Rhode Island Hep C Complications Projected to Continue

Laird Harrison

March 17, 2016

SAN FRANCISCO — It will be impossible to eliminate hepatitis C in Rhode Island in the next 15 years if Medicaid restrictions on treatment coverage remain, according to the latest projections.

The state Medicaid program currently restricts the coverage of hepatitis C medications to patients with a fibrosis stage of at least 3.

"We need to ramp up screening and treatment if we really want to eliminate hepatitis C," Ayorinde Soipe, MBBS, from Brown University in Providence, Rhode Island, told Medscape Medical News.

Dr Soipe presented findings from a study of the projected prevalence of hepatitis C here at the International Conference on Viral Hepatitis 2016.

For most patients, the hepatitis C virus can be effectively cleared with the new direct-acting antiviral drugs. In the United States, however, many infected people can't afford to buy their own drugs; instead, they rely on Medicaid for coverage.

But Rhode Island and many other states have imposed restrictions on coverage for hepatitis C therapies. In addition to fibrosis scores, some limit coverage to people who are not using alcohol or injecting drugs.

Denying Claims

A recent survey conducted in four mid-Atlantic states showed that Medicaid programs denied nearly half the claims for direct-acting antiviral drugs, as reported by Medscape Medical News. By comparison, Medicare denied only 5% of such claims.

Policymakers have justified the restrictions by saying that states can't afford to pay for the new drugs for all Medicaid patients with hepatitis C, so they have targeted the sickest patients and those who are not abusing substances.

Dr Soipe and his colleagues wanted to see what effect various restrictions would have on the prevalence of infections and complications in Rhode Island.

They developed a statistical model similar to one created to project trends in hepatitis C nationwide (Hepatology. 2013;57:2164-2170), but adapted it to specific conditions in Rhode Island. They then made four projections.

Their first model looked at the prevalence of hepatitis C in 2030 under the current Medicaid policy, which covers an estimated 120 patients annually with fibrosis of at least stage 3. They projected that the number of people infected will gradually decline out to 2030; however, rates of complications, such as cirrhosis, will continue to be high.

Cirrhosis, Liver-Related Deaths

Their second model looked at the prevalence of hepatitis C if Medicaid coverage was expanded to 360 patients annually with fibrosis of at least stage 2. They projected that by 2030 there would be a reduction in viremic infection of 20%, a reduction in cirrhosis of 25%, and a reduction in liver-related deaths of 23%.

The third model looked at the prevalence of hepatitis C if there were no limitations on the stage of fibrosis — the joint recommendation of the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America — and 360 patients were treated annually. They projected that by 2030, as in the second model, there would be a reduction in viremic infection of 20%. However, there would only be a 16% reduction in cirrhosis, and only a 14% reduction in liver-related deaths.

Their final model looked at the number of patients that would have to be treated to reduce viremic infection by 90% by 2030. They projected that this would require that the number of patients treated each year would have to increase to 2000 by 2025. If this many Rhode Islanders received treatment, there would be a reduction in cirrhosis of 72.4% by 2030, and a reduction in liver-related deaths of 67.5%.

 
At current levels, it looks to me like liver disease goes up at an alarming rate, and it only comes down because of deaths.
 

Dr Soipe pointed out that these projections made some assumptions that differ from actual circumstances in Rhode Island.

For example, he and his colleagues assumed that the incidence of new cases would continue unchanged. But in fact, the incidence might be affected by treatment; if more patients are treated, transmission rates should decrease.

However, the epidemic of the nonmedical use of opioid drugs could increase the incidence of hepatitis C infection. "Right now, because of the opioid epidemic, there is a growing group" of people with new infections, he said.

After the presentation, a member of the audience wanted to know if the researchers had done any analyses on the cost of treatment for the various projections. Dr Soipe reported that the team is currently working on that.

He subsequently told Medscape Medical News that he expects these models will show that expanding the number of patients treated will reduce the long-term costs to Rhode Island's Medicaid program because treatments become more expensive as patients' conditions worsen.

This study provides useful information on the degree to which coverage of treatment for hepatitis C should be expanded, said session moderator Daniel Fierer, MD, from the Icahn School of Medicine at Mount Sinai in New York City.

"At current levels, it looks to me like liver disease goes up at an alarming rate, and it only comes down because of deaths," he told Medscape Medical News.

Treating patients at an earlier disease stage might indeed be cost-effective, but decisions about whether to provide treatment should not be made solely on that basis, he explained. Should we look "patients in the eye and say, 'You cost too much money?' That's not the American way."

Dr Fierer reports that he holds stock in Gilead Sciences. Dr Soipe has disclosed no relevant financial relationships.

International Conference on Viral Hepatitis (ICVH) 2016: Abstract 19. Presented March 14, 2016.

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