Removal of medicaid restrictions were associated with increased hepatitis C virus treatment rates, but disparities persist.
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SUBMITTER: Nephew LD
PROVIDER: S-EPMC9314034 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Immediately after the approval of direct-acting antiviral medications for the treatment of hepatitis C virus (HCV) in 2013, state Medicaid programs limited access to these expensive treatments based on liver disease stage, absence of active alcohol or substance use, and prescriber limitations. New York State fee-for-service (FFS) Medicaid eliminated these requirements in May 2016, but the effect on providers and patients obtaining prior authorization (PA) from Medicaid managed care organizations (MCOs) was unknown. We used a mixed methods approach to assess whether the removal of HCV treatment restrictions was associated with changes in Medicaid MCOs' PA approval processes and length of time to treatment initiation at two large urban New York City provider organizations participating in Project INSPIRE, an HCV care coordination demonstration project. At baseline, the top criteria for clinic care coordinators ranking MCOs as being "most difficult" were liver staging criteria, delayed treatment, and requiring a urine toxicology test. At follow-up, liver staging criteria were replaced by medication formulary limitations. Univariate analysis of the Project INSPIRE participant data suggests a decrease in the percentage of participants with insurance/PA-related treatment delays pre- versus post-policy change (23% versus 15%, p value = 0.02). Interrupted time series analysis found a 2 percentage point decrease (p value = 0.02) in the proportion of PAs each month with insurance-related treatment delays that was attributable to policy change. These results from two urban clinics indicate New York State FFS Medicaid's policy change for HCV treatment may have been associated with some changes in Medicaid MCO PA decisions, but MCO PA denials and treatment delays were still observed "on the ground" by clinic staff.
| S-EPMC8382819 | biostudies-literature
Project description:IntroductionA total of 23 state Medicaid programs continue to restrict hepatitis C virus (HCV) medication access by liver disease or substance-use criteria, creating obstacles to HCV elimination and significant care disparities. Because public insurers often set precedents for private insurer coverage and clinician practice patterns, this study sought to analyze whether spillover occurs from state Medicaid HCV treatment restrictions to HCV screening and treatment rates in commercially insured individuals.MethodsInvestigators analyzed 2014‒2017 commercial claims data across 48 U.S. states (721,961,965 person-months) and used an interrupted times series design to compare hepatitis C virus screening and treatment rates before and after state Medicaid HCV treatment policy changes, adjusting for state-level random effects, Medicaid expansion status, and state drug overdose incidence rates, in states that relaxed Medicaid policy over the study period. Analysis occurred during 2019‒2021.ResultsHepatitis C virus screening rates among commercially insured individuals increased after the corresponding state Medicaid program relaxed HCV treatment policy. Among states that changed Medicaid policy, those that reduced fibrosis or both fibrosis and abstinence restrictions experienced increased HCV screening rates by the study end compared with states that changed only abstinence restrictions (rate ratio=1.29; 95% CI=1.15, 1.44; and rate ratio=1.32; 95% CI=1.17, 1.50, respectively). Similar patterns did not occur in HCV treatment rates, which declined after 2015 across groups.ConclusionsThese data show that HCV screening rates increased among commercially insured individuals after the removal of Medicaid HCV treatment restrictions in the same state. This suggests that Medicaid treatment policies can spill over to affect health outcomes among commercially insured populations.
| S-EPMC9676070 | biostudies-literature
Project description:BACKGROUND:Kentucky Medicaid enrollees, particularly those in the rural Appalachian region, face disproportionate smoking rates and tobacco-related disease burden relative to the rest of the United States (US). The Affordable Care Act (ACA) mandated tobacco cessation treatment coverage by the US public health insurance program Medicaid. Medicaid coverage was also expanded in Kentucky, in 2013, with laxer income eligibility requirements. This short report describes tobacco use incidence and tobacco cessation treatment utilization, comparing by Appalachian status before and after ACA-mandated cessation treatment coverage. METHODS:The study design was a retrospective cross-sectional analysis from 2013 to 2015. Subjects were Medicaid enrollees with 1) diagnosis of any tobacco use (2013 n = 541,349; 2014 n = 864,183; 2015 n = 1,090,274); and/or (2) procedure claim for tobacco cessation counseling, and/or (3) pharmaceutical claim for varenicline or any nicotine replacement product. Primary measures included tobacco use incidence and proportion of users receiving cessation treatment. Analysis was via chi square testing of change by year. RESULTS:Overall, the proportion of tobacco users utilizing cessation treatment decreased (4.75% tobacco users in 2013; 3.15% in 2015). Tobacco users receiving counseling decreased from 2.06% pre-ACA (2013) to 1.06% post-ACA (2015, p < 0.001), as did the proportion receiving nicotine replacement products post-ACA (2.69% in 2013 to 1.55% by 2015; p < 0.001). More Appalachians received cessation treatment than non-Appalachians in 2013 (2.72% vs. 2.03%), but by 2015 non-Appalachians received more treatment overall (1.50% vs. 1.65%; p < 0.001). Appalachians received more counseling and NRT, but less varenicline, than non-Appalachians. CONCLUSIONS:Utilization of all forms of tobacco cessation treatment throughout Kentucky, and particularly in rural Appalachia, remained limited despite Medicaid enrollment as well as coverage expansions. These findings suggest that barriers persist in access to tobacco cessation treatment for individuals in Medicaid.
| S-EPMC6971922 | biostudies-literature
Project description:ImportanceDirect-acting antiviral (DAA) treatment for hepatitis C virus (HCV) infection is highly effective but remains underused. Understanding disparities in the delivery of DAAs is important for HCV elimination planning and designing interventions to promote equitable treatment.ObjectiveTo examine variations in the receipt of DAA in the 6 months following a new HCV diagnosis.Design, setting, and participantsThis retrospective cohort study used national Medicaid claims from 2017 to 2019 from 50 states, Washington DC, and Puerto Rico. Individuals aged 18 to 64 years with a new diagnosis of HCV in 2018 were included. A new diagnosis was defined as a claim for an HCV RNA test followed by an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis code, after a 1-year lookback period.Main outcomes and measuresOutcome was receipt of a DAA prescription within 6 months of diagnosis. Logistic regression was used to examine demographic factors and ICD-10-identified comorbidities associated with treatment initiation.ResultsAmong 87 652 individuals, 43 078 (49%) were females, 12 355 (14%) were age 18 to 29 years, 35 181 (40%) age 30 to 49, 51 282 (46%) were non-Hispanic White, and 48 840 (49%) had an injection drug use diagnosis. Of these individuals, 17 927 (20%) received DAAs within 6 months of their first HCV diagnosis. In the regression analyses, male sex was associated with increased treatment initiation (OR, 1.24; 95% CI, 1.16-1.33). Being age 18 to 29 years (OR, 0.65; 95% CI, 0.50-0.85) and injection drug use (OR, 0.84; 95% CI, 0.75-0.94) were associated with decreased treatment initiation. After adjustment for state fixed effects, Asian race (OR, 0.50; 95% CI, 0.40-0.64), American Indian or Alaska Native race (OR, 0.68; 95% CI, 0.55-0.84), and Hispanic ethnicity (OR, 0.81; 95% CI, 0.71-0.93) were associated with decreased treatment initiation. Adjustment for state Medicaid policy did not attenuate the racial or ethnic disparities.ConclusionsIn this retrospective cohort study, HCV treatment initiation was low among Medicaid beneficiaries and varied by demographic characteristics and comorbidities. Interventions are needed to increase HCV treatment uptake among Medicaid beneficiaries and to address disparities in treatment among key populations, including younger individuals, females, individuals from minoritized racial and ethnic groups, and people who inject drugs.
| S-EPMC10403776 | biostudies-literature
Project description:ImportanceDirect-acting antivirals (DAAs) are safe and highly effective for curing hepatitis C virus (HCV) infection, but their high cost led certain state Medicaid programs to impose coverage restrictions. Since 2015, many of these restrictions have been lifted voluntarily in response to advocacy or because of litigation.ObjectiveTo estimate how the prescribing of DAAs to Medicaid patients changed after states eased access restrictions.Design, setting, and participantsThis modified difference-in-differences analysis of 39 state Medicaid programs included Medicaid beneficiaries who were prescribed a DAA from January 1, 2015, to December 31, 2019. DAA coverage restrictions were measured based on a series of cross-sectional assessments performed from 2014 through 2022 by the US National Viral Hepatitis Roundtable and the Center for Health Law and Policy Innovation.ExposureCalendar quarter when states eased or eliminated 3 types of DAA coverage restrictions: limiting treatment to patients with severe liver disease, restricting use among patients with active substance use, and requiring prescriptions to be written by or in consultation with specialists. States with none of these restrictions at baseline were excluded.Main outcomes and measuresQuarterly number of HCV DAA treatment courses per 100 000 Medicaid beneficiaries.ResultsOf 39 states, 7 (18%) eliminated coverage restrictions, 25 (64%) eased restrictions, and 7 (18%) maintained the same restrictions from 2015 to 2019. During this period, the average quarterly use of DAAs increased from 669 to 3601 treatment courses per 100 000 Medicaid beneficiaries. After states eased or eliminated restrictions, the use of DAAs increased by 966 (95% CI, 409-1523) treatment courses per 100 000 Medicaid beneficiaries each quarter compared with states that did not ease or eliminate restrictions.Conclusions and relevanceThe results of this study suggest that there was greater use of DAAs after states relaxed coverage restrictions related to liver disease severity, sobriety, or prescriber specialty. Further reductions or elimination of these rules may improve access to a highly effective public health intervention for patients with HCV.
| S-EPMC10998155 | biostudies-literature
Project description:ObjectiveTo examine county-level geographic variation in treatment admissions among opioid treatment programs (OTPs) that accept Medicaid in the continental United States.Data sources/study settingData come from the 2012 National Survey of Substance Abuse Treatment Services.Study design/data collectionWe used local measures of spatial autocorrelation (LISA) analysis to identify (1) clusters of counties with higher and lower than average rates of opioid use disorders and (2) clusters of counties with higher and lower than average treatment admissions among OTPs that accept Medicaid, adjusting for county population size.Principal findingsOur results reveal several clusters of counties with higher than average rates of opioid use disorder (OUD) and lower than average treatment admissions among OTPs that accept Medicaid. These clusters are highly concentrated in the Southeast region of the country and include Arkansas, Kentucky, Louisiana, Mississippi, and Tennessee.ConclusionsMedicaid enrollees in areas in the Southeast have the largest gaps between county-level OUD rates and estimated county-level capacity for treatment, as measured by county-level total treatment admissions among OTPs that accept Medicaid. Policy makers should consider strategies to increase the availability of OTPs with the capacity to serve Medicaid enrollees.
| S-EPMC5785305 | biostudies-literature
Project description:BackgroundIn Canada, interferon-free, direct-acting antiviral hepatitis C virus (HCV) regimens are costly. This presents challenges for universal drug coverage of the estimated 220?000 people with chronic HCV infection nationwide. The study objective was to appraise criteria for reimbursement of 4 HCV direct-acting antivirals in Canada.MethodsWe reviewed the reimbursement criteria for simeprevir, sofosbuvir, ledipasvir-sofosbuvir and paritaprevir-ritonavir-ombitasvir plus dasabuvir in the 10 provinces and 3 territories. Data were extracted from April 2015 to June 2016. The primary outcomes extracted from health ministerial websites were: 1) minimum fibrosis stage required, 2) drug and alcohol use restrictions, 3) HIV coinfection restrictions and 4) prescriber type restrictions.ResultsOverall, 85%-92% of provinces/territories limited access to patients with moderate fibrosis (Meta-Analysis of Histologic Data in Viral Hepatitis stage F2 or greater, or equivalent). There were no drug and alcohol use restrictions; however, several criteria (e.g., active injection drug use) were left to the discretion of the physician. Quebec did not reimburse simeprevir and sofosbuvir for people coinfected with HIV; no restrictions were found in the remaining jurisdictions. Prescriber type was restricted to specialists in up to 42% of provinces/territories.InterpretationThis review of criteria of reimbursement of HCV direct-acting antivirals in Canada showed substantial interjurisdictional heterogeneity. The findings could inform health policy and support the development and adoption of a national HCV strategy.
| S-EPMC5173474 | biostudies-literature
Project description:ImportanceLow-income older adults who are dually eligible (DE) for Medicare and Medicaid often experience worse outcomes following hospitalization. Among other federal policies aimed at improving health for DE patients, Medicare has recently begun reporting disparities in within-hospital readmissions. The degree to which disparities for DE patients are owing to differences in community-level factors or, conversely, are amenable to hospital quality improvement, remains heavily debated.ObjectiveTo examine the extent to which within-hospital disparities in 30-day readmission rates for DE patients are ameliorated by state- and community-level factors.Design setting and participantsIn this retrospective cohort study, Centers for Medicare & Medicaid Services (CMS) Disparity Methods were used to calculate within-hospital disparities in 30-day risk-adjusted readmission rates for DE vs non-DE patients in US hospitals participating in Medicare. All analyses were performed in February and March 2019. The study included Medicare patients (aged ≥65 years) hospitalized for acute myocardial infarction (AMI), heart failure (HF), or pneumonia in 2014 to 2017.Main outcomes and measuresWithin-hospital disparities, as measured by the rate difference (RD) in 30-day readmission between DE vs non-DE patients following admission for AMI, HF, or pneumonia; variance across hospitals; and correlation of hospital RDs with and without adjustment for state Medicaid eligibility policies and community-level factors.ResultsThe final sample included 475 444 patients admitted for AMI, 898 395 for HF, and 1 214 282 for pneumonia, of whom 13.2%, 17.4%, and 23.0% were DE patients, respectively. Dually eligible patients had higher 30-day readmission rates relative to non-DE patients (RD >0) in 99.0% (AMI), 99.4% (HF), and 97.5% (pneumonia) of US hospitals. Across hospitals, the mean (IQR) RD between DE vs non-DE was 1.00% (0.87%-1.10%) for AMI, 0.82% (0.73%-0.96%) for HF, and 0.53% (0.37%-0.71%) for pneumonia. The mean (IQR) RD after adjustment for community-level factors was 0.87% (0.73%-0.97%) for AMI, 0.67% (0.57%-0.80%) for HF, and 0.42% (0.29%-0.57%) for pneumonia. Relative hospital rankings of corresponding within-hospital disparities before and after community-level adjustment were highly correlated (Pearson coefficient, 0.98).Conclusions and relevanceIn this cohort study, within-hospital disparities in 30-day readmission for DE patients were modestly associated with differences in state Medicaid policies and community-level factors. This suggests that remaining variation in these disparities should be the focus of hospital efforts to improve the quality of care transitions at discharge for DE patients in efforts to advance equity.
| S-EPMC8903116 | biostudies-literature
Project description:ObjectiveTo assess health care disparities among black and Latino adults with schizophrenia receiving services during the period July 1994-June 2006, and to evaluate trends in observed disparities.Data sourcesAdministrative claims data from the Florida Medicaid program. Data sources included membership files (demographic information), medical claims (diagnostic, service, and expenditure information), and pharmacy claims (prescriptions used and expenditures).Study designWe identified adults with at least two schizophrenia claims during a fiscal year. We used generalized estimating equation models to estimate disparities in spending on psychotropic drugs, psychiatric inpatient services, all mental health services, and all health services.Principal findingsSpending on psychotropic drugs, mental health, and all health was 0.9-70 percent lower for blacks and Latinos than for whites. With the exception of blacks with substance use disorder comorbidity, minorities were less likely than whites to use psychiatric inpatient services. Psychiatric inpatient spending among users did not differ by race/ethnicity. With the exception of psychiatric inpatient utilization/spending, trend analyses showed no change or modest reductions in disparities.ConclusionsBlack and Latino Medicaid recipients diagnosed with schizophrenia experience health care disparities. Some but not all disparities narrowed modestly over the study period.
| S-EPMC2796317 | biostudies-literature
Project description:ImportanceBuprenorphine treatment for opioid use disorder (OUD) is associated with decreased morbidity and mortality. Despite its effectiveness, buprenorphine uptake has been limited relative to the burden of OUD. Prior authorization (PA) policies may present a barrier to treatment, though research is limited, particularly in Medicaid populations.ObjectiveTo assess whether removal of Medicaid PAs for buprenorphine to treat OUD is associated with changes in buprenorphine prescriptions for Medicaid enrollees.Design, setting, and participantsThis state-level, serial cross-sectional study used quarterly data from 2015 through the first quarter (January-March) of 2019 to compare buprenorphine prescriptions in states that did and did not remove Medicaid PAs. Analyses were conducted between June 10, 2021, and August 15, 2023. The study included 23 states with active Medicaid PAs for buprenorphine in 2015 that required similar PA policies in fee-for-service and managed care plans and had at least 2 quarters of pre- and postperiod buprenorphine prescribing data.ExposuresRemoval of Medicaid PA for at least 1 formulation of buprenorphine for OUD.Main outcomes and measuresThe main outcome was number of quarterly buprenorphine prescriptions per 1000 Medicaid enrollees.ResultsBetween 2015 and the first quarter of 2019, 6 states in the sample removed Medicaid PAs for at least 1 formulation of buprenorphine and had at least 2 quarters of pre- and postpolicy change data. Seventeen states maintained buprenorphine PAs throughout the study period. At baseline, relative to states that repealed PAs, states that maintained PAs had lower buprenorphine prescribing per 1000 Medicaid enrollees (median, 6.6 [IQR, 2.6-13.9] vs 24.1 [IQR, 8.7-27.5] prescriptions) and lower Medicaid managed care penetration (median, 38.5% [IQR, 0.0%-74.1%] vs 79.5% [IQR, 78.1%-83.5%] of enrollees) but similar opioid overdose rates and X-waivered buprenorphine clinicians per 100 000 population. In fully adjusted difference-in-differences models, removal of Medicaid PAs for buprenorphine was not associated with buprenorphine prescribing (1.4% decrease; 95% CI, -31.2% to 41.4%). For states with below-median baseline buprenorphine prescribing, PA removal was associated with increased buprenorphine prescriptions per 1000 Medicaid enrollees (40.1%; 95% CI, 0.6% to 95.1%), while states with above-median prescribing showed no change (-20.7%; 95% CI, -41.0% to 6.6%).Conclusions and relevanceIn this serial cross-sectional study of Medicaid PA policies for buprenorphine for OUD, removal of PAs was not associated with overall changes in buprenorphine prescribing among Medicaid enrollees. Given the ongoing burden of opioid overdoses, continued multipronged efforts are needed to remove barriers to buprenorphine care and increase availability of this lifesaving treatment.
| S-EPMC10589810 | biostudies-literature