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Dropping HCV RX prices without dropping HCV patients: Carve in and Carve Out

Carve in and Carve out policies are going to be part of larger conversations as the ACA’s medicaid expansions fully take hold. Especially with growing controversy regarding the price-point to the State alongside the limitations/requirements that Medicaid is levying.

The HCV Antibody only was still the primary method of detection in 2011 for nearly half of testing sites and this Morbidity and Mortality Weekly Report (MMWR) 2013 piece unveiled a trend which has come to be a crucial piece in understanding why people don’t go on a treatment.1 Testing locations for HCV Antibody-only had a potential morbidity rate of nearly two to one when compared to sites that also reported HCV RNA testing data. This was also great concern for what this means for care options, and quality of healthcare.

In the last five years we’ve seen monumental changes in focus in terms of how we deal with this virus. From a RX side with DAAs to a growing community of care-providers who are able to be more informed, and more capable of handling these issues with better care.

This is case for Carve-in and Carve-out.2

HCV meds are especially expensive and presently we’re seeing restrictions on Medicaid to access the treatment because of this.3

Carve-out policies hand the decision of dedicated treatment(s) to the State, where the State buys the lowest price on name brand. Carve-in policies allow dedicated treatments to be set by a Managed Care Organization, and those receive much smaller discounts on name brand. Carve-out policies allow for large discounts sometimes reaching 30%, whereas carve-in policies carry discounts around 5% and can expedite services in comparison and have more options in terms of care.2

Most large cost services fall under carve-out. But there is an odd relationship to consider, that potential 2:1 morbidity rate. The MMWR 2013 piece concluded that this 2:1 death ratio is possibly linked to healthcare access.

One of the quick comparisons when it comes to carve-out policy which exists is HIV/AIDS medications. The costs can be staggeringly similar, and the populations affected are somewhat similar. HIV/AIDs accounts for ~1.2 million Americans, Hep C accounts for 2.7-3.9 million Americans.4,5 AIDS presently has no cure, its treatment is to live, rather than prevent death. [although that could soon change, new RXs are on the rise thanks to some of the same tech behind DAA(Direct Acting Antivirals)] HCV has treatments to cure, the treatments are both to live and possibly prevent death. (Failing new DAA treatments can reset a persons’ viral load, and help the liver recover for a short period of time)

Both become more problematic the longer a person has it, and the quality of life drops, until it results in death. AIDS often falls into carve-out polices, and because of existing AIDS outreach, education, and the treatment options it would not benefit dramatically from carve-in. (Medi-cal tried a carve-in system) Hep C (HCV) could benefit by being carved-out, however it does not have the level of outreach or education, and it has lots of expensive options. Many combinations and vary by genotype. Conversely a Carve-in policy would continue the present issue of a lack of ethical care for HCV patients, but for the patients who do meet the qualifications will find better success than they may have at that same point of liver damage.

To make it even more frustrating, it is cheaper overall for everyone if the treatment is offered prior to serious liver damage. We’ll find resolution soon because bottom lines are on the table. Forget the ethical reality of not dealing with the Silent Epidemic (HCV) properly, the quality of life loss, the loss of work efficacy/work hours, the pareto loss (pareto loss is an overall shrinkage in market capacity), the affect it has on a family unit, and the potential 10% job loss due to the stigma.6,7 This has been a talking point for for over a year. We’ll find resolution soon because bottom lines are on the table.

This years NGA Considerations and Strategies for new HCV treatments said:

Because Medicaid rebates are now available to managed care organizations (MCOs) under the ACA, states and MCOs could work to increase the transparency around the drug rebate process. States might consider setting MCO drug formularies through contracts to ensure that MCOs use the most cost-effective drugs. If MCOs are unwilling to do so, they might consider using carve-outs as a last resort.

AIDs was in a similar boat more than a decade ago, when looking at the potential of Carve-outs because of rising costs.8

The ACA’s Medicaid expansions may be able to facilitate MCOs to do it, and it may not need to look at carving in/out. But a carve-out policy for HCV is more likely to positively impact HCV, so long as Medicaid focuses on comprehensive care for HCV patients.

The case for the now larger pool of Medicaid recipients would be able to help ensure better discounts than five years ago. (South Carolina is wasting no time on this, it started July 1, 2015!)9 But as we see with Medicaid’s present restrictions on HCV care and the overzealous testing requirements, there is a lack of care regarding the lack of care. With our present posture regarding expanding and protecting mental health services, comprehensive care doesn’t look so far fetched.10 Presently, HCV information and advocacy is growing, the stronger we are linked together the better we can help each other.

When my liver became decompensated and I entered the transplant list, I saw the world through comprehensive care for the first time, prior to this I had elements of comprehensive care offered to me, but not required.11 When HCV comes into your life, the future can be cloudy, comprehensive care can help this. Depression, Anxiety, Fatigue, Stress, the stigma and nature of HCV combine with chronic hepatitis, can show early on in ways you don’t notice at first.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.