Abstract
BackgroundWith some Medicaid state programs still restricting patient access to hepatitis C (HCV) treatment, it is important to demonstrate how states could expand treatment access to a broader Medicaid population and balance short-term budget concerns.MethodsWe used the HCV Transmission and Progression (TaP) Markov model to quantify the impact of removing restrictions to HCV treatment access on the infected populations, expenditures, and net social value for the North Carolina (NC), Oregon (OR), and Wisconsin (WI) Medicaid programs. Four HCV treatment access scenarios were modeled: 1) Baseline: Patients were treated according to Medicaid disease severity and sobriety requirements in 2015; 2) Remove Sobriety Restrictions: Disease severity restrictions were maintained, but people who inject drugs (PWID) were given access to treatment; 3) Treat Early: All patients, except for PWIDs, regardless of disease severity, were eligible for treatment and the diagnosis rate increased from 50 to 66%; and 4) Remove Access Restrictions: all patients, regardless of disease severity and sobriety, were eligible for treatment. Our key model outputs were: number of infected Medicaid beneficiaries, HCV-related medical and treatment expenditures, total social value, and state Medicaid spending over 10 years.ResultsAcross all three states, removing access restrictions resulted in the greatest benefits over 10 years (net social value relative to baseline = $408 M in NC; $408 M in OR; $271 M in WI) and the smallest infected population (5200 in NC; 2000 in OR; 614 in WI). Reduced disease transmission resulted in lower health care expenditures (-$66 M in NC; -$50 M in OR; -$54 M in WI). All of the expanded treatment access policies achieved break-even costs—where total treatment and health care expenditures fell below those of Baseline—in 4 to 8 years. Removing access restrictions yielded the greatest improvement in social value (net of medical expenditures and treatment costs, QALYs valued at $150 K per QALY).ConclusionsWhile increasing treatment access in Medicaid will raise short-term costs, it will also provide clear benefits relatively quickly by saving money and improving health within a 10-year window. Patients and taxpayers would benefit by considering these gains and taking a more expansive and long-term view of HCV treatment policies.
Highlights
With some Medicaid state programs still restricting patient access to hepatitis C (HCV) treatment, it is important to demonstrate how states could expand treatment access to a broader Medicaid population and balance short-term budget concerns
The limitations of short-term budget modeling can be seen in the case of Hepatitis C (HCV) treatment when direct-acting antiviral (DAA) therapies first came to market
Facing a growing affected population and rising costs of care for HCV, many state Medicaid programs have restricted access to effective, but more costly, DAA therapies used to treat HCV infection [4]. While these therapies have been demonstrated to cure HCV infection in 90–100% of treated patients [5], a 2014 survey of state Medicaid fee-for-service (FFS) programs conducted by the National Viral Hepatitis Roundtable and the Center for Health Law and Policy Innovation of Harvard Law School found a number of treatment access restrictions based on disease severity, sobriety status, and prescriber eligibility [6]
Summary
With some Medicaid state programs still restricting patient access to hepatitis C (HCV) treatment, it is important to demonstrate how states could expand treatment access to a broader Medicaid population and balance short-term budget concerns. Facing a growing affected population and rising costs of care for HCV, many state Medicaid programs have restricted access to effective, but more costly, DAA therapies used to treat HCV infection [4]. While these therapies have been demonstrated to cure HCV infection in 90–100% of treated patients [5], a 2014 survey of state Medicaid fee-for-service (FFS) programs conducted by the National Viral Hepatitis Roundtable and the Center for Health Law and Policy Innovation of Harvard Law School found a number of treatment access restrictions based on disease severity, sobriety status, and prescriber eligibility [6]. The Centers for Medicare and Medicaid Services (CMS) issued a letter to the states warning that these access restrictions may violate statutory requirements for Medicaid [4]
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