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Less than one-third of people diagnosed with hepatitis C virus (HCV) infections receive a treatment that cures nearly all cases of the disease, according to a new study from the Centers for Disease Control and Prevention. diseases (cdc). this treatment gap exists for people with private insurance and coverage through medicare or medicaid.

Direct-acting antiviral (DAA) treatment, recommended for most people with HCV infection, saves lives, prevents transmission and saves costs, the CDC says. Eight to 12 weeks of such treatment is recommended to cure 95% or more of HCV cases, but it is expensive. When it was first available in 2014, a course of treatment cost up to $94,500, though it can now be substantially less expensive thanks to the availability of competing drugs and generic versions.

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Although treatment costs remain substantial, the authors noted that research indicates that “treating all eligible patients without restriction would result in a substantial reduction in subsequent negative clinical outcomes, decreasing the proportion of total costs attributable to future care and generating considerable cost”. savings.”

More than 2 million American adults have HCV infection, causing about 14,000 deaths each year. The incidence of new infections continues to rise, with the highest rates of new infections occurring in adults under the age of 40, most commonly spread through injection drug use, fueled by the nation’s opioid crisis.

chronic hcv infection can lead to cirrhosis and liver cancer, and when symptoms do occur, they are often a sign of advanced liver disease that could have been prevented with prompt daa treatment. Also, because there is no vaccine for HCV, treating and curing people with the infection is an important way to slow the spread of new infections.

The study found that treatment rates are low overall, but vary by age and insurance payer.

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daa treatment initiation within 1 year of hcv diagnosis among people continuously enrolled in medicaid, medicare, or private insurance was 23% for those on medicaid, 28% for medicare beneficiaries, and 35% for those with insurance private. Among patients who received treatment, approximately 84% of private insurance beneficiaries began treatment within 180 days of diagnosis, compared to 75% of Medicaid beneficiaries and 77% of Medicare beneficiaries.

Compared with adults ages 50 to 59, adults younger than 40 years (a group that also has the highest rates of new HCV infections) were less likely to start DAA, regardless of type for sure.

Within medicaid, compared to white or asian beneficiaries, black or other people were less likely to receive daa treatment within a year of diagnosis. timely treatment was also less likely among people enrolled in medicaid plans in states that imposed restrictions before authorizing daa treatment, such as requiring patients to have liver fibrosis, sobriety, or abstinence from alcohol or drugs for at least 1 month, or a prescription by or in consultation with a specialist.

Only about 1.2 million people started DAA treatment between 2014 and 2020, which remains well short of the national elimination goal of treating all people diagnosed with HCV and reducing new infections by a 90% and HCV deaths by 65% ​​by 2030. Although current costs are considerably lower than when these drugs first became available in 2014, cost could still be a major factor in why more people would benefit of the treatment they do not receive.

for example, a new report from the u.s. department of health and human services office of the inspector general (oig) found that medicare beneficiaries with medicare part d plans, outpatient prescription drug coverage offered to medicare beneficiaries by private companies known as part d plan sponsors—are much less likely to receive low-cost, authorized generic versions of 2 brand-name hcv drugs (epclusa and harvoni) or other widely used low-cost HCV drugs compared to higher-cost ones. in 2020, some part d plans did not cover generic hcv drugs, limiting access to less expensive options, and medicare beneficiaries were also less likely to use other lower-cost brand-name options in 2020 compared with Medicaid recipients.

manufacturer rebates reduced overall part d spending for higher-cost hcv drugs. However, such rebates only lower the cost of a drug for Part D sponsors and pharmacy benefit managers (in exchange for favoring the manufacturer’s drug over competing therapies on plan formularies), and “provided little relief.” beneficiaries or the Medicare program,” the report found.

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The structure of the Part D program “may lead plan sponsors to prefer higher-cost versions,” the OIG report notes, resulting in beneficiaries paying thousands more out of pocket and Medicare paying million more than if generic drugs and other less expensive options were used. the oig recommended that the centers of medicare & Medicaid services encourage Part D plans to increase access to and use of licensed HCV generics and pursue strategies such as physician and pharmacy education to increase use of low-cost HCV therapies.

for their part, the cdc authors also suggested measures to increase access to treatment regardless of insurance type, such as removing eligibility restrictions and prior authorization requirements and providing treatment in places where patients already receive services, such as primary care clinics, community clinics, syringe service programs, substance use treatment centers, and correctional facilities. In addition, they said that treatment should be provided in as few visits as possible and called for expanding the number of primary care physicians who can treat HCV infection.

“People shouldn’t have to jump through hoops to access cost-effective, life-saving treatment,” Carolyn Wester, MD, mph, director of the CDC’s division of viral hepatitis, said in a statement. “removing barriers to treatment is a critical step, as is increasing screening for hepatitis c.”

Published: August 16, 2022. doi:10.1001/jamahealthforum.2022.3414

open access: This is an open access article distributed under the terms of the cc-by license. © 2022 stephenson j. jama health forum.

Corresponding Author: Joan Stephenson, PhD, Contributing Editor, Jama Health Forum (joan.stephenson@jamanetwork.org).

Conflict of interest disclosures: none reported.

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