By Jaymie Baxley
North Carolina’s top health official hopes the state can expand Medicaid access to Wegovy — the blockbuster weight-loss drug recently approved as a treatment for cardiovascular disease by the U.S. Food and Drug Administration — without breaking the bank.
On Tuesday, Kody Kinsley, secretary of the N.C. Department of Health and Human Services, gave lawmakers an update on Medicaid, the state and federal health insurance program that provides health care services for some 2.9 million North Carolinians. That number includes 389,411 beneficiaries covered by Medicaid expansion as of Tuesday, as the expansion population continues to increase by about 1,000 people per day.
Kinsley told lawmakers that Medicaid currently covers GLP-1 drugs such as Wegovy only for people with diabetes. Addressing members of the Joint Legislative Oversight Committee on Medicaid, he said that the drugs are “phenomenal” and the “promise of their therapeutic potential is huge.”
He added that a clinical trial among people who were given the drug after having a stroke or heart attack found “a 20 percent reduction in risk for continued situations or continued negative outcomes.”
This presents a “real value proposition” for the state, Kinsley told lawmakers. The issue, he said, is that the drugs are “stupid expensive.”
Sen. Ralph Hise (R-Spruce Pine), a member of the committee, cited a report from state Treasurer Dale Folwell warning that increased coverage of GLP-1 medications could cost the health plan for state employees as much as $225 million next year. The medication commonly retails for more than $1,300 a month. Pricing for the state would likely be less but could still top $10,000 a year per patient.
’It’s, frankly, so frustrating to me that they are so incredibly expensive relative to what we see in other countries,” Kinsley said. “I believe that they’re being held back from the people of North Carolina when they could be providing a great deal of value here in the buckle of the barbecue belt.”
Kinsley said his team “has looked very closely” at ways to offer the drug to more of North Carolina’s Medicaid participants. If they can figure out a “cheaper” way to do it, he believes the “value will far outpace” the state’s investment.
He said part of the challenge with reducing the cost to the state comes from the substantial rebates given to the state by drug companies for using their products. Those rebates tallied upwards of $1.4 billion this fiscal year, with the state retaining about a third of that cash after paying for the medications.
“I think we have a way that can still be priced right,” he said.
GLP-1s aren’t the only drugs that DHHS is working to expand access to. Kinsley said the agency recently put out a federal proposal for two gene therapy treatments approved by the FDA in December for patients with sickle cell disease that can actually produce a cure.
Kinsley said sickle cell disease is “incredibly painful” and affects more than 6,800 North Carolinians. At the same time, he said, the newly approved therapies are “incredibly expensive.”
“We’re working with the federal government to increase access to these therapeutics and to make them more affordable for the state,” he said.
Ransomware attack
Later during Tuesday’s meeting, the committee received an update on last month’s ransomware attack on the payment processing company Change Healthcare, which is part of the insurance behemoth UnitedHealthcare.
The company was hit with a cyber attack in late February, which has affected pharmacists and health care providers. UnitedHealthcare is one of the five large insurers managing the state’s Medicaid managed care regimen, handling the care for more than 436,000 of the state’s program beneficiaries.
The cyberattack created a national outage, leaving an untold number of providers unable to process Medicaid claims. Jay Ludlam, deputy secretary for N.C. Medicaid, said the attack was not as disruptive in North Carolina as it was in other states.
“I think we anticipated a big hit from providers and members, and we are not seeing that now,” he said.
Change Healthcare processes prescriptions and claims for insurers across the country. As cited in an article in The Washington Post, a federal lawsuit filed against UnitedHealthcare asserted that about half of the medical claims in the U.S. were processed through Change.
North Carolina was not entirely unscathed. Ludlam said some pharmacists “were literally submitting the claim in the moment” the ransomware attack happened, causing an “error” message to pop up on their computer screen.
“We have protocols, though, for our pharmacists, and they were able to continue to fill prescriptions in good faith and provide emergency supplies to our members,” he said.
Ludlam said the state’s managed care Medicaid providers have pivoted to offer “hardship payments” to providers unable to process claims for services during the attack. The partners are also waiving the requirement for providers to submit claims in a timely manner to be reimbursed through Medicaid until April, he said.
“By and large, unlike some other states, we are starting to see some quiet, but that doesn’t mean that the issue isn’t over,” Ludlam said. “We stand ready as a division to support providers if they need hardship payments as well.”
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I’m sorry, but state health plan members who pay for their insurance should get coverage back for wegovy before Medicaid users should get coverage at all. If the state has the money, those who are paying for insurance and taxes should benefit first and foremost.