Economic and Public Health Impacts of Policies Restricting Access to Hepatitis C Treatment for Medicaid Patients.
Interferon-free hepatitis C treatment regimens are effective but very costly. The cost-effectiveness, budget, and public health impacts of current Medicaid treatment policies restricting treatment to patients with advanced disease remain unknown.



To evaluate the cost-effectiveness of current Medicaid policies restricting hepatitis C treatment to patients with advanced disease compared with a strategy providing unrestricted access to hepatitis C treatment, assess the budget and public health impact of each strategy, and estimate the feasibility and long-term effects of increased access to treatment for patients with hepatitis C.



Using a Markov model, we compared two strategies for 45- to 55-year-old Medicaid beneficiaries: 1) Current Practice-only advanced disease is treated before Medicare eligibility and 2) Full Access-both early-stage and advanced disease are treated before Medicare eligibility. Patients could develop progressive fibrosis, cirrhosis, or hepatocellular carcinoma, undergo transplantation, or die each year. Morbidity was reduced after successful treatment. We calculated the incremental cost-effectiveness ratio and compared the costs and public health effects of each strategy from the perspective of Medicare alone as well as the Centers for Medicare & Medicaid Services perspective. We varied model inputs in one-way and probabilistic sensitivity analyses.



Full Access was less costly and more effective than Current Practice for all cohorts and perspectives, with differences in cost ranging from $5,369 to $11,960 and in effectiveness from 0.82 to 3.01 quality-adjusted life-years. In a probabilistic sensitivity analysis, Full Access was cost saving in 93% of model iterations. Compared with Current Practice, Full Access averted 5,994 hepatocellular carcinoma cases and 121 liver transplants per 100,000 patients.



Current Medicaid policies restricting hepatitis C treatment to patients with advanced disease are more costly and less effective than unrestricted, full-access strategies. Collaboration between state and federal payers may be needed to realize the full public health impact of recent innovations in hepatitis C treatment.
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA. Electronic address: apc10@pitt.edu.
Alexis P
AP
Chidi
University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
Cindy L
CL
Bryce
University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
Julie M
JM
Donohue
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA.
Michael J
MJ
Fine
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Douglas P
DP
Landsittel
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA.
Larissa
L
Myaskovsky
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA.
Shari S
SS
Rogal
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA.
Galen E
GE
Switzer
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA.
Allan
A
Tsung
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Kenneth J
KJ
Smith
D015081:2-Naphthylamine; D000813:Anilides / Q000191:economics / Q000627:therapeutic use; D000998:Antiviral Agents / Q000191:economics* / Q000627:therapeutic use; D001562:Benzimidazoles / Q000191:economics / Q000627:therapeutic use; D002219:Carbamates / Q000191:economics / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D003521:Cyclopropanes; D004338:Drug Combinations; D005260:Female; D005449:Fluorenes / Q000191:economics / Q000627:therapeutic use; D017320:HIV Protease Inhibitors / Q000191:economics / Q000627:therapeutic use; D006297:Health Services Accessibility / Q000191:economics*; D016174:Hepacivirus / Q000235:genetics; D006526:Hepatitis C / Q000188:drug therapy / Q000191:economics*; D006801:Humans; D047029:Lactams, Macrocyclic; D047028:Macrocyclic Compounds / Q000191:economics / Q000627:therapeutic use; D008297:Male; D008390:Markov Chains; D008484:Medicaid / Q000191:economics*; D008875:Middle Aged; D011392:Proline / Q000031:analogs & derivatives; D019438:Ritonavir / Q000191:economics / Q000627:therapeutic use; D012720:Severity of Illness Index; D000069474:Sofosbuvir; D013449:Sulfonamides / Q000191:economics / Q000627:therapeutic use; D014481:United States; D014498:Uracil / Q000031:analogs & derivatives / Q000191:economics / Q000627:therapeutic use; D014542:Uridine Monophosphate / Q000031:analogs & derivatives / Q000191:economics / Q000627:therapeutic use; D014633:Valine
D000813:Anilides; D000998:Antiviral Agents; D001562:Benzimidazoles; D002219:Carbamates; D003521:Cyclopropanes; D004338:Drug Combinations; D005449:Fluorenes; D017320:HIV Protease Inhibitors; D047029:Lactams, Macrocyclic; D047028:Macrocyclic Compounds; D013449:Sulfonamides; C000595958:ledipasvir, sofosbuvir drug combination; C586094:ombitasvir; D014498:Uracil; D011392:Proline; D015081:2-Naphthylamine; C588260:dasabuvir; D014542:Uridine Monophosphate; D014633:Valine; D019438:Ritonavir; C585405:paritaprevir; D000069474:Sofosbuvir
Medicaid; Medicare; cost-effectiveness; hepatitis C; interferon-free