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Managed Care &HCV Treatment AccessLauren Canary, MPH (Epidemiologist, she/hers)Director, National Viral Hepatitis Roundtable A Program of HEP
Prior Authorization & HCV TreatmentPrior authorization: Utilization management processused by some health insurance companies in the UnitedStates to determine if they will cover a prescribedprocedure, service, or medicationWhen can states impose prior authorization criteria? If the prescribed use is not for a medically acceptedindication If it does not have a therapeutic advantage over otherdrugs included in the formulary ( publicly availablewritten explanation for basis of exclusion)
Tracking Medicaid HCV DAA PriorAuthorization CriteriaLiver Disease SeveritySubstance AbstinenceProvider SpecialtyFor updates and details visit StateOfHepC.org
CMS Guidance is clear: Prior Authorization shouldnot be used to ration hepatitis C treatment“[T]he effect of (PA criteria) should notresult in the denial of access toeffective, clinically appropriate, andmedically necessary treatments usingDAA drugs for beneficiaries withchronic HCV infections.”“[T]he managed care plan may notuse a standard for determiningmedical necessity that is morerestrictive than is used in the stateplan.”
The courts have supported this stanceLitigated Results Washington: BE vs Teeter (injunction granted; settlementapproved, April 2017) Missouri: JEM vs Kinkade (policy reformed, November 2017) Michigan: JV vs Lyon (settlement reached, March 2018) Colorado: Ryan vs Birch (disease severity criteria removed andsettlement pending, April 2018)Pre-Litigation Settlements– CT, DE, FL, IL, MA– NJ, NY, PA, RI, VTSeveral pending cases in development!
States must track MCO practices to ensureenrollees in any MCO have equitable access to FFS42 CFR § 438.210: “Each contractbetween a State and an MCO. . .must. .[r]equire that. . .services. . .be furnishedin an amount, duration, and scopethat is no less than the amount,duration, and scope for the sameservices furnished to beneficiariesunder FFS Medicaid . . .”“States are urged to carefullymonitor the DAA HCV drugcoverage policies of their MCOs toensure enrollees have appropriateaccess.”
Managed Care Organization AccountabilityIncreasing MCO utilization by public payers makestracking that much more important and difficult Medicaid: 238 MCOs: 70% of Enrollees Medicare: 2,317 Medicare Advantage plans: 40% ofenrollees Correctional health: 27 states; 8% of personsincarcerated in state and federal prisonsMCO’s may have financial incentives (esp. in the short term) to denycare—the difference between capitated rate and actual spendingcreates profits, and for IPO’s can spur investor activity.
Number of Medicaid MCOs by state2011436*03*Includes six Health Insuring Organizations (HIOs), member plans in California's CountyOrganized Health Systems (COHS).64
Proportion of incarcerated persons in private stateprison facilities (2017)2% 0%1%1%1%24%Data from the 2019 Bureau of Justice Statistics Report0%20%
Incarcerated persons have a constitutional right toHCV treatmentPer the landmark Supreme Court case Estelle v. Gamble, this requires thatall people who are incarcerated receive the medical standard of care for anycondition.
Litigation for HCV Treatment inCorrectional FacilitiesSettled or Decided (4)Ongoing (10)Colorado: Aragon v. RaemischAlabama: Braggs v. DunnIndiana: Stafford et al v. CarterCalifornia: Bayse et al v. California Dept ofCorrections and Rehabilitation et alMassachusetts: Paszko v. O’BrienFlorida: Hoffer v. JonesPennsylvania: Chimenti v. PennsylvaniaDept of CorrectionsIllinois: Orr et al v. Eleya et alMinnesota: Ligons v. Minnesota Dept ofCorrectionsMissouri: Postawko v. Missouri Dept ofCorrectionsNorth Carolina: Buffkin v. HooksSouth Carolina: Geissler v. SterlingTennessee: Graham v. ParkerVirginia: Riggleman v. Clarke
MCO Accountability–Payment StructureDAA payment structure Paid by managed care Carved out of managed care Hybrid: paid by managed care, but state manages prior authorizationprocessHow does this work with subscription model?In Louisiana, DAAs are part of managed care capitated rates. The state hasincentive to increase utilization due to subscription model, but MCOs don’t.Louisiana created a risk corridor to mitigate risk and is closely monitoringutilization.
Managed Care HCV Treatment AccessMonitoringIn partnership withCHLPI we are trackingMCO coveragerestrictions, pharmacybenefit managers, andcarveout strategies on astate-by-state basis.
MCO Accountability–strategies Explicit language in contract (Medicaid DAA, Private Correctional Health Testing and Tx)Transparency—require MCO’s to make PA publiclyavailableBeneficiary complaints (make public to consumers)Monitor denials (encourage providers to prescribe andtrack denials, appeals processes, etc)Monitor treatment rates (claims data)Other reporting processes and indicators (newdiagnoses; delays in care)Compliance monitoring (review of final priorauthorization criteria)
MCO Accountability–State & FederalAdvocacy Engage patients and providers with state health insurance commissioners and governorsEncourage CMS to implement punitive measures forstates that fail to remove barriers to careLitigationEmpower consumers with knowledge ahead of openenrollment seasonEnact national and state legislation to further addressthe prior authorization process
Prior Authorization & HCV TreatmentOpportunity to address Medicaidand Correctional managed care?H.R.3107 - Improving Seniors' Timely Access to Care Act of 2019(1) use of prior authorization should be streamlined through electronic transmissions forcoverage of covered services for individuals enrolled in federally funded programs suchas Medicare, Medicaid, and federally contracted managed care plans to improvepatient access to medically appropriate services and reduce administrative burden throughautomation informed by clinical decision support;
We are happy to work with state andfederal partners to ensure equitableaccess to HCV care.NVHR.orgFor questions contact:Lauren@NVHR.org
and Correctional managed care? H.R.3107 - Improving Seniors' Timely Access to Care Act of 2019 (1) use of prior authorization should be streamlined through electronic transmissions for coverage of covered services for individuals enrolled in federally funded programs such as Medicare, Medicaid, and federally contracted managed care plans to improve
