FISCAL NOTE

Date Requested: January 14, 2020
Time Requested: 11:19 AM
Agency: Public Employees Insurance Agency (PEIA)
CBD Number: Version: Bill Number: Resolution Number:
1452 Introduced HB4162
CBD Subject: Insurance


FUND(S):

PEIA Basic Insurance

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. 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. In addition, the American Academy of Pediatrics fails to recognize the relationship between group A strep and PANDAS. IVIG does not have FDA approval for PANDAS. PEIA utilizes United Health Care medical policies which still consider IVIG treatment for PANDAS as experimental and investigational. In an Up to Date review of the disorder, immune modulating therapy or IVIG was not recommended for treatment of children with PANDAS outside of the research setting. The medical research is still ongoing with PANDAS and the effectiveness of IVIG therapy has not been agreed upon. Autoimmune encephalitis is a clinical syndrome with a wide range of complex neuropsychiatric symptoms. The condition is rare and is estimated by Mayo Clinic to be 14 cases per 100,000 people. The largest experience has been with NMDA receptor encephalitis which has responded well to immune therapy. 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 51,488 pediatric members. Using PEIA’s in state fee schedule, one dosage for an average ten-year-old child weighing 32kg could range from $2,270.00 to $4,540.00 based on dosage of 1gram/kg, doubled for 2gram/kg. Using the 1 in 200 statistic would mean that 257 of those children would be diagnosed with PANDAS and possibly need treatment with IVIG. 1 in 2000 would be 26 children. Depending on the rate of occurrence, a one-time dosage for 257 children would range from $583,390.00 to $2,332,275.00 depending on dosage used and brand. A one-time dosage for 26 children would be between $59,020.00 and $235,950.00. 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. For purposes of the fiscal note estimate, an average occurrence rate of 141.5 was used and the mid-point cost at this rate per the above dosages is $642,410.



Fiscal Note Detail


Effect of Proposal Fiscal Year
2020
Increase/Decrease
(use"-")
2021
Increase/Decrease
(use"-")
Fiscal Year
(Upon Full
Implementation)
1. Estmated Total Cost 0 642,410 642,410
Personal Services 0 0 0
Current Expenses 0 642,410 642,410
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):


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 51,488 pediatric members. Using PEIA’s in state fee schedule, one dosage for an average ten-year-old child weighing 32kg could range from $2,270.00 to $4,540.00 based on dosage of 1gram/kg, doubled for 2gram/kg. Using the 1 in 200 statistic would mean that 257 of those children would be diagnosed with PANDAS and possibly need treatment with IVIG. 1 in 2000 would be 26 children. Depending on the rate of occurrence, a one-time dosage for 257 children would range from $583,390.00 to $2,332,275.00 depending on dosage used and brand. A one-time dosage for 26 children would be between $59,020.00 and $235,950.00. 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. For purposes of the fiscal note estimate, an average occurrence rate of 141.5 was used and the mid-point cost at this rate per the above dosages is $642,410.



Memorandum


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 51,488 pediatric members. Using PEIA’s in state fee schedule, one dosage for an average ten-year-old child weighing 32kg could range from $2,270.00 to $4,540.00 based on dosage of 1gram/kg, doubled for 2gram/kg. Using the 1 in 200 statistic would mean that 257 of those children would be diagnosed with PANDAS and possibly need treatment with IVIG. 1 in 2000 would be 26 children. Depending on the rate of occurrence, a one-time dosage for 257 children would range from $583,390.00 to $2,332,275.00 depending on dosage used and brand. A one-time dosage for 26 children would be between $59,020.00 and $235,950.00. 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. For purposes of the fiscal note estimate, an average occurrence rate of 141.5 was used and the mid-point cost at this rate per the above dosages is $642,410.



    Person submitting Fiscal Note: Jason Haught
    Email Address: jason.a.haught@wv.gov