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Harvard Law School & National Viral Hepatitis Roundtable Announce Preliminary Findings in Project to Grade Medicaid Access to Hepatitis C Treatment
Analysis from ‘Hepatitis C: The State of Medicaid Access’ Reveals Some Improvement, But Discrimination Persists in Many States; Medicaid Directors Put on Notice to Confirm Restrictions & Any Plans to Comply with CMS Guidance
SAN FRANCISCO, CA & BOSTON, MA (Nov. 14, 2016) – The National Viral Hepatitis Roundtable (NVHR) and the Center for Health Law and Policy Innovation of Harvard Law School (CHLPI) today announced the preliminary findings of Hepatitis C: The State of Medicaid Access – a comprehensive assessment of state Medicaid programs’ discriminatory restrictions on curative treatments for hepatitis C, the nation’s deadliest blood-borne disease. The full report, with accompanying rankings and state-by-state report cards, will be released in early 2017.
Preliminary analysis from Hepatitis C: The State of Medicaid Access – announced today at The Liver Meeting® in Boston – shows some improvements in both state Medicaid program transparency and access since 2014, yet also demonstrates that most states continue to impose discriminatory restrictions which contradict guidance from the Centers for Medicare & Medicaid Services (CMS), as well as guidance from AASLD and the Infectious Disease Society of America. Also concerning is that nearly half of states may not be making all restrictions publicly available. To read the preliminary findings in full, visit http://www.chlpi.org/stateofhepc. (NOTE: Colorado data is not up-to-date.
The Hepatitis C: The State of Medicaid Access final report will grade and rank each state, as well as the District of Columbia, according to overall “state of access,” as determined by curative treatment restrictions related to three areas: 1) liver disease progression (fibrosis) requirements, 2) sobriety requirements, and 3) provider limitations. The report will also provide the first-ever national assessment of Medicaid Managed Care Organization (MCO) coverage of curative HCV treatments.
“With this announcement, we are officially putting state Medicaid programs on notice,” said Ryan Clary, executive director of NVHR. “State Medicaid directors need to make all treatment criteria publicly available and detail any plans to comply with CMS guidance, which clearly states that coverage policies cannot block hepatitis C patients’ access to effective, clinically appropriate and medically necessary treatments. It is unacceptable to have discriminatory restrictions that conflict with the CMS guidance or with established hepatitis C treatment standards. Our final report will grade and rank each state’s access criteria, and states that continue to discriminate will be called out.”
Robert Greenwald, clinical professor of Law at Harvard Law School and the faculty director of CHLPI, commented, “There is some good news and some bad news here. In comparing our current findings to a 2014 hepatitis C treatment access report I published with a team of researchers in the Annals of Internal Medicine, we find that many states have reduced discriminatory practices. Disappointingly, we also find that restrictions persist in many states, despite our hope that with established treatment guidelines, clear guidance from CMS, and successful litigation, we would see far more progress in eliminating discriminatory hepatitis C treatment restrictions.”
Greenwald continued, “While I think there is a general consensus emerging that discriminatory hepatitis C treatment restrictions will eventually be removed, voluntarily or by courts, we must hold state Medicaid programs accountable now, as some states still see a budgetary incentive in dragging their feet as long as possible.”
Key preliminary findings of the Hepatitis C: The State of Medicaid Access project include:
• Transparency surrounding state Medicaid program hepatitis C treatment access restrictions has increased overall since 2014;
• Access to hepatitis C treatment has improved since 2014 – primarily in the reduction/elimination of liver disease or fibrosis restrictions, while access restrictions related to sobriety and prescriber limitations have decreased to a far lesser extent; and
• While there are some MCOs with low levels of restrictions, many follow their states’ fee-for-service (FFS) Medicaid restrictions, while others impose more onerous restrictions in violation of federal law.
NVHR and CHLPI are asking state Medicaid directors to confirm all current treatment restrictions for curative hepatitis C treatments, and to detail any plans to broaden access and comply with CMS guidance. Medicaid officials may contact Ryan Clary (firstname.lastname@example.org) and Robert Greenwald (email@example.com).
States for which fibrosis, sobriety, and/or provider requirements remain unknown include: Alabama, Alaska, Arkansas, California, Delaware, Georgia, Indiana, Kentucky, Maine, Michigan, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, South Carolina, Tennessee Utah, Washington, and Wyoming.
According to the Centers for Disease Control and Prevention, hepatitis C affects approximately 3.5 million Americans. For the past several decades, hepatitis C treatment regimens revolved around painful interferon injections, which are vastly ineffective at managing the disease on an individual level and the epidemic on a public health level. In contrast, the new generation of treatments offer cure rates of near 100 percent with minimal side effects, providing hepatitis C patients with an unprecedented chance to live virus-free – and avoid liver failure, cancer-causing cirrhosis, liver transplants, and other health complications.
About the National Viral Hepatitis Roundtable (NVHR)
The National Viral Hepatitis Roundtable is a broad coalition working to fight, and ultimately end, the hepatitis B and hepatitis C epidemics. We seek an aggressive response from policymakers, public health officials, medical and health care providers, the media, and the general public through our advocacy, education, and technical assistance. NVHR believes an end to the hepatitis B and C epidemics is within our reach and can be achieved through addressing stigma and health disparities, removing barriers to prevention, care and treatment, and ensuring respect and compassion for all affected communities. For more information, visit www.nvhr.org.
About the Center for Health Law and Policy Innovation of Harvard Law School (CHLPI)
The Center for Health Law and Policy Innovation of Harvard Law School (CHLPI) advocates for legal, regulatory, and policy reforms to improve the health of underserved populations, with a focus on the needs of low-income people living with chronic illnesses. CHLPI works to expand access to high-quality healthcare; to reduce health disparities; and to promote more equitable and effective healthcare systems. CHLPI is a clinical teaching program of Harvard Law School and mentors students to become skilled, innovative, and thoughtful practitioners as well as leaders in health and public health law and policy. For more information, visit http://www.chlpi.org.
The American Association for the Study of Liver Diseases (AASLD) Liver Meeting took place in Boston, Massachusetts. The Liver Meeting is attended by more than 9,000 clinicians and researchers working to address liver diseases – including hepatitis B and C. This is a wonderful opportunity to encourage this important group of stakeholders to engage in national advocacy efforts. Denver-based Liver Health Connection is attending for Team HepC.
Board Prep Practice Questions | Clinical Liver Disease
Clinical Liver Disease (CLD) is an official digital learning resource of The American Association for the Study of Liver Diseases. This interactive, up-to-date source of education is designed for physicians and healthcare providers caring for the patient with liver disease.CLD offers a series of board-style question banks designed to help you determine which articles, videos, audiocasts, and issues are most useful to your practice.
Several states require that direct-acting antiviral medications for hepatitis C virus infection for Medicaid beneficiaries be prescribed by “specific provider types” — including infectious disease specialists, gastroenterologists, hepatologists and liver transplant specialists, according to CMS.
Infectious Disease News spoke with Stacey B. Trooskin, MD, PhD, director of viral hepatitis programs at Philadelphia Fight, about this specific Medicaid restriction, and whether specialized medication prescriptions from primary care providers should be covered by Medicaid.
If a provider is well-versed in the data and the literature and has experience treating HCV, it is in public health’s best interest to allow that provider to prescribe specialized medications.
This is particularly important in a resource-limited setting. For example, in rural environments there are often not enough specialists to provide subspecialty services and prescribe HCV medications to those in need. In those circumstances, it is critical that primary care physicians become trained in prescribing these medications, thereby making curative treatment accessible to patients living in rural environments.
There is definitely a need to expand treatment. We have seen the success of these models, particularly the ECHO model — Sanjeev Arora, MD, has published extensively on the success of PCPs providing HCV treatments in resource-limited settings with guidance and mentoring from subspecialty experts. This is an excellent way to train PCPs to become comfortable with using direct-acting agents.
- Arora S, et al. New Engl J Med. 2011;doi:10.1056/NEJMoa1009370.
Disclosure: Trooskin reports receiving grant funding from and serving in advisory positions for Gilead Sciences.
*Photo courtesy of Lorelei Narvaja
The Los Angeles Department of Health Services will start approving hepatitis C drugs for active IV drug users, the department’s chief medical officer has told KPCC. Until now, the department had withheld approval for anyone who had not been drug-free for at least six months.
The policy change comes after KPCC reported in August that L.A. County’s guidelines regarding IV drug users were more restrictive than those of the state’s Medi-Cal program.
Most people become infected with hepatitis C by sharing needles or other IV drug equipment. Acknowledging this, Medi-Cal expanded its treatment guidelines last year to include active IV drug among those considered eligible for hepatitis C drugs. Medi-Cal covers the cost of drugs for this population.
This summer, Dr. Hal Yee, the Department of Health Services’ chief medical officer, defended the county’s decision to not provide hepatitis C treatment to IV drug users.
“We believe it is likely that patients who are not using drugs are more likely to complete the treatment than people who are actively using illicit drugs,” Yee said at the time. He said very few IV drug users had requested hepatitis C treatment.