September 7, 2015
Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.
By now, the fact that HCV treatment carries a high price is a fact as well known to the medical and non-medical public as 1) a million dollars doesn't get you much in Manhattan or Bay-area real estate; 2) a Rolex is an expensive way to know what time it is; and 3) even though a Tesla doesn't need gas, buying one won't save you money.
But you know what? Something interesting has happened since the initial sticker-shock of the $1000/day pill and the cries of injustice from patients, the medical community and activists. First, the price has been aggressively negotiated, and now is substantially lower -- various unofficial estimates suggest the actual cost is around 50% of the wholesale acquisition cost. Still high, yes, but much less than the dizzying cost of HCV treatment during the "SIM-SOF" days in early 2014.
Second, a careful analysis of this miraculous therapy shows it's actually decent value. In other words, you pay a lot, but you get a lot too -- this is what the cost-effectiveness literature shows (several citations in bullet number two at this link), and the public is starting to take notice. An editorial last week in the Times got it right (though it could have used a bit of quick medical editing, which I've provided):
The benefits of these new drugs are undeniable. They can essentially cure [not essentially cure -- they do cure] the infection in eight to 24 weeks. ... Curing the patient decreases by more than 80 percent the risk of liver cancer, liver failure and the need for a liver transplant, thus saving money in the long run. Successful treatment can also greatly reduce the number of new cases of hepatitis C by preventing transmission of the virus through needle-sharing among drug addicts infected with HIV [HIV has nothing to do with it] ... the Institute for Clinical and Economic Review, previously a skeptic, estimated that a likely course of treatment with Harvoni would make it a high value for individual patients and for most health care systems.
The editorial goes on to recommend lifting restrictions on treatment, in particular for those who don't have advanced liver disease. This makes all kinds of medical sense, and will be great comfort to those of us battling with payors to get treatment to people before they have irreversible liver damage from HCV.
Meanwhile, one of our relatively obscure antimicrobials -- pyrimethamine -- has suddenly become staggeringly expensive. Used as part of treatment of toxoplasmosis (in particular for patients with AIDS), and rarely for malaria, pyrimethamine has been around for decades. A single pyrimethamine tablet, previously $13.50, now costs $750 -- that's a more than 50-fold increase.
It's not as if new research funded by industry has found some novel indication for a previously underused drug. Nope, this is pure monopolistic pricing -- in mid-August, a company purchased the rights to pyrimethamine, becoming the exclusive US distributor. As with the colchicine saga, this exclusivity allows them to dramatically drive up the price because, well, they can.
In short, sometimes you get what you pay for -- and, at least in the case of pyrimethamine, sometimes you don't.
Hey, this video doesn't cover treatment, but it sure is funny!
Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.
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