Huge Spread in Patient Copays for HCV Drugs

— From nothing to more than $25,000

MedpageToday

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LAS VEGAS -- One center's experience with arranging curative drug therapy for hepatitis C virus (HCV) infections showed an enormous variation in the out-of-pocket charges patients were asked to bear, researchers said here.

Among 300 patients treated in the Hofstra Northwell Physician Partners system in Manhasset, N.Y., with insurance from 31 private and public payors, copays ranged from zero to nearly $27,000, said Northwell's Susan Lee, PharmD at the American College of Gastroenterology annual meeting.

That top end of the range was charged under an OptumRx Medicare plan, noted study co-author David Bernstein, MD, also at Northwell, who pointed out that Medicare plans generally had the highest copays -- an average of $890, nearly three times the average for commercial plans ($317).

The patients "that can least afford it had the highest copays," he said.

The 300 patients included in the study were all those with complete copayment and payor documentation receiving treatment at Northwell with direct-acting HCV antivirals from October 2014 through September 2016.

Among the 31 payors, average copays ranged from zero to $1,872. For all 300 patients, the average was $320. Thirteen different drug combinations were provided to the patients.

One-quarter of the group were able to obtain assistance with copays: through manufacturers' coupons, foundations that receive funding from drugmakers, or private charities. For these patients, their ultimate out-of-pocket expenses ranged from nothing to $60.

But for the other 75% that had no assistance, the copay average was $428 and the patients paid an aggregate of nearly $100,000.

Lee explained that she and her staff work with patients, payors, and providers of assistance to make it possible for patients to start on direct antiviral therapies, which have shown cure rates of 85% to 95% in various studies. This can be a time-consuming process, she told MedPage Today. For some patients, it can take only a few weeks, but in some cases it can be 3 months or longer.

She noted that the negotiations took more than 1.5 years in one case before the patient was able to start on therapy, during which time the patient's clinical condition deteriorated significantly.

Besides Medicare and commercial plans, Lee and colleagues also examined copays under Medicaid, the Veterans Affairs system, and dual-eligibility Medicare-Medicaid plans. Those public insurers charged the smallest copays, with a maximum of $23 and most patients paying nothing.

There was also a very wide range of copays for different private insurers. Bernstein said it would not be fair, though, to conclude that those with high averages and/or exorbitant-looking maximums are greedy. Companies' behavior needs to be examined across all their policies, not just those for HCV drugs, he said. Also, for most of the 31 payors, the data covered 10 or fewer patients.

The findings are not really generalizable to other institutions, Lee said, because most centers don't have people like herself dedicated to securing insurance payment that minimizes the patients' out-of-pocket charges.

She told MedPage Today that it's an important service that other centers would do well to adopt. But when asked whether the need for such a services was a reflection on the complexity of the U.S. healthcare system, she chuckled and said, "Is it efficient? No!"

Disclosures

Study authors reported no relevant financial interests.

Primary Source

American College of Gastroenterology

Source Reference: Bernstein D, et al "Access to direct acting anti-viral (DAA) therapies for HCV infection: An analysis of various DAA therapies and copays by select insurance carrier" ACG 2016; Abstract P442.