Back HCV Policy & Advocacy AASLD 2015: Almost Half of U.S. Medicaid Recipients Denied Funding for Hepatitis C Treatment

AASLD 2015: Almost Half of U.S. Medicaid Recipients Denied Funding for Hepatitis C Treatment

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Around 1 in 6 people with hepatitis C in 4 U.S. states had their prescriptions for direct-acting antivirals for hepatitis C refused by private insurers, and almost half of Medicaid recipients were denied reimbursement in 2014 and early 2015, according to findings presented this week at the 2015 AASLD Liver Meeting in San Francisco.

[Produced in collaboration with Aidsmap.com]

Restrictions on Medicaid funding of direct-acting antiviral treatment by state governments in the U.S. has led the Centers for Medicare & Medicaid Services to write to state Medicaid directors to remind them that they are expected to cover new interferon-free antiviral therapies for hepatitis C without undue restrictions.

Access to direct-acting antiviral treatment may be restricted by insurers through medical criteria -- such as restricting treatment to people with advanced fibrosis -- or by applying requirements such as abstinence from alcohol or injection drug use. Insurers may also delay decisions about treatment, potentially risking a worsening of liver damage or even death.

The extent to which payers -- including private insurers, the publicly-funded Medicare system for people over 65 and disabled people, and the publicly-funded Medicaid system for people with low incomes or special needs -- restrict access to hepatitis C treatment was investigated by researchers from Assistant Professor of Medicine Vincent Lo Re from the University of Pennsylvania and colleagues. The researchers were particularly interested to find out whether Medicaid recipients faced greater difficulties in obtaining approval for treatment.

The study used data supplied by Burman's Pharmacy, looking at all hepatitis C medication prescriptions in 4 states -- Delaware, Maryland, New Jersey, and Pennsylvania -- between November 1, 2014 and April 30, 2015. The researchers evaluated what proportion of prescriptions submitted for insurer approval by the pharmacy were refused, the reason for refusal, and how long it took for prescriptions to be approved. These outcomes were assessed according to the type of insurer (private insurance, Medicare, or Medicaid).

During the study period 2321 people presented prescriptions for direct-acting antivirals which were subsequently submitted to an insurer and were eligible for analysis. The study excluded people with HCV genotypes 4-6, people whose medication had already been authorized prior to the pharmacy visit, uninsured people, and those who were not permitted to use Burman's Pharmacy by their insurer. The majority of people presenting prescriptions were covered by Medicare (800) or Medicaid (517), while 1025 people were privately insured. Most Medicaid recipients were receiving care through a Medicaid managed care plan.

Unsurprisingly, Medicare recipients were significantly older than other insurance groups, and Medicare and Medicaid recipients were more likely to be African-American (29% and 33% respectively, compared to 21% of privately insured), and to have cirrhosis (35% and 32% respectively, compared to 26% of the privately insured).

The vast majority of prescriptions were for sofosbuvir/ledipasvir (Harvoni) (80% of Medicaid and 86% of other insured persons) or for sofosbuvir (Sovaldi) plus ribavirin (11% of Medicaid).

Overall, 16% of prescriptions were refused. Recipients of Medicaid were significantly more likely to be refused -- 46% of Medicaid recipients were refused reimbursement, compared to 5% of Medicare recipients and 10% of the privately insured. Medicaid recipients were 10 times more likely to be refused reimbursement when compared to the privately insured.

Of those refused, lack of data to determine medical need was the most common reason, accounting for almost half of all Medicaid refusals. Around one-third of Medicaid denials were on the grounds of lack of medical need -- contrary to AASLD/IDSA hepatitis C guidelines, which say that almost everyone with HCV should be considered eligible for treatment. In comparison, half of all privately insured patients who were denied treatment were refused on the grounds of lack of medical need.

In each insurance category a disturbing proportion of patients denied treatment received no formal letter of denial, and the insurer did not bother to respond. Approximately 1 in 7 Medicaid recipients who failed to receive insurance authorization received no letter informing them that their prescription had been denied.

Drug and alcohol use were not major reasons for denial. Around 5% of Medicaid recipients were denied treatment on these grounds, compared to 10% of privately insured patients. However the researchers emphasized that they lacked information on drug or alcohol history, and that this information might be a confounding factor.

People without cirrhosis were significantly more likely to be denied treatment (adjusted odds ratio 2.85), as were people who presented prescriptions before  January 31 2015 (adjusted odds ratio 3.16).

People insured by Medicaid had to wait significantly longer than others for their prescription to be approved -- a median of 24 days compared to 14 days for others, and a quarter had to wait over 49 days. People on Medicaid who were initially denied approval but appealed or tried again received their medication in a median of 46 days compared to 35 and 32 days for Medicare and commercial insurance.

Denial of treatment and delays in treatment are likely to result in worse outcomes, the investigators warned.

11/17/15

Reference

V Lo Re, C Gowda, PN Urick, et al. Incidence and Determinants of Denial of DAA Treatment for Chronic HCV Infection by Insurance Type During the First 6 Months of the Modern HCV Treatment Era. AASLD Liver Meeting 2015. San Francisco, November 13-17, 2015. Abstract LB-5.