Cleaveland: Soaring cost of drugs must stop

photo Dr. Clif Cleaveland

In the late 19th century, German physician and scientist Paul Ehrlich popularized the term "magic bullet" to describe his goal of discovering a precise treatment for each infectious disease. From infections to cancer, the pursuit of this goal continues with many dramatic successes along the way.

Earlier this year, I wrote of Sovaldi, a new drug that targets hepatitis C which, in its chronic form, causes liver failure and cancer. It infects an estimated 3.2 million Americans. The virus is transmitted most often by shared intravenous needles, but a small minority of infections may be sexually transmitted. When administered with another anti-viral agent, Sovaldi cures the great majority of persons suffering from hepatitis C. A course of therapy typically costs $84,000.

Health insurance plans already struggled to pay for costly therapies for various malignancies and chronic inflammatory conditions before Sovaldi entered the marketplace. Placing the new drug on its list would force a health plan either to raise premiums or copayments substantially.

Half of all victims of hepatitis C infection depend upon public assistance for their health care. In addition to straining the resources of private health insurance and pharmacy management plans, the disease places an almost unsustainable burden upon Medicaid programs and health care plans for prisoners. An estimated 750,000 Americans with chronic hepatitis C infections depend upon these programs.

A study by Express Scripts, an online pharmacy, estimates that state governments may have to spend up to $55 billion to provide Sovaldi for hepatitis C victims covered by Medicaid programs. For Tennessee, this would cost $1.23 billion ($189 per resident), for Georgia $1.92 billion ($192 per resident), for Alabama $1.1 billion ($227 per resident). California could pay up to $6.68 billion.

How state legislatures and governors respond to such expense is anyone's guess. Raise taxes? Cut benefits for Medicaid recipients? Reduce payments to providers? There is no obvious choice.

Providing Sovaldi for 1.3 million state and 200,000 federal prisoners will be even more challenging. Prisoners are entitled by federal law to health care. Hepatitis C infects an estimated 17 percent of incarcerated persons compared to 1.5 percent in the general population. While state Medicaid programs typically can negotiate drug prices, prison systems generally pay non-discounted, retail prices. California and Illinois have announced plans to provide Sovaldi to prisoners infected with hepatitis C.

If cure rates are sustained, Sovaldi will reduce prolonged hospitalizations, the need for liver transplants, and ultimately deaths related to hepatitis C. In the near term, however, cost will pose both an economic and an ethical dilemma for everyone involved in approving the use of the drug for each constituency.

Though less publicized, a myriad of other discoveries by biotechnical companies will inevitably drive up the cost of health care dramatically. "Specialty drug" is the designation for a medication designed to treat an uncommon disease. Such drugs have significantly impacted therapy for a host of malignancies and chronic inflammatory conditions. Years of very expensive research and testing are invested in each new drug. A report by Prime Therapeutics, which is owned by 13 BlueCross BlueShield plans, subsidiaries and affiliates, estimates that by 2018 specialty drugs such as Sovaldi could account for half of all drug costs. The squeeze on the health care budget could be severe.

How can we afford such progress? Who should determine what is a reasonable profit for a company bringing a new drug to market? What demarcates profit from profiteering?

Years ago, Harmon Smith, a wise, medical ethicist posed the question: "Who gets how much of what when there is not enough to go around?"

How long can we defer seeking an equitable answer?

Contact Clif Cleaveland at cleaveland1000@comcast.net.

Upcoming Events