An ongoing dialogue on HIV/AIDS, infectious diseases,
September 7th, 2014
It’s OK to Limit Who Prescribes HCV Therapy, but Insurers Shouldn’t Be Deciding
Some insurers would like to limit the prescribing of HCV treatment to gastroenterologists, hepatologists, or infectious diseases specialists. Not surprisingly, this doesn’t sit well with either the HIV Medicine Association (HIVMA) or the American Academy of HIV Medicine (AAHIVM), both of which have long acknowledged that some of the most seasoned HIV providers are generalists:
“There is no medical rationale for excluding some HIV providers from prescribing HCV medications,” said Donna Sweet, MD, AAHIVS, chair of the AAHIVM Board of Directors, an internist and HIV specialist. “HIV providers who have been treating HCV/HIV co-infected patients for years are uniquely qualified to manage potential drug toxicities and side effects stemming from combining treatment for HIV and HCV.”
I completely agree. Who is more qualified to prescribe HCV treatment, a provider with extensive experience managing HIV/HCV coinfection, or a gastroenterologist who has spent 90+% of his/her career practicing what some have called “lumen-oriented medicine” (see video below for explanation). And there are many ID specialists who do only inpatient ID consults — they would have as much chance correctly identifying ledipasvir, dasabuvir, and daclatasvir as winning the lottery.
The problem, of course, is that whether they say it or not, a motivation of the insurers is to delay treatment. I’m not so cynical to think it’s their only motivation, but it’s inevitably one of them. In the inherent conflict of interest that exists between medical insurance companies and expenditures for expensive short-term therapies, anything that delays treatment increases the likelihood that 1) other options will become available that drive down costs, or 2) the patient’s insurance will change, and it won’t be their problem anymore.
And as everyone learns in Econ 101, dollars spent in the future are worth less than those expended now — it’s called “discounting,” remember?
But is the concept of limiting who prescribes HCV therapy inherently wrong? Of course not — the benefit to the patient is so great, and the financial stakes are so high, it is eminently reasonable that only those qualified to do so should treat HCV.
It just shouldn’t be that the companies paying for the treatment, on their own, get to decide who the qualified providers are — they’re hardly disinterested enough to make this judgment wisely.
Everyone sing along now:
3 Responses to “It’s OK to Limit Who Prescribes HCV Therapy, but Insurers Shouldn’t Be Deciding”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
Learn more about HIV and ID Observations.
NEJM Journal Watch — Recent Infectious Disease Articles- Sulopenem Etzadroxil plus Probenecid (Orlynvah) for Uncomplicated Urinary Tract Infections
- Radiolabeled p-Aminobenzoic Acid as a Marker to Detect Bacterial Endocarditis
- Clostridioides difficile Vaccines: Promising Contenders
- Observations from ID and Beyond: Marking a Social Media Mass Migration — Until the Next One
- Incidence of Autoimmune Diseases Involving the Skin, After Acute COVID-19
Thanks for the video, Paul. It started my day with a laugh!
Dr. Sax, I appreciate your notes (as always). I am a retired Internist who worked as an HMO CMO for 10 years (not for the past 16 years). What the insurers had was data that the doctors (and the hospitals and governemtn) did not. The insurers could see who was consistently an outlier, whether from length of stay, utilization of testing, utilization of other resources etc. The HMO I worked with sent participating doctors comparisons with their peers in multiple areas of utilization. We rarely “fired” doctors. We had a panel of doctors who met regularly to look at new applicants and to review outliers and outcomes. You state the insurers should not decide who should be prescribing these medications. The US government is now publishing much worse (and often inaccurate) data about doctors. I can tell you that state medical societies and your peers rarely deal with doctors who overuse or misuse resources, often for their own gain (Look at the Dartmouth data). What organization should be making the decision about who can prescribe these very expensive medications? How can these prescribers be kept up to date and fairly reviewed? To our government everything looks like a nail and they are a hammer. I suggest that your ID society should be working hard to develop good relationships with each insurer, and show them that you can offer them assistance instead of always question their motives. In past years HMOs became the boogie man, but almost all independent studies showed that they improved the quality of care and lowered the cost of care. And whether we like it or not, cost is a quality measure. Thanks.
Dr. Sax, I believe payors may have missed (maybe not) the important point which is newer HEP C therapy will usher in certain factors that:
Should be safer in terms of side effects
Easier to monitor your patient’s therapy
Easier to identify whether or not a patient can/should be treated
Easier to prescribe
Thus in the near future more non-specialist providers should feel more comfortable managing more HEP C patients than in the past. Maybe not all patients, but certainly a lot more. These points should actually make it more challenging for payors to micromanage/deny therapy, not make it easier for them to exclude patients from receiving therapy although there still will be debate (as there is currently) as to “who” should be treated “now” versus later, especially patients in county-state government institutions such as correctional facilities. There are studies underway that may hopefully assist providers with these questions, studies that will point to patients that have more of a likelyhood to progress faster as well as potentially progress to a worse clinical outcome (HCC-Cirrohosis). Treatment = Prevention is only true when society is willing to pay for it. Hopefully folks who get treated and cured will not get reinfected, thus in the long run a vaccine will be necessary in my opinion.