by Amanda Conschafter, blog editor
Patients who battle both hepatitis C and a health plan that denies coverage for the cure have a new recourse: legal action. Class action lawsuits in several states have put new emphasis behind patient complaints that cost concerns – not questions of medical necessity – are driving insurers to limit access to curative treatments.
The 2015 introduction of the first direct-acting antiviral treatments marked a watershed moment for the hepatitis C patient population. The treatments have a 95 success rate at curing the disease, which affects an estimated 3.5 million Americans. But the innovative treatment’s high price tag sent government and private health insurers scrambling. Health plans began to employ extensive prior authorization processes designed to ration treatment to only the sickest patients – leaving those in the earlier disease stages to experience liver damage until they qualify for treatment.
Health care providers questioned the ethics of such an approach, while patients railed against restrictions that seemed to prioritize health plan budgets over patient health. Several states, such as Connecticut, proactively adjusted their Medicaid policies to expand access to more patients. Meanwhile, the Centers for Medicare and Medicaid Services issued a November notice reminding state Medicaid systems of their legal obligation to patients.
But over the past several months, some patients have also turned to legal action. As reported by the Pew Charitable Trusts, class action lawsuits have been filed over the past eight months in Indiana, Massachusetts, Minnesota and Pennsylvania. The Seattle Times also reported earlier this month that two Washington state insurers have been targeted by class action lawsuits for denying access to hepatitis C cures.
Patients’ cases may be bolstered by updated guidelines from the American Association for the Study of Liver Diseases, which affirm the value of curative treatment for “nearly all” patients with chronic hepatitis C. But in the meantime, insurers continue to clash with patients over the meaning of “medical necessity,” an interpretation at the heart of the access issue. And at least one state, Massachusetts, has threatened legal action against the manufacturer of a curative hepatitis C treatment.
As patients await policy or legal solutions to the access problem, their health hangs in the balance. The Centers for Disease Control and Prevention reports that 75–85 percent of those infected with hepatitis C will go on to develop chronic infection, 5-20 percent will develop cirrhosis and 1-5 percent will die as a result.