest CCO. "At $1 a pill, we treat everyone."
Since that's not the case, tough choices must be made, he said.
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