Comparative Evaluation of State-Level Subscription-Based Payment Models for Hepatitis C Drugs

Area of Science:

• Public Health
• Health Services Research
• Infectious Disease Epidemiology

Background:

• Subscription-based payment models (SBPMs) are increasingly used in Medicaid programs to improve access to hepatitis C virus (HCV) treatment.
• Evaluating the real-world impact of these payment models on HCV care continuum outcomes is crucial for public health policy.

Purpose of the Study:

• To assess the effect of SBPMs on HCV screening, RNA testing, and direct-acting antiviral (DAA) uptake among Medicaid Managed Care enrollees in Louisiana and Washington.
• To identify factors contributing to the differing policy impacts observed between the two states.

Main Methods:

• A quasi-experimental study employing the synthetic control method was used.
• Outcomes in Louisiana and Washington (implementing SBPMs in July 2019) were compared to weighted combinations of 14 control states.
• Data from payer-complete closed claims for adults aged 18-64+ enrolled in Medicaid Managed Care (January 2018-December 2022) were analyzed for monthly HCV screening, RNA testing, DAA initiation, and refill rates.

Main Results:

• Louisiana's SBPM was linked to significant increases in HCV RNA testing (+35.2/100,000 persons/mo) and DAA initiation (+7.8/1000 patients/mo) and refills (+24.4/1000 patients/mo).
• Washington's SBPM showed nonsignificant changes in screening but significant declines in DAA initiation (-3.6/1000 patients/mo) and refills (-12.9/1000 patients/mo).
• The positive effects in Louisiana were broadly observed across subgroups and geographically, while Washington's effects were uniformly negative or null.

Conclusions:

• SBPMs produced divergent outcomes in Louisiana and Washington, suggesting state-specific factors influence their effectiveness.
• Louisiana's gains may be attributed to Medicaid expansion and prior removal of DAA restrictions, creating a larger treatment-eligible population at SBPM implementation.
• Washington's earlier Medicaid expansion and fibrosis restriction removal might have already met the demand, highlighting the need for comprehensive strategies beyond payment reform for HCV elimination.