The Medicaid Drug Utilization Review Board, an advisory panel, voted Dec. 6 to lift certain restrictions that make it harder or impossible for some Medicaid patients with the disease to get specialty drugs.
The Department of Vermont Health Access, which administers Medicaid, will need to decide whether to accept the board’s changes. The department has historically set strict restrictions on the drugs because of their high cost.
Steven Costantino, the commissioner of the Department of Vermont Health Access, said in February the cost of the drugs is “a critical concern” to the state from a financial perspective and “kind of an ethical dilemma” for people running state Medicaid programs.
He was not available for comment this week.
In 2015, the state spent $11.9 million to buy the hepatitis C drug Harvoni, and it spent $3.3 million in 2014 on Sovaldi, another hepatitis C drug, according to a VTDigger investigation. While the state eventually received rebates for both of those drugs, they are widely considered some of the most expensive drugs on the market.
But the board says the Department of Vermont Health Access should pay for more Medicaid patients to get the hepatitis C drugs, including patients who have stage 2 liver disease. Currently, the department restricts the drugs to only people whose liver disease has progressed to stage 3 or 4, who often already have irreversible liver scarring.
The department also says patients can get the hepatitis C drugs only if they have not used drugs or alcohol for the six months before treatment and make themselves subject to drug testing throughout their treatment. The board voted against that restriction too.
The vote follows more than a year of advocacy from a coalition of organizations led by Vermont Legal Aid’s Office of the Health Care Advocate. The coalition includes the American Civil Liberties Union of Vermont, the Prisoners’ Rights Office and the Vermont People with AIDS Coalition.
In November 2015, after federal regulators at the U.S. Centers for Medicare and Medicaid Services said Medicaid patients should be allowed to get hepatitis C drugs, the Office of the Health Care Advocate sent a letter to the Department of Vermont Health Access asking for the restrictions to be lifted.
The department responded in December 2015: “We believe our actions regarding the limitations of hepatitis C medication are proper. We will, as required by law, continue to monitor the drug’s usage, including a case-by-case determination” when patients request to use the drug.
Julia Shaw, a policy analyst for the Office of the Health Care Advocate, said the state and society in general are tolerating limits on treatment for people with hepatitis C because the disease still carries a stigma.
Hepatitis C is a blood-borne virus often transmitted sexually or through sharing heroin needles, according to the U.S. Centers for Disease Control and Prevention. In the long term, hepatitis C causes liver damage.
“From our perspective, we don’t punish people for their other behaviors,” Shaw said. “We don’t withhold treatment for lung cancer because someone smokes, or we don’t withhold treatment for diabetes because somebody didn’t eat right or didn’t exercise.”
“I don’t think people would tolerate this type of rationing of medication based on the cost for cancer — pretty much for everything else,” Shaw said. “The only explanation is because it’s a stigmatized disease.”