Case example

Dr. Moore is a gastroenterologist working in a large multi-specialty private medical practice. One of his long-term patients is Father Nolan, a 54-year-old Episcopal priest with chronic hepatitis C virus (HCV) infection. Father Nolan contracted this infection more than twenty-five years ago, probably through a blood transfusion, and he has had slowly progressive liver injury over the past two decades. Until very recently, the only available drug treatment regimen for HCV infection was lengthy, arduous, and only partially effective. Father Nolan began this treatment regimen five years ago, but suffered severe complications and had to discontinue the treatment.

A new drug, sofosbuvir, has just been approved for the treatment of HCV infection. The early evidence suggests that this new drug is a genuine medical breakthrough. Treatment with a combination of sofosbuvir and other medications is short in duration, is well tolerated, and has a more than 95 percent cure rate. Dr. Moore would prescribe the new drug for Father Nolan right away, but for one stumbling block – the cost of the treatment regimen is about $140,000. Father Nolan has private health insurance; his parish provides this insurance to its staff through a non-profit insurer that specializes in health insurance plans for small religious institutions. In an attempt to control its costs, the insurance company has placed strict limits on who can be reimbursed for this drug, reserving it for only those patients with severe liver disease who need immediate treatment. The company has decided that its many other chronic HCV patients can wait until competing drugs now being developed by other manufacturers enter the market over the next few years, and the subsequent competition drives down drug prices.

Father Nolan does not meet his insurer's strict conditions for receiving the new HCV treatment. He is not acutely ill, but he does have continuing symptoms caused by liver damage, including fatigue, loss of appetite, and swelling in his lower body. Dr. Moore believes that his patient would clearly benefit from receiving the new treatment as soon as he can. He is considering several options. He could report exaggerated symptoms to the insurance company in order to make Father Nolan eligible to receive the new treatment.