FISCAL NOTE

Date Requested: February 10, 2022
Time Requested: 04:05 PM
Agency: Public Employees Insurance Agency (PEIA)
CBD Number: Version: Bill Number: Resolution Number:
2613 Introduced SB615
CBD Subject: Insurance


FUND(S):

PEIA Basic Insurance Fund

Sources of Revenue:

Special Fund

Legislation creates:

Creates New Expense



Fiscal Note Summary


Effect this measure will have on costs and revenues of state government.


The purpose of this bill is to require Medicaid and insurance coverage of intravenous immunoglobulin therapy (IVIG) for pediatric autoimmune neuropsychiatric disorders associated with streptococcal (PANDAS) infections and pediatric acute onset neuropsychiatric syndrome (PANS) and other autoimmune encephalopathies with prior authorization once all other standard therapies have been exhausted. The incidence and prevalence of PANDAS is not known at this time. Up to Date, a resource of scholarly articles and peer reviewed literature, states the incidence is rare and case studies identified only 10 cases among 30,000 throat cultures. Statistics quoted in the medical literature range from 1 in 200 children to 1 in 2000 children. This disorder is controversial as outlined in the Up-to-Date review of the disorder and immune modulating therapy including IVIG remains controversial, as they are as yet unproven and carry risks. There are few well-designed trials of treatment for PANDAS. In addition, the American Academy of Pediatrics fails to recognize the relationship between group A strep and PANDAS. PEIA currently covers antibiotics for group A streptococci infections, behavior and medical therapy for Obsessive-Compulsive Disorder and Tic Disorders, intravenous or oral steroids, plasmapheresis for PANDAS and autoimmune encephalitis, and IVIG for certain types of autoimmune encephalitis for these diagnoses. The cost to PEIA for coverage of IVIG therapy for PANS/PANDAS is unknown since the dosage, number of treatments and the frequency of treatment has not been standardized. PEIA currently has 33,590 pediatric members. Using PEIA’s in-state fee schedule, an average 10-year-old child weighing 32kg would use 32-64 grams/kg dosage ranging from $3,200 to $6,400 per infusion plus a $100 infusion charge. Using the 1 in 200 and the 1 in 2000 statistics, there would be a range of 17 to 168 children who would be diagnosed with PANDAS and possibly need treatment in PEIA’s pediatric population. PEIA assumes 25% of the range diagnosed with PANDAS, or between 4 to 42 children, may receive prior authorization indicating that all other treatment methods have been exhausted. A one-time dosage for 4 to 42 children, with prior authorization, would be between $13,436 and $268,720. IVIG treatment monthly at the midpoint of each range (Cost $4,800; Population 19 children) per the above dosage, plus the $100 infusion charge, would cost $1,088,416 annually. Current literature and studies range from one-time dosage of IVIG to monthly IVIG infusions. Cost will be increased if medication is used more than once or if the member is having infusions out of state and out of the PEIA fee schedule.



Fiscal Note Detail


Effect of Proposal Fiscal Year
2022
Increase/Decrease
(use"-")
2023
Increase/Decrease
(use"-")
Fiscal Year
(Upon Full
Implementation)
1. Estmated Total Cost 0 1,088,416 0
Personal Services 0 0 0
Current Expenses 0 1,088,416 0
Repairs and Alterations 0 0 0
Assets 0 0 0
Other 0 0 0
2. Estimated Total Revenues 0 0 0


Explanation of above estimates (including long-range effect):


Statistics quoted in the medical literature range from 1 in 200 children to 1 in 2000 children. Using the 1 in 200 and the 1 in 2000 statistics, there would be a range of 17 to 168 children who would be diagnosed with PANDAS and possibly need treatment in PEIA’s pediatric population. PEIA assumes 25% of the range diagnosed with PANDAS may receive prior authorization. IVIG treatment monthly at the midpoint of each range (Cost $4,800; Population 19 children) per the above dosage plus the $100 infusion charge, would cost $1,088,416 annually.



Memorandum


Current literature and studies range from one-time dosage of IVIG to monthly IVIG infusions. Cost will be increased if medication is used more than once or if the member is having infusions out of state and out of the PEIA fee schedule.



    Person submitting Fiscal Note: April Taylor
    Email Address: April.a.taylor@wv.gov