Managing Hepatitis C: The High Price of Not Prioritizing Therapy
December 2015
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Hepatitis C Condition Overview Hepatitis C Virus (HCV) is a chronic infection that causes severe liver disease and is the leading cause for liver transplants. HEPATITIS C OVERVIEW
A contagious liver disease, spread primarily though contact with infected blood • Top 6 class by spend under pharmacy benefit • Estimated 3.2 million have Hepatitis C, most are unaware • Each year 17,000 Americans become infected POPULATION Z
• 1% national prevalence
• Estimated that 50% are undiagnosed
• 81% of chronically infected patients born between 1945‐1965 GENOTYPES Identified by lab test and helps determine therapy, length of treatment and predicting therapy response. • Genotype 1 is most common in U.S. accounting for 70% • Genotypes 2‐3 are less common (20‐30%) • Other genotypes are rare in the U.S. Copyright © 2015 MedImpact Healthcare Systems, Inc. All rights reserved.
Big Changes for Hepatitis C Until recently, Hepatitis C has been difficult to treat and nearly
Impossible to cure with existing therapies.
Hepatitis C virus infection is the most common chronic blood‐borne infection in the United States, with approximately 3.2 million people infected. It has at least six genetic variations that respond differently to drug therapies. A recently approved test quickly identifies the exact form of the virus; breaking a barrier for treating Hepatitis C.
For every 100 people infected with Hepatitis C virus
75‐85 will develop chronic infection
60‐70 will develop chronic liver disease
5‐20 will develop cirrhosis
1‐5 will die of cirrhosis or liver cancer
0
20
40
60
80
US annual cost to treat with traditional therapies:
$9,000,000,000
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*Source: http://www.cdc.gov/hepatitis/hcv/hcvfaq.htm, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3763475/
100
Prioritizing Treatment
Patients that progress to chronic infection
75‐85% of patients
Of those…
Stable
Variable
Severe
30% 40% 30% of patients
Time from infection to cirrhosis
20 years:
16% of patients
of patients
30 years:
41% of patients
of patients
Chance of progressing in Metavir score
in a given year
10%
Thein HH et al. Estimation of stage‐specific fibrosis progression rates in chronic hepatitis C virus infection: A meta‐analysis and meta‐regression. Hepatology 48, 418‐431 (2008)
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Impact of New Therapies Prescription Cost and Projected Cure Rates Cost
Cost
Cost
Cost
$20k ‐ 40k
Cure Rate
$95k ‐ 300k
$50k ‐ 70k
Cure Rate
Cure Rate
71% ‐ 89%
$65k ‐ 190k
Cure Rate
87% ‐ 100%
72%
44%
2001‐2011
Dual therapy
Peg‐interferon (injection), ribavirin (oral) 2011‐2013
2013(Q4)‐2014
2014‐2015
Incivek® or Victrelis® Sovaldi®, Olysio®* Harvoni®, Viekira Pak™
Added to dual therapy Copyright © 2015 MedImpact Healthcare Systems, Inc. All rights reserved.
*Or Peg‐interferon (injection) + ribavirin (oral) Replaces Incivek and Victrelis. *Source: Medispan AWP data and assumed average AWP discount of 15%.
Who should be treated is debated: PA Approval Rates
Options for aggressive to moderate controls for utilization and trend management
ESI
CVS
90‐100% 90‐100%
Prime
MedImpact
92.6%
31%
Optimized Spend
Hepatitis C drug treatment does not have an ROI
•
$136 ‐ $188 billion of projected drug cost vs. $16 billion in cost avoidance*
“The timing and nature of therapy for patients with minimal or no fibrosis (METAVIR score F0–F1) and no severe extra‐hepatic manifestations is debatable, and informed deferral can be considered.”
• EASL Recommendations on Treatment of Hepatitis C 2015
•
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*Source: http://www.prnewswire.com/news‐releases/what‐is‐the‐real‐cost‐of‐treating‐all‐patients‐with‐hepatitis‐c‐282068441.html
PA Approval rates for ESI and CVS based upon projected Gen1 patients meeting prior authorization criteria based upon publicly available prior authorization criteria and/or public commentary by entity.
Cost of Each Approach – Per 10,000 members
$919,000
=
x
x
x
$906,000
Patients presenting Approval Rate
Cost of Therapy
Duration of Therapy
$392,000
$244,000
$7.65 PMPM
$7.55 PMPM
ESI
CVS
$3.27
PMPM
Prime
$2.03
PMPM
MedImpact
Optimized Spend
Annual Patients ‐ % of Population – 0.09%
Avg Cost of Harvoni Therapy – weighted on duration ‐ $100,705
Assumptions
B bvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvp‐0
Avg Cost of Viekira Pak Therapy – weighted on duration ‐ $102,118
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Sources: Prime – PBMI Webinar: “Hepatitis C – Forecasting and Management.” ESI and CVS figures – projections based upon average cost of therapy, HCV patient presentation rate in MedImpact population, and PA approval rates in previous slide. Low Net Cost; Control versus Rebate Value
PBM
Estimated
HCV Gen1 Proportion
of HCV Patients Estimated Gen1 Requesting HCV Treatment Therapy
Patients Per 10,000 Requests Per Approved
Per Year
10,000
Total Est. Cost Treated HCV of Treatment (Accounts for Gen1 Patients per Medical Event Offset)
Year
Additional
Rebate per 30‐day
brand claim
required to offset cost*
Additional
Rebate per specialty brand claim
required to offset cost*
ESI
100
9
90%‐100%
9.0
$827,000 $32.03 $771
CVS
100
9
90%‐100%
9.0
$815,000 $31.37
$755
Prime
100
9
58‐92%
8.3
$353,000
$5.99 $144
MedImpact
100
9
31%
2.80
$244,000
$ ‐
$ ‐
Does the incremental shared rebate cover the difference? Vendor price differences do not offset the increased cost of non‐prioritized treatment protocols
Copyright © 2015 MedImpact Healthcare Systems, Inc. All rights reserved.
•
Assumptions: Non‐specialty products ‐ PMPY utilization of 13.50 30‐day Rxs and 86.5% generic fill rate. Specialty products – PMPY utilization of 0.11 Rx and 30% generic fill rate.
The Advantage of a Low Net Cost Approach
In conclusion – questions for a plan sponsor…
• Sponsors customarily benefit financially from a low net cost approach. They do not always benefit from rebate contracting.
– Are you receiving the negotiated rebate (i.e. 100% of specialty rebates)?
– What is the rebate guarantee if you manage utilization?
– Does owning fulfillment or flat specialty rebate guarantees create adverse incentives?
HCV is one of many upcoming mega‐blockbuster classes in the next three years – similar decisions will present themselves
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