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Assessing the Past, Present, and Future of Treatment of Hepatitis C in the D.C. Medicaid Population Open Access

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Starting in late 2013, new direct-acting antiviral medicines (DAAs) offered the chance of a cure for chronic hepatitis C virus (HCV) infection. In clinical trials, DAAs helped more than 90% of patients achieve sustained viral response (SVR), commonly considered to be a cure that will stop progression of related liver disease and prevent transmission of the virus to others. Prices for these medicines are now around $20,000 per treatment after discounts from manufacturers, due to competition. In late 2016, the medical director for D.C. Medicaid asked what it would take to eradicate hepatitis C in the city. This dissertation focused on that question for Medicaid alone, to inform policy discussions and identify next steps. I profiled beneficiaries with chronic HCV infection based on medical claims from 2014-2016; interviewed medical providers and policymakers to learn more about their decision-making processes and to identify opportunities to expand treatment, as well as potential barriers; and created an Excel-based Markov model that estimates outcomes and costs under different scenarios. Only 799 individuals, about 10% of the D.C. Medicaid beneficiaries identified as having chronic HCV infection, received treatment with DAAs in 2014-2016. Providers and policymakers are committed to treating this population, but treatment rates remained low through 2018. I estimate that roughly 80% of Medicaid beneficiaries with chronic HCV had not been treated at the start of 2019. Beneficiaries with chronic HCV infection often have other physical, mental, and behavioral health conditions that might keep them from seeking treatment for an often-asymptomatic HCV infection. They often miss scheduled appointments and/or are lost to follow-up. Most live east of the Anacostia River, where there are fewer providers. Even if they engage in care, government or health plan policies might discourage or prevent individuals with low levels of liver damage from getting prior authorization for treatment. Broader use of DAAs in D.C. Medicaid will allow more people to achieve SVR, potentially decreasing future healthcare costs for some and saving lives. A moderate (50%) increase in treatment rates among those with low liver damage could enable about 300 additional patients to achieve SVR over 10 years, at a net cost of $6.1 million. A 50% increase in treatment rates among those with moderate liver damage could enable more than 500 additional patients to achieve SVR over 10 years, keep more than 160 from severe liver damage, and avoid 19 early deaths. The net cost of the second scenario is $6.5 million, a smaller increase per person achieving SVR because curing those with moderate liver damage is more likely to avoid high healthcare costs.The District must weigh the upfront costs of expanding use of DAAs against uncertain long-term benefits and inherent budget limitations. I recommend that D.C. develop a more complete profile of Medicaid beneficiaries with HCV infection; work toward universal screening and sustained monitoring of at-risk populations; collaborate with key stakeholders to develop policies, practices, and tools to engage beneficiaries in care; and reduce prior authorization requirements that might deter or prevent treatment when beneficiaries and health care providers are ready.

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