In just five years, Hepatitis C has gone from being a difficult-to-treat chronic condition to one that is easily cured with a short course of medication. medical advances have now created the possibility of eliminating hcv transmission, but they also present a new challenge for the health system: how to identify people who carry the hepatitis c virus (hcv) and how to pay for life-saving treatments . This issue summary reviews recent evidence on the cost-effectiveness of screening and treatment strategies, and advocates for universal, one-time screening for HCV for all American adults.
more than 3.5 million people in the united states are chronically infected with hcv, and about 19,000 die each year from hcv-related illnesses. Hepatitis C is one of the leading causes of liver cancer and the leading cause of liver transplants; Baby boomers (people born between 1945 and 1965) account for three-quarters of all hepatitis C-related cases and deaths. The incidence of HCV infection is increasing among younger people, primarily due to injection drug use.
A high proportion (45% to 85%, according to the CDC) are unaware they have the disease and can infect others. In 1998, the CDC recommended HCV testing only for people at high risk, such as a history of injection drug use or exposure to blood products before effective screening, a strategy that left most people unaware of their status. Due to a disproportionately high prevalence of hepatitis C among baby boomers, the CDC increased its recommendations in 2012 to include a single test of all people in that birth cohort. In 2013, the United States Preventive Services Task Force (USPSTF) gave this recommendation a “B” rating, meaning the screening would be covered by insurance with no cost-sharing under the Affordable Care Act. A few months later, the first effective direct-acting antivirals hit the market, offering a cure rate of nearly 90% and the potential to eliminate HCV transmission. However, that potential was limited by the initial price ($84,000 per course of treatment) and the budgetary impact on public payers, such as Medicaid and corrections departments, which cover a disproportionate number of people with HCV. in response, these payers have limited treatments for patients with advanced disease or use other restrictions.
In an era of effective treatments, identifying people with hepatitis C takes on even greater urgency as the initial step in a “care cascade” leading to cure and possible elimination of HCV transmission. But the combination of a prevalent disease with an expensive cure and the burden of treatment on public budgets creates a significant economic barrier to HCV care.
new detection guidelines have an impact
In a study of the effects of new CDC testing guidelines, Barocas, Wang, White, et al. (2017) found an “immediate and sustained impact of hepatitis c testing guidelines in clinical practice.” analyzed hepatitis C detection rates in 2.8 million commercially insured adults before and after the recommendations, using a cohort born after 1965 (but at least 18 years old) as a comparison group. as shown below, they found a 49% increase in detection rates among the birth cohort after publication of the recommendations, but no increase among the comparison cohort.
Rodriguez, Rubenstein, Linas, et al. (2018) confirmed the effects of CDC and USPSTF screening recommendations in an observational study of 665,000 adults who visited Kaiser Permanente clinics between 2003 and 2014. They documented a consistent increase in screening over time, with a jump remarkable in detection after uspstf recommendations. As shown below, HCV detection increased 29% between 2013 and 2014, compared to 4% between 2012 and 2013.
Adjusting for other factors, the authors found that screening in the birth cohort more than doubled, which was a 20% greater increase than screening in other age groups. The authors note that insurance coverage for screening and the availability of effective treatment after the USPSTF recommendation may have led to a greater increase in screening than screening guidelines alone.
hcv treatment provides good value
Despite its cost, HCV treatment offers good value for money, expressed in terms of cost-effectiveness. In a recent review, Linas and Nolen (2018) note that most studies in the last five years find HCV treatment to be within the generally accepted value of $100,000 per quality-adjusted life year (QALY). point out that these studies do not reflect the price declines that have occurred in the past 1-2 years, but the substantial cost burden remains. A critical question is not whether to treat HCV patients, but when to do so, because of the significant time lag between infection and disease. Facing costs that could overwhelm fixed budgets, many payers have restricted treatments to those with advanced illnesses (for example, liver cirrhosis) or those who do not use alcohol or drugs.
In one study, Linas, Morgan, Pho, et al. (2017) modeled the cost-effectiveness and budget impact of different treatment strategies, from the payer’s point of view. found that the five-year budget impact of HCV treatment was high ($1-$2.3 billion per 10,000 HCV-infected patients, depending on the treatment regimen). confirmed that treatment strategies are cost-effective; Compared to treating more advanced disease alone, early treatment of disease is likely to be cost-effective and may even be cost-saving, avoiding many years of decreased quality of life and increased health care costs associated with hcv infection. they conclude that payers seeking to control costs would be better off negotiating prices in a newly competitive drug market rather than restricting treatment. treating all people infected with hcv with the least expensive direct-acting antiviral would be the cost control strategy that produces the best results.
There is some evidence that public payers are relaxing their eligibility restrictions (such as severity of illness and abstinence from substance use) for hepatitis c treatment. Kapadia, Jeng, Schackman, and Bao (2017) analyzed Medicaid drug use data from 2014 to 2016 and found that states that loosened their restrictions had a faster increase in direct-acting antiviral prescriptions than states that kept them in place. its restrictions. The 31 states that implemented Medicaid expansion under the Affordable Care Act experienced a much larger increase in utilization than states that did not.
what is the optimal hcv detection strategy?
using a simulation model, barocas, tasillo, eftekhari yazdi, et al. (2018) compared the clinical costs, outcomes, and cost-effectiveness of four HCV testing strategies: the existing one (single test for all people born between 1945 and 1965); single test for adults age 40 or older, 30 or older, or 18 or older. all strategies included testing targeted at people at higher risk, such as those who inject drugs. as shown below, expanded age-based strategies increased identification and lifetime cure rates.
figure 3. continuous hcv care throughout life, by strategy
The authors estimate that the existing strategy would identify 71% of all people infected with HCV and that 44% of them would be cured in their lifetime. Compared to existing screening tests, an age 18+ strategy would result in the identification of an additional 256,000 people, an additional 28,000 cures, and 4,400 fewer cases of hepatocellular liver cancer over the lifetime of this age group. for people born outside of the baby boomer cohort, case detection rates would increase from 74% to 85% and cure rates would increase from 49% to 61%. overall, this would represent a 21% reduction in liver-attributable mortality and an increase in life expectancy from 67.2 to 68.2 years among the affected population.
all strategies reduced costs related to the management of chronic HCV and advanced liver disease. the cost of the hcv test in the existing strategy amounted to $2,500 per diagnosed case; in the strategy for those over 18 years of age, the cost of the tests increased to $4,400 per diagnosed case. the 18+ strategy was cost-effective, providing the highest quality-adjusted life expectancy and the lowest cost/qaly gained ($28,000 per qaly).
Figure 3 above also illustrates the importance of linking identified patients to care in an overall strategy that yields high cure rates. schackman, gutkind, morgan and others. (2018) modeled the cost-effectiveness of screening-treatment linkages in a population of high-risk patients in a methadone maintenance treatment (MMT) program, using data from a randomized trial. the study estimated the costs and outcomes of on-site hcv screening and education or active hcv screening, education and care coordination, compared with intervention. the model took into account the probability of reinfection if patients engaged in injecting drug use risk behavior.
As shown in Figure 4, on-site assessment and education resulted in a projected 35% linking to care within six months and 31% achieving cure (sustained virologic response). adding an active coordination component resulted in 60% bonding and 54% healing. the active care coordination intervention was cost-effective at $24,600/qaly gained, compared with no intervention, and $76,500/qaly gained, compared with screening and education alone. therefore, the authors conclude that hcv care coordination interventions that include screening, education, and active linkage to care in mmt settings are likely cost-effective at a conventional threshold of $100,000/qaly.