Removing Prior Authorization for Hepatitis C Treatment Will Save Lives
Prior authorization (PA) for treatment of Hepatitis C virus (HCV) creates unnecessary burdens for providers and patients that lead to delayed access to care and worsened health outcomes. Given the high cost of HCV treatment, PA requirements in state Medicaid plans are especially burdensome and reinforce existing disparities in access to care. According to the CDC, people with Medicaid are 46% less likely to receive HCV treatment than those with private insurance. This is also a racial equity issue as people of color on Medicaid are 27% less likely to receive timely treatment than White Medicaid recipients. Unfortunately, Illinois has one of the worst ratings in the entire country for Medicaid HCV treatment access, being one of just two states to receive an F grade according to the Hepatitis C: State of Medicaid Access project. Removing PAs for HCV treatment in Illinois Medicaid will substantially lower barriers to care and lead to more timely and equitable care for patients. Twenty-one states, including Wisconsin and Indiana, have eliminated PA requirements for most patients, leading to thousands of more patients with HCV gaining access to treatment. Illinois should be next!
HCV is a liver infection that, left untreated, can become a serious chronic disease resulting in life-threatening conditions like cirrhosis and liver cancer. An estimated 2.4 million people are living with HCV in the United States, with 2,873 confirmed cases in Illinois in 2020. While there is no vaccine for HCV, there is highly effective treatment available. Antiviral medication for HCV has a 95% cure rate. Early detection and treatment is critical to prevent more serious negative health consequences. Unfortunately, treatment can be very costly, with an average 12-week treatment course costing between $66,000 – $94,000. As such, many low-income people living with HCV depend on Medicaid programs to cover costs, and if they cannot meet the numerous Medicaid PA requirements they may instead be forced to delay or go without treatment. Procedural barriers with obtaining PA should not be preventing people from accessing an effective cure, but HCV care teams overwhelmingly report the PA process was the greatest obstacle delaying treatment initiation.
In Illinois, Medicaid PA requires a multi-step process involving a series of tests and restrictions to navigate. To meet PA requirements, patients must have a diagnosis of chronic HCV and lab documentation of the specific genotype of HCV. Patients must also have a documented Metavir test to determine the level of fibrosis the liver may be experiencing. Furthermore, patients must also provide several additional liver function and blood tests, and most of these tests must be completed within a three-month period. In some cases, insurance providers require that patients prove they have chronic HCV infections by presenting labs that are 6 months apart. Some of these tests are medically necessary, especially for patients with more advanced disease and/or liver damage. However, at Howard Brown we are seeing less patients present with advanced liver damage. The extent of testing required for PA is unnecessary for many of our patients, especially those that are younger. Unfortunately, Illinois Medicaid requires all of the testing regardless of if it is really necessary for each patient, and all of the different test requirements and conflicting timelines can be extremely burdensome for patients to understand and manage. Missing any one of the required tests or falling outside of the designated timeframes can result in patients having to restart the entire PA process, only further delaying access to treatment.
Understanding how to receive PA approval from insurance companies require that HCV treatment staff specialize in PAs for multiple insurance providers. In 2017, Howard Brown’s Social Services department formed our HCV program because patients were presenting for HCV care and our medical staff did not have the capacity to complete all the requisite steps to obtain treatment. Because of the burdensome PA requirements, we witnessed clients experiencing years of avoidable disease progression, in some cases leaving them with permanent liver damage and forever increasing their risk of liver cancer and decompensation. Our HCV team is a multi-disciplinary team equipped with a part-time pharmacist specifically dedicated to helping patients access and navigate care, and because of their work and specialized expertise, we’ve been able to cure hundreds of HCV patients. Most centers of care, especially those in more rural areas of the state, do not have the capacity or resources to hire and train specialized teams to do this work. In fact, many of Howard Brown’s HCV patients live outside of Chicago and are referred to us because they do not have access to support navigating the PA process in their own communities. If Illinois were to remove the Medicaid PA requirements, more clinics across the state could treat HCV and contribute towards a common goal of HCV elimination.
Luckily, we can take action to remove the burdensome PA requirements and improve access to care. Legislation (HB 2631) was introduced into the Illinois General Assembly in 2023to remove PAs for HCV treatment in Illinois Medicaid. You can contact your state elected officials to ask let them know that this is a critical issue for health equity. Additionally, you can email policymakers to urge them to increase access to HCV treatment for Medicaid recipients.
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