Hepatitis C Medicaid Affinity Group: Supporting State-Generated Solutions to Eliminating HCV
The Hepatitis C Medicaid Affinity Group (Affinity Group) began in December 2017 with the aim of increasing the number and percentage of Medicaid beneficiaries diagnosed with hepatitis C virus (HCV) who are successfully treated and cured.
In December 2018, the second year of the Affinity Group was launched with eight new participants. For the second year, the Affinity Group aims to help new participants develop and implement their own strategies, explore issues and strategies related to HCV in correctional settings, and support the continued efforts of states that participated in the first year.
The efforts of the Affinity Group are driven by state teams made up of representatives from state Medicaid agencies, public health departments, correctional agencies, and other programs such as those that address behavioral health care and substance use disorders.
Nine states participated in the first year of the Affinity Group, and eight states were selected to participate in the second year.
Year 1 State Participants: Kentucky, Louisiana, Maryland, Massachusetts, New York State, Vermont, and Washington.
Year 1 & Year 2 State Participants: Indiana and Wisconsin
Year 2 State Participants: Alaska, District of Columbia, Los Angeles County, Michigan, Tennessee, and Virginia
The CDC estimates that approximately 2.5 million people in the United States are living with HCV infection. A disproportionate number of these individuals receive public insurance, including Medicaid, or are in correctional settings.
A recent analysis found that HCV infection leads to more than 2.3 million outpatient medical visits and over 73,000 emergency room visits annually, as well as a total of 2.8 million days of inpatient care. The cost of inpatient visits for one year was more than $15 billion.
Increasing access to screening, diagnosis and early HCV treatment for Medicaid patients can make a significant contribution toward saving lives, reducing new infections, controlling health care costs, and ultimately eliminating viral hepatitis, all goals described in the National Viral Hepatitis Action Plan (Action Plan).
New HCV treatments can result in a cure for approximately 95% of people who take them. People who are cured of HCV experience multiple health benefits and are significantly less likely to develop severe liver disease, liver cancer, and liver failure, which can be very costly conditions and can be fatal. However, many states have experienced challenges in providing HCV treatment for patients with Medicaid and other public insurance. More intensive efforts are needed and model programs must be replicated to increase screening and diagnosis, ensure follow up care, manage the costs of treatment, and raise provider and public awareness about HCV risks and new treatments that offer a strong chance of a cure.
A short Expression of Interest form was developed for states to apply to participate in the Affinity Group and a recorded introductory webinar further described the benefits of participation. Future opportunities for new states to join the group will depend on funding and will be featured on the viral hepatitis blog.
States are the key leaders in public health innovation, but do not always have opportunities to share effective strategies and collaborate to identify solutions to common challenges. The Affinity Group addresses this need by bringing states together to support the development and implementation of innovative strategies for scaling up HCV treatment.
The Affinity Group is a continuous quality improvement project that supports the development of evidence-based practices and implementation strategies to improve Medicaid systems’ efforts to address HCV. It will be evaluated to identify the most effective activities for states and to inform future efforts. The project aims to:
- Foster state collaboration and share promising practices;
- Develop and implement innovative HCV-related policies and programs; and
- Increase the number and percentage of Medicaid beneficiaries diagnosed and successfully treated (or cured) for HCV.
Convened by the Office of Infectious Disease and HIV/AIDS Policy (OIDP) in the Office of the Assistant Secretary for Health, the Affinity Group is a collaborative effort across HHS that also engages the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the HHS Office of Minority Health (OMH), and the Substance Abuse and Mental Health Services Administration (SAMHSA) to provide technical assistance and consultation to participating states.
Example of Hepatitis C Medicaid Affinity Group activities undertaken by states include:
- Calculating the HCV care cascade, leveraging work conducted by the HIV Affinity Group: States have developed data use agreements between state Medicaid programs and public health agencies to share data on HCV screening, diagnosis, and treatment. By calculating care cascades, states aim to identify screening and treatment patterns and develop targeted approaches to improve access. Populations of interest include individuals co-infected with HIV, people who inject drugs, women, and infants born to women with HCV.
- Enhancing provider knowledge of HCV testing and treatment: States have developed new curricula and trained providers on HCV treatment. States are also increasing provider capacity to treat people for HCV through Project ECHO, a tele-mentoring program. Finally, they are analyzing data to identify high burden areas and prescribing patterns to inform provider capacity-building efforts.
- Assessing and revising prior authorization processes for HCV medication: States are assessing the financial and clinical impact of lifting Medicaid restrictions on HCV medications. At least one state removed prescriber specialty requirements and modified criteria related to substance use.
- Improving treatment for people who inject drugs: States are exploring opportunities to co-locate HCV screening and treatment with treatment for substance use disorder. At least one state has offered HCV screening at harm reduction sites.
- Connecting individuals in correctional settings to screening and treatment: Under a new focus area for the second year of the Affinity Group, several states have proposed increasing screening and treatment rates of inmates and improving care coordination efforts so, upon release, individuals can enroll into Medicaid and continue/start HCV treatment.
Affinity Group state participants met with federal partners and other subject matter experts in Washington DC on February 8-9, 2018 for the first in-person convening of the Affinity Group. The in-person convening helped states obtain and share information to advance their goal of increasing the number of people cured of HCV. State participants also meet with subject matter experts during monthly calls to continue their efforts throughout the year. Links to some of the presentations are below.
Viral Hepatitis: We Can Eliminate Hepatitis C, Update on the Most Recent AASLD Recommendations. Bruce Luxon, MD, PhD from the American Association for the Study of Liver Diseases (AASLD) and Georgetown University presented the latest AASLD treatment guideline: “Treatment is recommended for all patients with chronic HCV infection, except those with short life expectancies that cannot be remediated by treating HCV...”. He also described the progression of liver disease with HCV, changes in cure rates with medication advances, and the cost effectiveness of treatment.
Hepatitis C: The State of Medicaid Access, 2017 National Summary Report. Elizabeth Paukstis, MA, JD summarized findings of a study conducted by the National Viral Hepatitis Roundtable on the status of Medicaid reimbursement criteria for direct acting antiviral drugs (DAAs). While more states are eliminating/reducing restrictions related to severity of illness and prescriber qualifications, many have maintained sobriety restrictions.
Prior Authorization of Hepatitis C Medications in NYS Medicaid Fee for Service (FFS) and Medicaid Managed Care. Monica Toohey, RPh from the New York State Department of Health described the state’s Drug Utilization Review process and timeline to first implement and then lift DAA reimbursement criteria. To streamline DAA prior authorization, the state relies on automation and encourages managed care organizations to use standardized criteria and processes.
Reframing Reinfection: Public Health Strategies for the Era of Hepatitis C Elimination. Daniel Raymond from the Harm Reduction Coalition described why it is important to cure people who inject drugs of HCV despite risk of re-infection. He also recommended strategies for preventing re-infections.
The Affinity Group meets monthly to discuss HCV-related strategies with subject matter experts. Links to some of the presentations from these monthly calls are below.
HCV Testing and Treatment in the Corrections Context. Mandy Altman, MPA, CCHP from the Hepatitis Education Project presented in March. She discussed barriers and opportunities to treating incarcerated populations for HCV, including how prisons purchase medications.
HCV Medication Prior Authorization. Paulina Deming, PharmD from the University of New Mexico presented in May on strategies for addressing Medicaid and other insurers’ prior authorization requirements for HCV medications and the role of pharmacist clinicians in HCV care.
Project ECHO and HCV Treatment. Greg Howe from the Center for Health Care Strategies presented in June on state Medicaid financing models for Project ECHO and other potential financing mechanisms.
Treating People Who Inject Drugs (PWID) for HCV. Lynn E. Taylor, MD, FACP, FAASLD from the University of Rhode Island and Director of HIV and Viral Hepatitis Services, CODAC Behavioral Health presented in July on the rationale for and benefits of treating HCV in people who inject drugs and discussed facilitators of HCV cure among PWID.
Using the Cascade of Care to Inform Models of Care. Pamela S. Belperio (PharmD, BCPS, AAHIVP) from the U.S. Department of Veterans Affairs presented in August. She discussed the role of pharmacists in HCV management and how the HCV PharmD provider framework could be replicated in other settings.
How States Use Medicaid and State Health Department Data to Improve Health Outcomes of People Living with HIV (National Academy for State Health Policy, NASHP)
MassHealth Value-Based Pharmacy Purchasing Proposal (MassHealth)
Medicaid Financing Models for Project ECHO (Center for Health Care Strategies, Inc.)
Reducing Substance Use Disorders – Technical Support for Medicaid Agencies Opioid Data Analytics Cohort & Additional Opportunities (Medicaid Innovation Accelerator Program)
Webinar - Hepatitis C: The State of Medicaid Access (National Viral Hepatitis Roundtable)