Here in Washington state, bureaucrats and even physicians have imposed draconian rules and restrictions that limit access by patients on state Medicaid to the newest treatments and therapies for HIV. These rules require patients to start treatment with regimens consisting of more pills, and potentially more toxicity, than modern regimens that frequently consist of a single pill containing multiple drugs with lower toxicity. This can lead to treatment failure and/or an increased risk of long-term side effects.
The state’s justification is that some of the components of older regimens are now generic, and therefore less costly, while remaining “almost as good” as newer regimens.
On Wednesday, the Washington state Pharmacy and Therapeutic Committee and Drug Utilization Review Board is scheduled to meet to discuss the continued implementation of these rules that currently prevent patients from accessing the latest and safest HIV therapies. If the board is serious about ending the HIV epidemic in Washington state — and has any thought for patients — it must stop the continued implementation of these restrictions.
For three years, these rules have positioned the state of Washington to have some of the worst patient access to HIV treatments and therapies in the country. It is an embarrassment.
As an HIV doctor who works in Washington state, my primary concern has always been to deliver the best care possible, and let the patient/provider relationship drive important treatment choices. Many of my Medicaid patients also bear the burdens of racism and socioeconomic challenges that can lead to poorer health outcomes.
Pharmaceutical innovation has led to HIV treatments that are simpler and less toxic. Newer medicines have addressed issues of complexity and toxicity, reduced the number of pills and created treatment regimens that are far more patient-friendly, making it easier for patients to adhere to their treatment. This is good news for individuals taking HIV antivirals for treatment or prevention of HIV infection — except, of course, if those individuals live in Washington state.
For example, the state’s “fail-first” policies, such as so-called “step therapy” and “utilization management,” mean that providers may not be able to prescribe what they think is the best treatment option, instead starting with what they feel is an inferior regimen. The physician must then monitor the ineffectiveness of that treatment to justify to the state why their patient should instead be prescribed a “non-preferred” (that is, more expensive) therapy.
The state argues that efforts to reduce complexity and toxicity are trumped by cost considerations. Acknowledging that HIV medications are expensive, nevertheless, according to the database Fingertip Formulary, 49 other states do not have the same restrictions on HIV prescribers and patients. Unlike Washington, most other states do not interfere with the doctor-patient relationship in choosing the most appropriate regimen to treat the patient’s HIV.
As the situation currently stands in Washington state, if a doctor believes that a patient is more likely to succeed on a single-tablet regimen with lower toxicity versus two or three daily pills, the state can deny the request, maintaining that those reasons are insufficient to justify the use (and therefore the cost) of “non-preferred” medications.
Of course, there are multiple problems with this approach.
First, the “failure” of an initial HIV regimen, either due to tolerability or lack of efficacy, can bear a high price. Failure may lead to mutations in the virus that preclude many other valuable medications. Poor tolerability with the first regimen may make the patient averse to try other HIV treatments.
Second, I and my colleagues who care for and treat patients are forced to betray a moral and ethical commitment to make the best treatment decisions possible for our patients. The decision-makers in Olympia have little context for looking patients in the eye and telling them they will have to take several prescriptions, instead of one, to treat their newly diagnosed HIV. And they are not the ones who have to prescribe an older regimen for the patient while knowing that newer, simpler, and safer treatment is available to others but not for this patient because they are on Medicaid.
Finally, because of all this, a rift emerges in the patient-provider relationship. Being compelled to prescribe a treatment I know may adversely affect my patients, when I know a better option is available, is not an approach that builds openness and trust between a provider and a patient who needs to be seen regularly while being treated.
Another year of substandard Medicaid access to HIV treatments may be just around the corner. But on Wednesday, there will be an opportunity for those in power to reevaluate a broken approach that has damaged the state’s health care system, impeded providers’ ability to do their job faithfully and ethically, and potentially caused harm to some of the state’s most stigmatized and vulnerable patient populations.
On behalf of physicians across the state, I urge them to take advantage of it.