Louisiana developing ‘Netflix’ style subscription plan for HCV treatment

The Louisiana Department of Health is currently developing a “subscription style” payment plan with pharmaceutical manufacturers to provide state residents with access to hepatitis C treatment.

Pete Croughan

HCV Next spoke with the department’s chief of staff, Pete Croughan, MD, about the landscape of HCV in the state and the novel payment model designed to expand treatment despite the expensive cost of direct-acting antivirals.

“Hepatitis C is definitely an epidemic here, like it is in many places, and equally tied to the opioid epidemic due primarily to transmission through reuse of needles,” Croughan told HCV Next. “National data has shown that rates of acute infections tripled in the last 5 years. This corresponds with our own internal data on increased rates of infection.”

While the state has adequate data on the number of individuals infected with HCV through Medicaid, Croughan explained that the health department is focused on improving surveillance in correctional facilities, which is significantly lacking. National data, he said, place HCV prevalence in correctional facilities between 15% and 40%. Until screening is expanded in Louisiana, “we’re not going to know how many people are infected with HCV in our justice system,” he said.

Prior authorization criteria had also presented a barrier to treatment for state residents. Like many states, prior authorization initially restricted treatment based on at least 1 year of sobriety, prescriber specialty and the patient’s fibrosis score. However, cost-effective data that followed the introduction of new DAAs led the health department to evaluate what criteria was the most restrictive and least evidence-based with the help of the physician community and health advocates in New Orleans.

“We wound up changing our sobriety restriction to only needing a provider access statement that the patient is able to complete treatment, we removed the provider specialty restriction, and we eliminated fibrosis scores for HCV and HIV-coinfected individuals,” Croughan said. “Our hope is to eliminate this disease — that’s been our goal from the beginning — but the challenge has been how to pay for it. We’re among the poorer states and we’re trying to find space to treat large numbers of people. That’s where we think the subscription model in a win-win-win, for patients, the state and potentially pharmaceutical partners.”

Working with Rebekeh Gee, MD, Secretary of the Louisiana Department of Health, Croughan and colleagues developed the concept of a subscription payment model that has been described by some as the “Netflix model.”

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“We want to go from Blockbuster where you’re paying per rental to Netflix where you’re paying a subscription amount for unlimited streaming,” Croughan explained. “Or in this case, the streaming would be access to medication.”

The model would take the state’s annual Medicaid and correctional facility’s budget for HCV treatment and offer the lump sum to a partnered pharmaceutical manufacturer for a specific duration. Currently, the department has discussed a period of 3 years to 5 years.

“It would then be incumbent on the state, the public health community and the provider community to get as many people screened, linked to care and treated as much as possible,” he said. “For one company in a competitive space, they now expand their reach into a market that previously did not exist because the rate of access for corrections and Medicaid has been so low. In our mind, this wouldn’t cut into the more lucrative bottom line, it’s only adding to it.”

The department estimates that this plan could increase treatment from approximately 3% of people on Medicaid and in correctional facilities up to nearly 60%.

“We’ve actually had conversations with all three hepatitis C manufacturers — AbbVie, Gilead and Merck — and all three have expressed interest in potentially partnering with us,” he said. “The plan is to ultimately select a partner through a request for proposal process, but we’re willing to work with any company that gives us the best deal.”

Croughan said that this has been a rare policy project as they have not experienced any pushback. “Patients, providers and pharmaceutical companies are in support,” he said. Additionally, while there are some potential regulatory barriers, Croughan said that the federal government has otherwise expressed interest in the model, “so it’s really a matter of details at this point.”

Regarding the next steps, the department is continuing to review request for information submissions for ideas and solutions as to how to structure the final model.

“We’re developing our concept paper and materials that we need to have that conversation with the federal government,” Croughan said. “We need to figure out whether we need to start drafting waivers or if can we get it done with just some regulatory guidance from CMS. So, it’s a little bit of a back and forth over the next few months.”

Croughan explained that the department expects to have a clear sense of the regulatory path by early 2019 and have drafted a request for proposal that will be released to selective pharmaceutical partners with the hope of beginning the program in mid-2019. – by Talitha Bennett

Disclosure: Croughan reports no relevant financial disclosures.