Michigan's removal of prior authorization last month for Medicaid patients to receive expensive but effective hepatitis C medications could begin to expand access to the cure for up to 200,000 people in the state living with the virus, said a University of Michigan specialty physician.
If left untreated, hepatitis C can cause cause liver damage or cancer and death, said Dr. Ponni Perumalswami, a Michigan Medicine gastroenterologist and transplant hepatologist.
Despite advances in treatment for hepatitis C the past four years, Michigan has seen a 71% increase in acute cases over the same time period.
"There's been this dramatic increase nationally and Michigan. It is quite pronounced in rural areas and it parallels areas where there's been increased numbers of opioid use disorder and opioid-use related overdose deaths," said Perumalswami, who also sees many veterans at the VA Ann Arbor Healthcare System.
"You also have all these unintended infectious disease-related complications," she said. "Hepatitis C, notably, is one of those big infectious complications we've seen."
In 2018, Michigan's rate was 1.4 new cases per 100,000 people, the Michigan Department of Health and Human Services said. The 2018 national rate is 1.2 new cases per 100,000, according to the Centers for Disease Control and Prevention.
"Since 2010, hepatitis C has risen for those under the age of 40, nearly doubled from 22% to 41%" of cases, Perumalswami said. Nationally, there are more than 50,000 total cases of hepatitis C.
With Michigan, seven states now do not require prior authorization for hepatitis C treatment, including California, Indiana, Louisiana, New York, Washington and Wisconsin, according to the Center for Health Law and Policy Innovation of Harvard Law School and the National Viral Hepatitis Roundtable.
Michigan has been a leader in removing barriers to hepatitis C treatment for several years, a CHLPI spokesperson said. Effective April 1, MDHHS removed prior authorization requirement for the antiviral Mavyret, one of several hepatitis C medications,
"We encourage all payers and providers to immediately implement policies that eliminate prior authorization and other forms of unduly burdensome utilization management to help improve individual and public health outcomes, especially amid the ongoing coronavirus pandemic," Phil Waters, a staff attorney with CHLPI, said in a statement.
One of the barriers for people with hepatitis C is prior authorization restrictions for testing and treatment for Medicaid and private health insurance patients. Another has been the expensive treatment. When the newer pill-based hepatitis C medications were first approved in 2016, one treatment course ran about $90,000. Prices have dropped recently for the three or four available drugs to about $50,000 for a 12-week course, but could be lower as larger health care companies buy in bulk.
Mavyret has been priced by AbbVie at $13,200 per month, or $26,400 per treatment course, before various discounts and significantly lower than other hepatitis C treatments, according to GoodRx.
Medicare covers screenings to detect hepatitis C and Medicare Part D plans must include at least one hepatitis C treatment medication.
To get the word out, the Michigan Department of Health and Human Services also has launched a public service initiative, "We Treat Hep C," to eliminate hepatitis C as a health threat. It also unveiled a plan for providers to eliminate hepatitis C virus in the state.
Gov. Gretchen Whitmer on Tuesday announced May as Hepatitis Awareness Month to encourage Michigan residents to get tested.
"It is crucial that all Michiganders receive hepatitis C virus testing at least one time in their life, and more frequently if they are in an at-risk category," Dr. Joneigh Khaldun, the state's chief medical executive, said in a statement. "HCV is curable, and we are committed to making both testing and treatment accessible for all residents in need."
Perumalswami said Michigan's initiative will help raise awareness among at-risk populations for hepatitis C, encourage testing and screening for hepatitis C, and reduce barriers to curative hepatitis C treatment.
"It is encouraging to see states like Michigan develop hepatitis C elimination plans, and as a part of that, improve hepatitis C testing and treatment options. Removing prior authorizations for preferred treatment eliminates one unnecessary hurdle for getting patients the care they need," Adrienne Simmons, NVHR's director of programs, said in a statement.
In a statement, Blue Cross and Blue Shield of Michigan said it would contact Medicaid members ages 18 and older about the importance of getting tested for the hepatitis C virus.
"Blue Cross Complete also will be reaching out and educating providers and pharmacies on this initiative," the statement said. "We'll also be doing telephonic outreach and care coordination, including for those testing positive to initiate treatment with Mavyret."
For its commercial policies, Blue Cross said prior authorization criteria will continue.
"We believe the review process helps our members get the right drug at the right time and provides ample access. It supports correct regimen selection, prevents too short a treatment course and accurate genotype matching. It also helps ensure that past member treatment experience and member comorbidities are taken into account," Blue Cross said.
But Perumalswami said prior authorization policies don't fully take into account the 71% increase in hepatitis C numbers in Michigan and how to slow the upward trend.
"We have a lot of young people engaged in injections and we need an integrated approach" to testing for hepatitis C and also opioid use disorder," said Perumalswami, who also is part of the provider advocacy group the National Viral Hepatitis Roundtable.
"Hepatitis C is so very stigmatized and we need to reach these populations," she said.
Hepatitis C is a disease caused by a virus that infects the liver. The infection can lead to inflammation of the liver and cause the immune system to attack healthy liver cells.
The biggest difference between hepatitis B and hepatitis C is that people may get the much more common hepatitis B from contact with the bodily fluids of a person who has the infection. Hepatitis C usually spreads through blood-to-blood contact. Combined, chronic hepatitis B and C account for approximately 80 percent of the world's liver cancer cases.
"My focus the past few years has really been on viral hepatitis and trying to understand the barriers, mostly on the system level, and then provider barriers to engaging patients at risk for treating patients living with viral hepatitis, both C and B," Perumalswami said.
Last year, the CDC updated its guidelines on who should be tested for hepatitis C. The CDC said that every adult should be tested at least once in their lifetime and any person who's pregnant should be getting tested.
"Testing the first critical step to getting people treated. Like if you don't know who's diagnosed and living with it, we can't effectively treat them. So the hope is now that we will get more people tested."
But Perumalswami she said more testing is needed because a lot of people are living with hepatitis C because it's a "silent infection" as many people don't know they have it.
"The medications result in more than 95% of people getting cured. And it's very safe and tolerated very well by patients," she said.
Over the past six months, Perumalswami has been working with a group of 15 providers across Michigan, mostly in rural counties, to support them with hepatitis C testing and treatment for their patients.
"We've discussed 50 cases with one-third having started treatment and two are already cured," she said. "We talk about very practical strategies of how to encourage people into treatment. It's expensive but much less so compared with a liver transplant."
Perumalswami said she hopes treatment costs go down to the point where people can go to a retail pharmacy and get hepatitis C medication the same day.
"Michigan can be the model here, but it really starts with testing," Perumalswami said. "We have got to get the word out about every person getting tested, every woman who's pregnant with these pregnancy tested and then get them into treatment."
