Removal of medicaid restrictions were associated with increased hepatitis C virus treatment rates, but disparities persist

Abstract

Despite the release of a growing number of direct-acting antivirals and evolving policy landscape, many of those diagnosed with hepatitis C virus (HCV) have not received treatment. Those from vulnerable populations are at particular risk of being unable to access treatment, threatening World Health Organization (WHO) HCV elimination goals. The aim of this study was to understand the association between direct-acting antivirals approvals, HCV-related policy changes and access to HCV virus treatment in Indiana, and to explore access to treatment by race, birth cohort and insurance type. We performed a retrospective cohort study of adults with HCV from 05/2011-03/2021, using statewide electronic health data. Nine policy and treatment changes were defined a priori. A Lowess curve evaluated treatment trends over time. Monthly screening and treatment rates were examined. Multivariable logistic regression explored predictors of treatment. The population (N = 10,336) was 13.4% Black, 51.8% was born after 1965 and 44.7% was Medicaid recipients. Inflections in the Lowess curve defined four periods: (1) Interferon + DAA, (2) early direct-acting antivirals, (3) Medicaid expansion/ optimization and (4) Medicaid restrictions (fibrosis/prescriber) removed. The largest increase in monthly treatment rates was during period 4, when Medicaid prescriber and fibrosis restrictions were removed (2.4 persons per month [PPM] in period 1 to 72.3 PPM in period 4, p < 0.001; 78.0% change in slope). Multivariable logistic regression analysis showed being born after 1965 (vs. before 1945; OR 0.69; 95% 0.49-0.98) and having Medicaid (vs. private insurance; OR 0.47; 95% CI 0.42-0.53), but not race was associated with lower odds of being treated. In conclusion, DAAs had limited impact on HCV treatment rates until Medicaid restrictions were removed. Additional policies may be needed to address HCV treatment-related age and insurance disparities.

Vital Signs: Hepatitis C Treatment Among Insured Adults — United States, 2019–2020

“…Removing these eligibility restrictions is necessary, but not sufficient. Addressing other barriers, including burdensome preauthorization requirements as well as integrating routine screening and treatment into primary care and other settings where persons with hepatitis C receive services, could also increase coverage (15)(16)(17).…”

“…Interventions to increase access to hepatitis C treatment with DAA agents include removing policies limiting patient eligibility based on fibrosis stage or sobriety, requiring treatment through specialists, and requirement for preauthorization ( 11 , 17 ). Universal hepatitis C screening coupled with simplified treatment protocols should be integrated into primary care and other settings serving persons with hepatitis C, and the number of primary care providers treating hepatitis C expanded, especially Medicaid providers serving populations disproportionately affected by hepatitis C. Increasing access to hepatitis C treatment to all populations, regardless of insurance type, is essential to reducing viral hepatitis–related disparities and achieving hepatitis C elimination.…”

Health disparities in chronic liver disease

“…National and state health care policy changes and local initiatives have enhanced efforts to improve access to DAA therapies for socially disadvantaged populations. Removal of Medicaid restrictions on DAA therapy including fibrosis, sobriety, and prescriber requirements led to increased treatment rates in a large Indiana cohort; however, patients with Medicaid still had less access than those with private insurance, suggesting that additional efforts at the policy level will be needed to promote health equity 83…”

Hepatitis C Screening and Antibody Prevalence Among Newly Arrived Refugees to the United States, 2010–2017

“…Linkage to care is an important next step for those with chronic hepatitis C. It is important to train healthcare providers on testing procedures and asking patients about hepatitis C risk factors [19]. Compared to private health insurance, Medicaid was associated with lower odds of being treated [20,21]. However, treatment rates improved after Medicaid removed the specialist provider and advanced fibrosis restriction requirements for treatment.…”