Insurance Coverage Issues Persist in Hepatitis C Care

Comorbidities lead to more complex treatment and higher costs.

A new study authored by global consulting firm Milliman and Primrose Healthcare details the costs and common comorbidities associated with patients affected by hepatitis C virus (HCV).

The study identified the wide range of health care services available to HCV-infected patients, along with the cost and effectiveness in relation to the disease with comorbidity factors. The high costs and prevalence of comorbidities to those affected by HCV indicate a growing need for a treatment approach that focuses on the overall health of HCV patients, including comorbid conditions.

According to the study, average costs associated with treating HCV patients with commercial insurance are about 4 times greater than for those without the condition. This variation cannot be explained by drug costs alone. On average, HCV patients incur higher per patient per month (PPPM) costs across all types of services than do members of a population of similar age and sex who are HCV-free.

The average incremental annual costs for an individual with HCV are $21,888. However, members with more advanced disease progression, such as decompensated cirrhosis and liver cancer, can cost nearly $50,000 more per year than people who are HCV-free.

In addition to the cost of treatment, the study details the comorbidities associated with the disease. The analysis reveals that diabetes, mental health issues, substance abuse and hyperlipidemia are much more prevalent in patients with HCV.

HIV/AIDS is nearly 15 times more commonly diagnosed in the HCV population than in HCV-free populations. Additionally, alcohol dependency is 9 times more common, drug dependency is 20 times more common, and diabetes is present in 25% of the HCV population.

These added conditions contribute to the HCV patient’s costs and make treatment much more complex, which can lead to poorer outcomes in HCV populations.

“This data clearly explains why the cost challenges experienced by payers will not be mitigated by prior authorization and other tactics that focus on new specialty drugs alone,” said Henri Cournand, CEO of Primrose Healthcare. “While drug costs dominate the headlines and today’s research around HCV, there is a much more compelling argument to be made that improving the holistic management of this condition is the most effective cost control strategy.”

According to Cournand, payers must invent a consistent approach for all HCV patients that should not only include antiviral medications, but also intensive outreach to address comorbidities, poor treatment adherence, behavioral health issues, and substance abuse.

“While many payers are focused on addressing the financial burden of new drug treatments for hepatitis C, they may be missing a bigger picture perspective on the underlying cost drivers within these populations,” add Helen E. Blumen, MD, MBA, Principal and Healthcare Management Consultant for Milliman. “The health care system must zero in on interventions that optimize the patient’s liver health while addressing both HCV and comorbidities that lead to disease progression and poor outcomes in the long term.”