The whopping price tag of a promising new drug-- $1,000 a pill -– that could help an estimated 95,000 sick Oregonians has the state and commercial insurers balking at coverage.
Gilead Sciences wants to sell more Sovaldi, a new drug hailed as a near-miracle cure for the sometimes-fatal Hepatitis C.
But citing the 12-week treatment cost of $84,000, Oregon officials want to put strict new restrictions on access to the drug, especially for those in earlier stages of the disease. Commercial insurers already have some access rules, but are watching the state's battle closely.
Hepatitis C is a progressive disease caused by a virus of the same name and often transmitted through intravenous drug use. It eventually causes liver failure and may lead to cancer or other life-threatening conditions.
Gilead executives flew a delegation to Oregon this week to meet with state officials and lawmakers in advance of a hearing Monday of the House Health Care Committee. They want to convince officials that the drug won't bust Oregon's budget.
"We're here to help the state," says Gilead executive vice president Gregg Alton. "It may be a thousand-dollar pill but it ... cures the person for life."
If you don't cure those afflicted, he added, they will face other costly illnesses and complications. "You actually end up with a much higher cost."
Because the drug was approved by the federal government last year, patients can theoretically obtain the drug if they have health insurance. But in practice it can be more difficult.
Linda Harrison, 67, of Portland, caught the virus when when she injected heroin, as a member of the counterculture Hippie movement in the 70s.
Linda Harrison
Now, the former Portland General Electric and University of California employee is in the most advanced stage of the condition, and she's worried that time is running out. Already, she suffers from a litany of symptoms ranging from foot problems to arthritis and cirrhosis of the liver.
It took her nine months to finally get a Sovaldi prescription, but her commercial insurer won't cover the other drug she needs to go with it..
The last time she went to see her doctor to fight the decision, "He just went on about how bad Gilead is, how bad insurance is," Harrison said. "He said his office doesn't have time to do the appeals."
Meanwhile, about 20,000 Oregonians with Hepatitis C belong to the Medicaid-funded Oregon Health Plan. State officials are trying to set up restrictions so that Sovaldi only goes to the most severely ill Hepatitis C sufferers.
If they don't restrict access to Sovaldi, officials say it will cost the state an additional $168 million in just the first year. Oregon would become the third state to adopt such harsh restrictions, following Illinois and Arkansas.
"We will over the course of ten years get the drug to everybody," says Tom Burns, who oversees the state's drug coverage policies. "But we can't get it to them right now."
The state's hard line concerns Lorren Sandt of the Portland-based patient advocacy group Caring Ambassadors, which has received funding from Gilead Sciences.
"Our state is ignoring science," she said. "We really want everybody to come to the table and sit down. Let's just figure this out."
Gilead's Alton does not try to hide that Sovaldi's price is generating huge profits. Though it paid $11 billion for the company that developed Sovaldi, the company will recoup its investment in almost no time. "We'll make it back this year," he said.
Though state officials have blasted Gilead for failing to offer discounts, the company says that's not true. They have offered Oregon prices closer to what they offer Canada, which pays $55,000 for a 12-week treatment. That's a discount of about one-third off the sticker price.
Burns, the state pharmacy official, does not dispute the discount offer, but says it came with strings—the pill must go to anyone who wants it, thus ensuring Gilead can sell it as fast as people can get a prescription from their doctor.
Burns wants to ensure providers consult with specialists to make sure the patients gets individualized treatment. Sovaldi often has to be administered with other drugs depending on a variety of factors.
He also want to make sure the patient has a support network to ensure they take their medications as director, so the money going for Sovaldi is well spent.
Burns says it's not only doctors that are prescribing the pill. Rural nurse practitioners and physician's assistants are too, but may lack the necessary training to make sure the treatment works. "That's what concerns me the most," he said.
Burns says he can't speak to the problems faced by Harrison, whose problem is with her commercial insurer. He says the drug should be going to people who really need it, regardless of cost. "Doctors should be prescribing what is medically appropriate for their patients and working with their patients to pay for it."
Meanwhile, Harrison keeps waiting. Her best hope, she says, is that the competitors to Sovaldi that are coming to the market soon help drive the price down.
"After waiting for 40 years and getting sicker by the day, it would be nice to be well," she says.
--Nick Budnick