Medicaid Subscription-Based Payment Models and Implications for Access to Hepatitis C Medications

Abstract

IMPORTANCE Hepatitis C virus (HCV) can be cured with direct-acting antiviral medications, but state Medicaid programs often restrict access to these lifesaving medications owing to their high costs. Subscription-based payment models (SBPMs), wherein states contract with a single manufacturer to supply prescriptions at a reduced price, may offer a solution that increases access.Whether SBPMs are associated with changes in HCV medication use is unknown. OBJECTIVE To estimate changes in Medicaid-covered HCV prescription fills after Louisiana and Washington implemented SBPMs on July 1, 2019. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study examined trends in prescription fills of Medicaid-covered direct-acting antiviral HCV medications in Louisiana and Washington after implementation of SBPMs. A synthetic control approach was used to compare changes in HCV prescription fills between states that did and did not implement SBPMs. The unit of analysis was state-quarter. Outpatient direct-acting antiviral HCV prescription fills from the Medicaid State Drug Utilization Data files were obtained from all 50 US states and the District of Columbia from January 1, 2017, to June 30, 2020. EXPOSURES Implementation of SBPMs for Medicaid-covered direct-acting antiviral HCV medications. MAIN OUTCOMES AND MEASURES Direct-acting antiviral HCV prescriptions filled per 100 000 Medicaid enrollees. RESULTSIn the year preceding SBPM implementation, the mean (SD) rate of quarterly HCV prescription fills per 100 000 Medicaid enrollees was 43.1 (8.6) prescriptions in Louisiana and 50.1 (4.1) in Washington. After SBPM implementation, the mean (SD) rate of quarterly HCV prescription fills per 100 000 enrollees was 206.0 (51.2) prescriptions in Louisiana and 53.9 (11.0) in Washington.In synthetic control models, SBPM implementation in Louisiana was associated with an increase of 173.5 (95% CI, 74.3-265.3) quarterly prescription fills per 100 000 Medicaid enrollees during the following year, a relative increase of 534.5% (95% CI, 228.7%-1125.0%). Washington did not experience a significant change in prescription fills following SBPM implementation. CONCLUSIONS AND RELEVANCEIn this cross-sectional study, Louisiana experienced substantial increases in HCV medication use among its Medicaid-enrolled population following SBPM implementation, whereas Washington did not. These differences may partially be explained by statelevel variation in SBPM implementation, historical restrictions on access to HCV medications, and responses to the COVID-19 pandemic.

Uptake of hepatitis C virus treatment in a multi‐state Medicaid population, 2013–2017

“…40 Balancing budgetary constraints with longer-term public health benefits is challenging, but some state Medicaid agencies have explored innovative payment models to manage costs to increase access to these medications, such as subscription models implemented in Washington and Louisiana. 41 Maryland has proposed a "total coverage" model, where the state receives a credit from Medicare to offset Medicaid investments in HCV treatments that could lead to Medicare savings. 42 In the absence of drug pricing reform that addresses the range of factors contributing to high drug costs, ensuring access to costly medications may require Medicaid agencies to explore these and other novel strategies.…”

“…Balancing budgetary constraints with longer‐term public health benefits is challenging, but some state Medicaid agencies have explored innovative payment models to manage costs to increase access to these medications, such as subscription models implemented in Washington and Louisiana 41 . Maryland has proposed a “total coverage” model, where the state receives a credit from Medicare to offset Medicaid investments in HCV treatments that could lead to Medicare savings 42 .…”

“…Age (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49), and 50-65 years) and gender (male/female) were obtained from Medicaid enrollment files. Race/ethnicity was not examined in this analysis due to a large percentage of missing values.…”

From COVID Vaccines to HIV Prevention:Pharmaceutical Financing and Distribution for the Public’s Health

“…The result was more than a five-fold increase in prescriptions without an increase in spending. 3 Even in the midst of the COVID pandemic, Louisiana is on track to achieve its ambitious goals. 4 What these efforts have in common is a primary focus on achieving health outcomes that go beyond successfully treating patients one by one.…”

Medicare Enters the Pharmaceutical Purchasing Business

“…States such as Louisiana and Washington paid pharmaceutical companies a fixed amount of money based on what they thought they would spend on hepatitis C drugs at existing prices, but made the payment as a fixed amount. 4 Because the overall payment was fixed, any additional use was welcome by states. States thus promoted treatment widely.…”