Evaluating the Medicaid Subscription-Based Payment Model in Hepatitis C
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| Publicado en: | ProQuest Dissertations and Theses (2025) |
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| Acceso en línea: | Citation/Abstract Full Text - PDF |
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| Resumen: | BackgroundHepatitis C virus (HCV) remains a major contributor to liver cirrhosis, hepatocellular carcinoma, and liver transplantation in the United States, imposing substantial clinical and economic burdens. Although direct-acting antivirals (DAAs) offer cure rates exceeding 95%, access remains constrained due to high drug costs, limited screening uptake, and Medicaid-specific treatment restrictions. In July 2019, Louisiana and Washington implemented subscription-based payment models (SBPMs), which decouple drug pricing from volume to promote broader treatment access through fixed-cost agreements. While theoretically promising, the real-world impact of SBPMs on HCV care delivery and their long-term societal value remains insufficiently evaluated.MethodsThis study integrated retrospective claims-based analysis with decision-analytic modeling to evaluate the clinical and economic implications of SBPMs. Aim 1 used a comparative effectiveness design using payer-complete claims data from the Komodo Health database (2018– 2022), identifying Medicaid Managed Care (MMC) beneficiaries aged 18–64. Synthetic control methods were applied to construct counterfactuals for Louisiana and Washington using data from 14 comparator states, matched on pre-policy trends, state, and patient characteristics. Primary outcomes included HCV screening, RNA testing, and DAA initiation and refill rates, with subgroup and geographic stratification.In Aim 2, a state-specific, lifetime Markov model was developed to simulate disease progression across health states representing chronic infection (F0–F4), decompensated cirrhosis, hepatocellular carcinoma, liver transplantation, background mortality, and liver-related mortality. The model was parameterized using real-world behavioral inputs from Aim 1. Outcomes were assessed from a societal perspective and included total costs, quality-adjusted life years (QALYs), and incremental net monetary benefit (INMB), using a willingness-to-pay (WTP) threshold of $150,000 per QALY.ResultsAim 1: In Louisiana, SBPM implementation led to statistically significant and sustained increases in RNA testing (+35.2 per 100,000 population; P<0.10), DAA initiation (+7.8 per 1,000), and refill rates (+24.4 per 1,000), with improvements consistent across age, sex, and comorbidity subgroups. Conversely, Washington experienced a significant decline in treatment uptake, with DAA initiations and refills decreasing by 3.9 and 12.9 per 1,000 patients, respectively (P<0.10), with no corresponding improvements in screening or RNA testing.Aim 2: In Louisiana, the SBPM generated 6,377,658 QALYs at a societal cost of $56.1 billion, compared to 6,372,194 QALYs and $56.6 billion under traditional pricing. The model projected $506 million in cost savings and an INMB of $1.3 billion, indicating that the SBPM strategy was highly cost-effective. In Washington, SBPM implementation resulted in slightly fewer QALYs (2,235,301 vs. 2,235,972) and higher cost incurred ($95.2 million), yielding a negative INMB and suggesting that the strategy was not cost-effective in that context.ConclusionSBPMs offer a scalable approach to improving access to curative HCV treatment and can yield substantial societal benefits when implemented effectively. However, the different outcomes between Louisiana and Washington underscore the importance of state-level implementation context. DAAs financing reform alone is insufficient to achieve HCV elimination; investments in screening infrastructure, provider engagement, patient outreach, and real-time data monitoring are essential to maximize public health impact. These findings highlight the critical role of integrated policy and system-level interventions in advancing equitable and cost-effective HCV care. |
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| ISBN: | 9798288833786 |
| Fuente: | ProQuest Dissertations & Theses Global |