Hepatitis C virus (HCV) infections continue to be a serious public health threat in the United States. Accordingly, in recent years, several states have developed elimination plans to address and prevent the severe consequences of HCV. Particularly, states have turned to innovative payment models as a part of HCV elimination strategies to increase access to treatment services.
In July 2021, the O’Neill Institute for National and Global Health Law released an analysis of innovative payment models in Louisiana, Washington, and Michigan as a means to secure hepatitis C medication for people receiving state-sponsored health care. In our analysis, we documented the similarities and contrasts between these emerging innovative payment models and distinguished their expenditure cap models from true subscription models. We concluded that payment models are only one tool in eliminating HCV infections; HCV elimination strategies should complement these payment models with equal prioritization of upstream interventions, such as HCV screening and prevention.
Recent findings in the Journal of the American Medical Association (JAMA) support our reasonings and recommendations on the effectiveness of subscription-based payment model (SBPM) implementation in Louisiana and Washington.
In their cross-sectional study, the authors employed a synthetic control approach to track differences between Louisiana’s and Washington’s HCV prescription fills based on their SBPMs, using data between January 2017 and June 2020 from the Medicaid State Drug Utilization Data. While Louisiana experienced a 534.5% increase in HCV prescription fills following the SBPM implementation, there were no significant changes in prescription fills for Washington. This significant increase in Louisiana’s HCV prescription fills could be attributed to their removal of liver damage and sobriety restrictions from Medicaid. However, this dramatic change was not visible in Washington, because the state removed these Medicaid treatment restrictions before the duration of the study.
HCV Elimination Requires Investments in Screening, Treatment, and Prevention
Through their analysis on the effectiveness of SBPM, the authors underscore that “removing liver damage and other access restrictions may be necessary but not sufficient to dramatically increase use of HCV medications.” There is no doubt that Medicaid restrictions on liver damage and sobriety status serve as a major barrier to HCV treatment. Some state Medicaid programs continue to impose liver damage requirements for HCV treatment eligibility, bar patients with a history of alcohol or substance use, and/or limit the number of specialists who can prescribe a cure. These restrictions disproportionately impact minoritized communities, such as persons who inject drugs and/or LGBTQIA+ communities — those who are more likely to report higher substance use due to pervasive discrimination.
However, removing Medicaid restrictions is not enough.
About 51% of people living with HCV remain unaware of their HCV status. As a result, they are more likely to transmit their infection, more likely to suffer from severe consequences of HCV, and less likely to benefit from early and life-saving treatment. Therefore, prioritizing comprehensive screening services to timely diagnose HCV is an urgent step needed to facilitate both HCV treatment and prevention.
At the same time, integrating community engagement within HCV elimination is critical. Barriers within linkage to care, patient navigation, and screenings — compounded by distrust of healthcare providers and stigma — limit access to treatment. These barriers disproportionately impact minoritized communities that already bear a higher HCV burden. Working with community organizations can effectively provide prevention education and services, such as vaccinations, screenings, linkage to care, and patient navigation with the help of trusted messengers — thereby, alleviating barriers of distrust and stigma.
We cannot eliminate HCV without screening, treating, and curing all existing cases, and preventing future occurrences. Thus, it is critical that HCV elimination strategies are designed to be systemic, collaborative, and community-based approaches that meaningfully invest in robust and upstream interventions.
Prashasti Bhatnagar is a research assistant at the O’Neill Institute and is a fourth-year J.D.-MPH candidate at Georgetown University Law Center and Johns Hopkins Bloomberg School of Public Health.