Faced with the highest hepatitis C mortality rate in the country, Oregon is on the brink of expanding hepatitis C treatment to all Medicaid beneficiaries regardless of the severity of their condition. The move could help the state eliminate transmission of the virus within a decade.
Chronic hepatitis C infection is the leading cause of complications from chronic liver disease, including cirrhosis, liver failure and liver cancer, and is the main reason for liver transplants in the U.S. Until recently, hepatitis C treatment had not been very effective. But new medications came on the market in 2013 with cure rates approaching 95 percent and a price tag of up to $84,000 per patient.
To make the best use of limited funds, the Oregon Health Plan initially restricted treatments to hepatitis C patients with the greatest need. Most OHP members who qualified were older patients experiencing the complications of long term hepatitis C infections. That meant younger patients in the initial stages of the disease who had the highest transmission rates weren’t sick enough to be treated.
On Thursday, an advisory committee recommended the Oregon Health Authority remove those restrictions, opening up treatment to all Oregon Health Plan patients with chronic hepatitis C infection.
“OHA has been continually taking steps to expand treatment since these drugs became available,” said Dana Hargunani, chief medical officer for the Oregon Health Authority. “Their recommendation is really the last step in allowing us to treat all stages of hepatitis C in the state.”
The committee also recommended removing the requirement for individuals with substance use disorders to be in addiction treatment in order to get hepatitis C medications.
The recommendation goes to the Oregon Health Authority Director Patrick Allen, who has signaled his support.
“I look forward to approving this recommendation to expand treatment coverage for OHP members,” Allen said. “We have an opportunity to eliminate hepatitis C in our state, and this is a key strategy to get us there.”
The state will have to wait out a mandatory 60-day notification period, but could start treating patients under the new policy as soon as March.
Hargunani said the move was made possible by the continued drop in prices in hepatitis C medications. Gov. Kate Brown included a $107 million request in her budget proposed for the next biennium to pay for the drugs.
“That will help us get to the treatment levels we were hoping for,” Hargunani said.
The state has been able to reach only about 13 percent of OHP patients with hepatitis C, much lower than the 18 percent treatment rate nationwide. A statewide registry includes more than 75,000 Oregonians with the condition, although state officials believe the total number of people infected could be twice that amount.
Most new cases are linked to intravenous drug use, although infections can occur through other types of contact with bodily fluids, including sexual intercourse, exposure to blood in health care settings, and through tattoos or piercings. The blood supply is screened for hepatitis C, although many older Americans had been infected through blood transfusions before screening was in place. Health officials have urged all baby boomers to get screened for the infection.
Oregon’s restrictions on treatment for fiscal reasons have likely contributed to a faster spread of the disease in recent years. While older patients in later stages of the disease are at greater risk for death and other complications, they tend to have lower transmission rates. Younger individuals in the early stages of infection are generally healthier, but have higher transmission rates.
To qualify for treatment, OHP members had to undergo a special test to determine the amount of fibrosis, or scarring of their liver. Those with stage 2 or higher fibrosis qualified, while those with stage 1 fibrosis had to wait.
The greater availability and affordability of a hepatitis C cure now have public health officials thinking about treatment as a way to prevent transmission. A recent modeling of transmission rates showed that treating just 12 percent of people who inject drugs per year could eliminate hepatitis C transmission within 10 years.
“That is why we’ve been working so hard get to this last stage,” Hargunani said. “This is really a public health issue, and we think by expanding treatment to all (stages), that’s when we’re going to really be able to get a hold on the transmissions that are happening.”
While the drugs remain expensive — at about $30,000 per patient — the state is likely to save money in the long run by reducing new infections and preventing costly complications. OHP will also realize some short term savings by avoiding the tests needed to stage patients.
The agency plans to increase patient and provider awareness about the need for screening to identify those with infections, and will be encouraging primary care providers to take on treatment of patients who are in the initial stages. Most hepatitis C treatment is currently provided by specialists who are better equipped to deal with some of the complications common in later stages.
State health officials believe they could all but eliminate the virus from the state in the next decade.
“We know other states have this goal,” Hargunani said. “We think this is in sight, and this is the goal we will be working for.”
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