Hepatocellular carcinoma (hc) death rates are rising faster than those for any other cancer, nearly doubling since the 1980s.1 only one in five people diagnosed with hc will survive 5 years after diagnosis despite the improvements in treatment.1 one of the top three contributing factors to hcc deaths is the high prevalence of hepatitis c virus (hcv) infection.1,2 the number of u.s. residents currently infected with hcv is estimated at approximately 3.5 million.3 Baby boomers account for 81% of all new HCV diagnoses, and this cohort has the highest rates of HCV-related liver transplantation secondary to HCV development.4 It has been problematic to connect to HCV-infected patients with medical care because about half of people with HCV are asymptomatic and do not seek treatment. 5.6
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The need for HCV screening has increased significantly as a result of the development of highly effective direct-acting antiviral (DAA) treatments, which can cure over 90% of patients.7 Curing HCV offers substantial health benefits and durable. including reduction in the incidence of liver cancer.7 a consensus committee of the national academies of sciences, engineering, and medicine (nasem) has proposed a strategy to decrease hcv prevalence by 2030.5 their models predict that if 260,000 patients can If treated annually, HCV incidence would be reduced by 90% relative to 2015 levels. This model assumes that all patients with chronic HCV infection would be treated, regardless of their level of fibrosis. in an effort to increase capacity to meet these treatment goals, the nasem committee recommended using primary care as a result of the limited number of specialists to meet the high demand for hcv treatment.5 moreno et al8 reported that expanding coverage to patients regardless of their level of fibrosis was highly cost-effective, saving a net societal benefit of $500 billion at a valuation of $150,000 per quality-adjusted life year. the study found that the benefits of the treatment extended beyond the immediate improvement of the patient’s health by reducing the pool of people who can spread the infection and by lowering future health care expenses related to end-stage liver disease. 8
However, treating this population presents significant challenges. For example, Texas has one of the highest liver cancer death rates in the country.1 South Texas, specifically Region 11, encompasses a 19-county area in the Rio Grande Valley and has the highest prevalence of liver cancer in the state.9 More in the course of implementing screening and treatment guidelines, significant challenges have been identified in addressing the HCC epidemic in this region. up to a third of people live in poverty, well above the state average of 17.5%, and up to a third of people do not have health insurance (state average of 24.8%).10 this population tends to have less education and less health care literacy.11 furthermore, this region is over 50,000 square miles and access to health services is limited by lack of transportation and poor proximity to care.10 all of these factors present significant challenges for the detection and treatment of hcv. There is a significant need for health policy to increase funding or reimbursement for social services in this region and regions like these in the United States.
However, even people with private insurance can experience significant cost barriers to care if they are found to have chronic HCV infection. Because screening is a recommendation from the US Preventive Services Task Force. In the US,12 HCV testing and supporting labs are covered by insurance, but treatment can be difficult to afford. it is not unusual for hcv antiviral therapies that previously cost $60,000 to $80,000 for a 12-week course of treatment to require a 20% to 30% cost-sharing responsibility on the part of the patient.13 abbvie recently launched glecaprevir /pibrentasvir (Mavyret; Abbvie, North Chicago, IL), which is significantly lower in cost than other DAAs on the market at $13,200 per month or $39,600 for a 12-week course.13 This may help lower the cost out of pocket, although the cost of treatment remains considerable, especially in a region where a significant number of people live in poverty. A study of patients seeking HCV treatment showed significant disparities in access to these medications.14 Many insurance companies, as well as government-sponsored insurers, strive to reduce spending by limiting access to these medications. up to 46% of medicaid recipients, 10% of private insurance recipients, and 5% of medicare recipients have been denied hcv treatment.14 this high cost sharing can cause significant financial toxicity for people with private insurance, and many are faced with the decision to seek treatment at significant financial risk or to withhold treatment until their liver is irreparably damaged. Unfortunately, it is easier for the uninsured to obtain DAAS because of drug assistance programs that provide medications for free.15 A change in health policy is needed to decrease out-of-pocket costs for patients insured for DAAS. .
texas health and human services report that more than 4 million people in the state rely on texas medicaid for their health insurance.16,17 there are particular concerns, however, that texas medicaid poses significant challenges to the access to hcv care. The National Viral Hepatitis Roundtable and the Center for Innovation in Health Policy and Law at Harvard Law School developed the “Hepatitis C: The State of Medicaid Access” report card for each state.17 Texas earned a low rating, receiving a d+.17 The report identified severely restricted access to HCV drugs as a cost-containment measure, citing requirements such as severe liver damage, a prescription written by or in consultation with a specialist, and 90 days of sobriety as the main barriers to access to medicines. Overall, the report cites restrictions that limit treatment to people with severe fibrosis as a major barrier to receiving HCV medications, not just in Texas but across state Medicaid programs.17
At the first restriction, as nasem emphasizes, the benefit of prevention of end-stage disease is greatly reduced or lost by restricting treatment to people who already have severe fibrosis. Although it is immediately profitable for the organization, the pool of people who can spread the infection will not decrease substantially, so this measure does not generate long-term cost savings. Legislation is needed in all state Medicaid programs to open up treatment to all infected people.
A second restriction, texas medicaid requires that a board-certified specialist must prescribe the daa.18 patients often face transportation challenges to receive specialty care as a result of the limited number of specialists in rural areas of texas . Although in South Texas there are telehealth programs such as Project Echo (Outreach for Community Health Care Outcomes),19 which helps connect primary care providers with specialists using telecommunications, most clinics serving vulnerable do not have access to this query. More funding is needed for telehealth programs because remote consultation from specialist to primary care could play a larger role for texas medicaid hcv treatment in south texas.
Finally, there are restrictive texas medicaid requirements regarding drug and alcohol addiction for HCV treatment.16 If a patient has a history of illicit drug use, the patient must have started an addiction disorder program. substance use for 6 months prior to eligibility. for treatment.16 In addition, a patient may be denied treatment if he or she consumes alcohol.16 Access to substance use disorder programs in South Texas is a significant barrier to HCV treatment due to limited availability of treatment programs and transportation issues.20 Data show no difference between high rates of sustained viral response for people who use alcohol while on DAAS and those who are abstinent.21 Physicians should press Texas Medicaid to remove this restriction. additionally, more funding is needed to support substance abuse treatment statewide.
Medical oncologists have an ethical obligation to advocate for health interventions that aid in cancer prevention, especially in settings where effective cancer treatment options are limited. Although cancer death rates are declining for almost all other types of cancer, they continue to rise for liver cancer. treatment of hcv infection could reduce the rate of hcc increase, however, the high price of curative hcv treatments creates significant barriers to patient access, especially in areas with low socioeconomic status. payers who try to control spending by treating only the sickest patients may undermine the benefit that could be achieved in hcv control and liver cancer prevention. Until these challenges are addressed through effective health policy reform in a collaborative effort between specialists and primary care physicians, not only at the local level but also at the national level, the severe impact of HCV will not be mitigated and hcv in morbidity and mortality.