The release of an extremely costly medicine (sofosbuvir) for the treatment of chronic hepatitis C illustrates a great number of dilemmas facing health care policy in America: how to appropriately manage our financial resources in caring for populations, how to ascertain which patients will benefit the most from expensive treatments, and even how other countries have gotten the same drugs — reportedly priced at about $84,000 in the U.S. for one three-month cycle of treatment — for less.

One uglier fault line in American health care revealed by these very expensive drugs is the poisonously hierarchical nature of health delivery and payment systems, which has resulted in guidelines requiring that in order for them to be paid for by Maryland Medicaid, they must be prescribed by a specialist in gastroenterology or infectious disease.


There are plenty of good reasons to make rules such as these; we certainly wouldn't want primary care physicians giving out IV chemotherapy in their offices. However, there don't seem to be any good reasons in this case besides the cost of the drugs, which reportedly had a cure rate of nearly 95 percent in clinical trials. Family medicine and internal medicine providers in Maryland who have already been treating hepatitis C are being denied the opportunity to extend this potentially life-saving treatment (along with a second-generation version not yet approved that combines sofosbuvir with the drug ledipasvir) to low-risk patients.

My own practice exclusively serves the homeless, which is a population that is both overwhelmingly affected by hepatitis C and frequently beset with obstacles to accessing specialty care. There are some counties in Maryland that don't even have gastroenterologists or infectious disease specialists, forcing patients in these regions to travel to other counties or other states for treatment. Allowing primary care doctors to treat patients using these new regimens will allow some of the most vulnerable populations in the state to access treatment.

The only data that I could find on this subject demonstrates that more than half of specialists surveyed would feel comfortable with primary care clinicians treating hepatitis C. Admittedly, this was a relatively small survey and it also revealed that a third of PCPs would still always refer. However, just as HIV care by non-specialists has shown comparable outcomes to that by specialists, so hepatitis C patients may see the same benefit — or greater, given the limited duration of treatment with sofosbuvir.

The population of primary care providers who will prescribe hepatitis C treatment is a small and self-selecting group that has a clear interest in judiciously managing resources, assessing patient risk factors, and working with patients at the margins of our health care system. Many even have systems within their offices to help ensure patient adherence that specialists lack. Primary care providers can be expected to take this responsibility seriously and can be held accountable in any way that the Department of Health and Mental Hygiene sees fit.

Even if the Maryland Medicaid program and its associated managed care organizations cannot tolerate primary care physicians independently managing hepatitis C, they could at least establish a working group similar to Project ECHO in Arizona and Utah, wherein telemedicine was used to connect primary care clinicians in a variety of settings to specialists for the purposes of treating more patients with hepatitis C. Another possibility would be to create a special certification with an online training program, similar to that used for prescribing buprenorphine. There are many options for managing the complex issues that come along with a new treatment; none have to be as draconian as restricting prescribing to specialists.

Primary care physicians are a diverse group; many of them work with extremely vulnerable patients whose lives could be saved by sofosbuvir and ledipasvir. Restricting the Medicaid formulary for these patients is shortsighted and unjust; genuine concerns about safety and responsibility could be ameliorated through a variety of different programs. In the end, not paying for these drugs when they're prescribed by a primary care provider doesn't make sense for doctors or patients.

Dr. Matthew Loftus is a family physician at Healthcare for the Homeless. His email is loftus.matthew@gmail.com; Twitter: @matthew_loftus.

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