As state Medicaid programs eased or eliminated restrictions on access to antiviral treatment for hepatitis C, the number of prescriptions significantly increased every quarter from 2015 through 2019, according to study findings published in JAMA Health Forum.

“The results of this study suggest that Medicaid coverage restrictions were associated with a slowed uptake of a costly but highly effective public health intervention and that further loosening of these restrictions may improve access to curative hepatitis C virus treatment,” the study authors concluded.

Direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) infection is highly effective, with a cure rate exceeding 95%. But when Sovaldi (sofosbuvir) first became available in late 2013, it cost more than $80,000 for a 12-week course. Despite the availability of effective therapy, only a third of people with hepatitis C receive timely treatment, and the numbers are even worse for people on Medicaid, which covers around 80% of people with hepatitis C.

To curb high expenses, many state Medicaid programs limited access by implementing restrictions, such as treating only people with advanced liver fibrosis, requiring that care be managed by a liver specialist or mandating a period of abstinence from drugs and alcohol. It wasn’t until 2015 that a slew of lawsuits led states to ease up on these restrictions. Plus, as more DAAs were approved over time, competition led to reduced prices.

Benjamin Rome, MD, MPH, of Brigham and Women’s Hospital in Boston, and colleagues set out to determine whether HCV antiviral use changed after state Medicaid programs became more lenient with prescriptions.

The analysis included beneficiaries covered by 39 state Medicaid programs. All participants were prescribed DAA therapy between January 2015 and December 2019. The study period started after the approval of Harvoni (sofosbuvir/ledipasvir), the first DAA coformulation, and ended before 2020 to avoid confounding due to changes in access related to the COVID-19 pandemic. Over the course of this period, various states removed restrictions related to liver disease severity, specialist care and substance use.

The researchers analyzed changes in access and the number of treatment courses prescribed each quarter for every 100,000 Medicaid beneficiaries. Of the 39 states, seven (18%) removed all restrictions, 25 (64%) eased up on some restrictions and seven (18%) did not change their access rules.

From 2015 to 2019, the average number of quarterly courses of antivirals rose from 669 to 3,601 per 100,000 beneficiaries. Compared to states that did not ease or remove restrictions, states with looser or no restrictions saw 966 more treatment courses prescribed per 100,000 beneficiaries each quarter. Across the board, more Medicaid recipients with hepatitis C were prescribed antivirals over time, possibly due to the growing availability of cheaper medications.

“The 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,” wrote the researchers. “Further reductions or elimination of these rules may improve access to a highly effective public health intervention for patients with HCV.”

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