Almost half of US Medicaid recipients denied funding for hepatitis C treatment, 4-state study shows

Around one in six people with hepatitis C in four US states had their prescriptions for direct-acting antivirals refused by insurers, and almost half of Medicaid recipients were denied reimbursement in 2014 and early 2015, a study by the University of Pennsylvania has found. The findings were presented on Monday at the 2015 AASLD Liver Meeting in San Francisco.

Restrictions on Medicaid funding of direct-acting antiviral treatment by state governments in the United States 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 injecting drug use. Insurers may also delay decisions on treatment, potentially risking a worsening of liver damage or even death.

Glossary

Medicaid

In the United States, a programme providing health insurance to people on low-incomes of all ages. Provision varies from state to state, although some types of care are covered in all states.

Medicare

In the United States, a federal health insurance programme that guarantees health coverage for people aged 65 and over and some younger people with disabilities.

antiviral

A drug that acts against a virus or viruses.

cirrhosis

Severe fibrosis, or scarring of organs. The structure of the organs is altered, and their function diminished. The term cirrhosis is often used in relation to the liver. 

adjusted odds ratio (AOR)

Comparing one group with another, expresses differences in the odds of something happening. An odds ratio above 1 means something is more likely to happen in the group of interest; an odds ratio below 1 means it is less likely to happen. Similar to ‘relative risk’. 

The extent to which insurers – including the Medicare system of publicly-funded insurance for over-65s and the Medicaid publicly-funded system for people on low incomes – restrict access to hepatitis C treatment was investigated by researchers from University of Pennsylvania, led by Assistant Professor of Medicine Vincent Lo Re. 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 four states – Delaware, Maryland, New Jersey and Pennsylvania – between 1 November 2014 and 30 April 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 for over-65s and the disabled, and Medicaid for people with low-income or special needs).

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 genotypes 4-6, people whose medication had already been authorised prior to the pharmacy visit, uninsured people or 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); 1025 people were privately insured. Most Medicaid recipients were receiving care through a Medicaid-approved 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, p < 0.001), 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)/ribavirin (11% of Medicaid).

Overall, 16.2% of prescriptions were refused. Recipients of Medicaid were significantly 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 ten 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. 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 refused treatment received no formal letter of denial, and the insurer did not bother to respond. Approximately one in seven Medicaid recipients who failed to receive insurance authorisation 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 emphasised 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 31 January 2015 (aOR 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 (p < 0.001), and a quarter had to wait over 49 days.

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

References

Lo Re V et al. Incidence and determinants of denial of DAA therapy by type of insurance during the first six months of the modern HCV treatment era. AASLD Liver Meeting, San Francisco, abstract LB-5, 2015.