Patient lawsuits over denials of pricey drugs pile up

Lawsuits to force insurers to pay for a procedure aren’t new, but they could reflect a new reality for most insurers as they find a way to pay for high-priced drugs.

The latest lawsuit was filed on Thursday by a group of prisoners against the Massachusetts prison system for denying access to new hepatitis C drugs.

“Over 1,500 state prisoners in Massachusetts have hepatitis C, but as of the present time only three are being treated for it,” according to the lawsuit.

That is despite advances in treatment that have been able to effectively cure the chronic liver disease. The problem is those treatments are very expensive.

Gildead Sciences makes both Sovaldi and Harvoni hepatitis C drugs. The former can cost about $84,000 and the latter nearly $100,000 for a treatment course.

Individual patients also have filed several lawsuits.

Take Californian Shima Andre, who sued Blue Cross of California last month for denying coverage of Harvoni.

Blue Cross, a subsidiary of insurance giant Anthem, wrote in a denial letter to Andre that the drug was not “medically necessary.” The problem was that Anthem didn’t receive a copy of Andre’s liver biopsy results.

Approval of Harvoni hinges on whether the liver has a lot of scarring, and Andre’s records showed that hers did not. Andre was not able to send in a liver biopsy, which may have shown such scarring.

However, Andre’s doctor had recommended she get the treatment, said Richard Echeverria, a partner with the law firm Shernoff Bidart Echeverria Bentley, which is handling the case.

“How can it not be medically necessary?” he said.

Anthem declined to comment and the Massachusetts Department of Corrections did not return a request for comment.

The lawsuits don’t end there.

Echeverria said he already has 30 similar cases, all against insurers centering on the denial of paying for Harvoni.

“It is the same basis for denial” as the Andre lawsuit, he told the Examiner. “The reality of it is they just don’t like the price.”

Insurers aren’t the only ones to feel the legal heat.

Last year, a Philadelphia transit union sued Gilead over the high price of Sovaldi, saying that the treatment could bankrupt its health plan.

High drug prices for hepatitis C and other specialty drugs such as cancer treatments have become a pressing concern for Americans.

A poll of 2,059 voters released last month by the think tank Morning Consult found that 75 percent believe prescription drugs are too expensive.

The pharmaceutical and insurance industries have battled over who to blame for the prices.

Drug spending only accounts for 10 percent of U.S. healthcare spending and that is because insurers aggressively negotiate discounts, according to the trade group Pharmaceutical Research and Manufacturers of America. Generic medicines, which are much cheaper than the brand-name version, account for nearly 90 percent of all dispensed drugs.

However, drug companies are setting prices much higher than ever before, counters Clare Kusing, spokeswoman for the insurance trade group America’s Health Insurance Plans.

In 2014, U.S. spending on prescription drugs jumped 13 percent to $374 billion, the biggest spike in more than a decade, she added.

Obamacare provisions, such as limiting the out-of-pocket costs for patients, also mean insurers bear more of the costs for covering a drug, Krusing said.

While more attention has been paid to drug prices, Congress has done little on the issue.

The House Energy and Commerce Committee recently advanced legislation intended to make it easier for companies to conduct clinical trials, which could in turn lower the drug development costs. That legislation, part of the 21st Century Cures Act, could lower prices in a roundabout way.

President Obama sought a different tack by seeking new powers that allow the federal government to negotiate with companies over prices for drugs reimbursed by Medicare and Medicaid. That effort included in the president’s budget has seen little to no traction in Congress.