Blame Payers for Only 1:3 Patients Receiving HCV Cure

On August 9th, the Centers for Disease Control and Prevention (CDC) provided an early release of a Morbidity and Mortality Weekly Report (MMWR), detailing the massive inequity between insured patients in need of curative Hepatitis C (HCV) treatment. By evaluating the HealthVerity claims and encounters database, researchers were able to identify particular patient characteristics, including payer type (private, Medicaid, and Medicare), sex, race, and age. Of particular note, assessment included recognition of various restrictions some state Medicaid programs impose on patients.

Importantly, the CDC notes that about 2.2 million people in the United States are living with an HCV diagnosis and 14,000 people die of HCV-related conditions annually. These deaths are largely preventable thanks to the development of curative treatments through direct acting agents (DAA)s. The analysis also cites previous research finding that providing timely, curative HCV care reduces costs to payers (and their sponsors) compared to costs of denying care. This remains true even when patients experience reinfection or treatment interruptions. Essentially, a cornerstone of public health is affirmed in curing patients of HCV, patient quality of life and health, engagement in society, and the economic benefits thereof are well-served when patients have ready access to life-saving treatment. This all emphasizes why the disparities displayed in the findings of this report are unacceptable and must be addressed with urgency.

Generally, for inclusion in the analysis, patients needed to be enrolled in health insurance coverage consistently just before and during the time period used in the paper. Of the unique patient files evaluated, just under 48,000 qualified for inclusion in this analysis. Medicaid and patients with private insurance saw about the same number of HCV screenings performed, however, Medicaid patients were more than twice as likely to receive an HCV RNA test whereas Medicare patients were most likely to receive an HCV RNA test than the other two payer types with rate of HCV positivity was highest among Medicaid patients. Of Medicaid patients qualified, more patients lived in states with treatment restrictions (47%) than in states without restrictions (38.8%). Overall, patients enrolled in private care were most likely to initiate DAA treatment inside of the following year (35%) and Medicaid patients were the least likely (23%). Treatment initiation was most likely to occur within 6 months of diagnosis. Critically, there did not seem to be a massive racial disparity within a particular payer type, except those patients who selected “other” or were missing racial information in their claim. For Medicaid patients, the drop was significant (19% and 20% respectively). Patients enrolled in Medicaid in states with program restrictions were 23% less likely to initiate treatment than Medicaid patients in states without restrictions.

The authors urge some caution because the qualification for inclusion required a long period of continuous insurance enrollment and did not include uninsured, incarcerated people, or people who receive coverage through other public payers (Veterans Administration or AIDS Drug Assistance Programs). The CDC expects treatment initiation for people who experience disruption in insurance coverage are less likely to initiate curative HCV treatment, in general. And the data provided has no ability to inform the “why” behind delays in initiation or failure to initiate curative treatment.

The data did not mention how the COVID-19 pandemic may have affected claims, treatment initiation, screening and testing, or even insurance enrollment during the period of time included in the assessment.

The Center for Health Law and Policy Innovation at Harvard and the National Viral Hepatitis Roundtable issued a lengthy statement urging policymakers to take note of the report. The groups highlighted their annual report on barriers to care in state Medicaid programs, Hepatitis C: State of Medicaid Access, pointing toward to work as a guidepost for reducing barriers to care and increasing patient access. The report has recently undergone an update in metrics assessed as progress has been made on fronts regarding issues raised in previous reports. Notably, the updated metrics include an “other restrictions” category to include restrictions on treating reinfections, requirements in on medication adherence (including adherence to medications not used to treat HCV), and refusal to cover lost o stolen medications. That last piece needs note because the state of Florida is one of those (9 in total) programs which limit coverage for lost and stolen medications and these barriers, under issues of natural disasters, institute yet one more barrier to care and burden when patients can afford disruption the least – such disruptions also impact adherence, creating what can amount to an unwinnable situation for many Medicaid patients.

Significantly, the CDC’s report opens with noting that all of this is preventable. Advocates should consider pressing this report with their federal and state electeds and policymakers, emphasizing these findings represent the “best” of circumstances, in terms of coverage, and many of their constituents (and ours) do not enjoy the best circumstances.