{"id":5405,"date":"2014-09-07T11:02:02","date_gmt":"2014-09-07T15:02:02","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=5405"},"modified":"2015-05-18T11:09:30","modified_gmt":"2015-05-18T15:09:30","slug":"its-ok-to-limit-who-prescribes-hcv-therapy-but-insurers-shouldnt-be-deciding","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/its-ok-to-limit-who-prescribes-hcv-therapy-but-insurers-shouldnt-be-deciding\/2014\/09\/07\/","title":{"rendered":"It’s OK to Limit Who Prescribes HCV Therapy, but Insurers Shouldn’t Be Deciding"},"content":{"rendered":"

Some insurers would like to limit the prescribing of\u00a0HCV treatment to\u00a0gastroenterologists, hepatologists, or infectious diseases specialists.\u00a0Not surprisingly, this doesn’t sit well<\/a> with either the HIV Medicine Association (HIVMA) or the American Academy of HIV Medicine (AAHIVM), both of which have long acknowledged that some of the most seasoned HIV providers are generalists:<\/span><\/p>\n

\u201cThere is no medical rationale for excluding some HIV providers from prescribing HCV medications,\u201d said Donna Sweet, MD, AAHIVS, chair of the AAHIVM Board of Directors, an internist and HIV specialist. \u201cHIV providers who have been treating HCV\/HIV co-infected patients for years are uniquely qualified to manage potential drug toxicities and side effects stemming from combining treatment for HIV and HCV.”<\/span><\/p>\n

I completely agree. Who is more qualified to prescribe HCV treatment, a provider with extensive experience managing HIV\/HCV coinfection, or a gastroenterologist who has spent 90+% of his\/her career practicing\u00a0what some have called\u00a0“lumen-oriented medicine” (see video below for explanation). And there are\u00a0<\/em>many\u00a0<\/em>ID\u00a0specialists who do only<\/em> inpatient ID consults — they\u00a0would have as much chance\u00a0correctly identifying ledipasvir,\u00a0dasabuvir, and daclatasvir as winning the lottery.<\/p>\n

The problem, of course, is that whether they say it or not, a motivation of the insurers is to delay\u00a0treatment. I’m not so cynical to think it’s their only motivation, but it’s inevitably one of them. In the inherent conflict of interest that exists between medical insurance companies and expenditures for expensive short-term therapies, anything that delays treatment increases the likelihood that 1) other options will become available that drive down costs, or 2) the patient’s insurance will change, and it won’t be their problem anymore.<\/p>\n

And as everyone learns in Econ 101, dollars spent in the future are worth less than those expended now — it’s called “discounting,”<\/a> remember?<\/p>\n

But is\u00a0the concept of limiting who prescribes HCV therapy inherently wrong? Of course not — the benefit to the patient is so great, and the financial stakes are so high, it is eminently reasonable that only those qualified to do so should\u00a0treat HCV.<\/p>\n

It just shouldn’t be that the companies paying for the treatment, on their own, get to decide who the qualified providers are\u00a0—\u00a0they’re hardly disinterested enough to make this judgment wisely.<\/p>\n

Everyone sing along now:<\/p>\n