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Healthc (Amst). 2017 Sep;5(3):105-111. doi: 10.1016/j.hjdsi.2016.11.001. Epub 2016 Dec 5.

Long-term disease and economic outcomes of prior authorization criteria for Hepatitis C treatment in Pennsylvania Medicaid.

Author information

1
Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, PA, USA.
2
Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
3
Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA.
4
Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA; Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA.
5
Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
6
Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA; Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA. Electronic address: walid.gellad@pitt.edu.

Abstract

BACKGROUND:

Several highly effective but costly therapies for hepatitis C virus (HCV) are available. As a consequence of their high price, 36 state Medicaid programs limited treatment coverage to patients with more advanced HCV stages. States have only limited information available to predict the long-term impact of these decisions.

METHODS:

We adapted a validated hepatitis C microsimulation model to the Pennsylvania Medicaid population to estimate the existing HCV prevalence in Pennsylvania Medicaid and estimate the impact of various HCV drug coverage policies on disease outcomes and costs. Outcome measures included rates of advanced-stage HCV outcomes and treatment and disease costs in both Medicaid and Medicare.

RESULTS:

We estimated that 46,700 individuals in Pennsylvania Medicaid were infected with HCV in 2015, 33% of whom were still undiagnosed. By expanding treatment to include mild fibrosis stage (Metavir F2), Pennsylvania Medicaid will spend an additional $273 million on medications in the next decade with no substantial reduction in the incidence of liver cancer or liver-related death. Medicaid patients who are not eligible for treatment under restricted policies would get treatment once they transition to the Medicare program, which would incur 10% reduction in HCV-related costs due to early treatment in Medicaid. Further expanding treatment to patients with early fibrosis stages (F0 or F1) would cost Medicaid an additional $693 million during the next decade but would reduce the number of individuals in need of treatment in Medicare by 46% and decrease Medicare treatment costs by 23%. In some scenarios, outcomes could worsen with eligibility expansion if there is inadequate capacity to treat all patients.

CONCLUSIONS AND RELEVANCE:

Expansion of HCV treatment coverage to less severe stages of liver disease may not substantially improve liver related outcomes for patients in Pennsylvania Medicaid in scenarios in which coverage through Medicare is widely available.

KEYWORDS:

Claims analysis; Direct-acting antivirals; Hepatitis C; Hepatocellular carcinoma; Liver transplant; Microsimulation; Pennsylvania Medicaid

PMID:
27932263
PMCID:
PMC5459672
DOI:
10.1016/j.hjdsi.2016.11.001
[Indexed for MEDLINE]
Free PMC Article

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