Policy Options for Expanding Access to HCV Testing and Treatment

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1 Policy Options for Expanding Access to HCV Testing and Treatment Jeffrey Levi, PhD A National Summit to Improve Access to HCV Testing, Treatment, and Cure June 17, 2014

2 A tale of four people with HCV 100% FPL, Medicaid expansion state 100% FPL, nonexpansion state 100% FPL, nonexpansion state, coinfected with HIV 200% FPL, any state (mono or co-infected) Screening with no cost sharing? Monitoring/behavioral support covered (with cost sharing limits) Yes Yes Yes No No No Yes Yes Yes Yes Yes Yes Rx coverage (with cost sharing limits)

3 The Quality of HCV Management Must Improve for Patients to Benefit from HCV Therapy 120% 100% ~ 3 million persons living with HCV 80% 60% 40% 20% 0% 50% 38% 23% 11% 6% N.B.: HCV RNA test indicates whether patient s infection is current or not. Holmberg S, et al, NEJM, 2013)

4 Policy challenges How do we align new opportunities from the Affordable Care Act with a realignment of investments from categorical programs? How do we (should we?) address geographic disparities in access to life-saving treatment? Have we defined what needs to surround the treatment cascade?

5 ACA Opportunities Coverage of screening without cost sharing (private plans, Medicaid expansion, Medicare) Coverage of all medical aspects of care Coinsurance caps for those below 400% of FPL and purchasing insurance on the exchanges Coinsurance limits for Medicaid expansion

6 Remaining challenges (1) Outreach for screening Performance measure for plans? Population health responsibility for Accountable Care Organizations and ACO look-alikes? Financial penalties if not reaching targets for screening? Options for Medicaid coverage of community health workers Warm handoff from screening to care Patient navigators Categorical funding support?

7 Remaining challenges (2) Behavioral support prior to treatment Personal health (obesity, alcohol use) Prevention of transmission Community health workers Community-based organizations Supported within and outside health care financing Classification of drugs by exchange plans Federal/state policy decisions

8 Improving Population Health Outcomes Depends on Transforming the Health System to Coordinate and Integrate Primary Care, Public Health and Community Prevention Efforts Incentives for providers to achieve pop. health outcomes and improve quality Incentives for plans/acos to address population health outcomes Funding mechanisms that enable braiding of financing streams Interventions at the intersection of primary care, public health and the social determinants of health require: Common agendas and goals Shared responsibility A compelling story Partnerships and collaboration Leadership and Integrators Data Financing systems Accountability mechanisms Policy leadership on programs and policies that improve community health Community health assessments Educating policymakers, agencies, and stakeholders regarding pop. health Population health data tracking and analytic tools Payers, Insurers, and ACOs Health Care System/ Primary Care Interventions At The Intersection Public Health Community Prevention/ Social Determinants of Health (SDOH) Public policy is a critical lever to support all of these activities Improved Population Health, Health Outcomes, and Lower Costs (Triple Aim) Primary care & team based care Patient assessments include personal data and SDOH regarding patients homes and communities Quality improvement Leveraging, linkages and referrals to community resources Data collection & EHRs contribute to community health data base Coordination with community health outreach workers Chronic disease mgmt Social and support services Disease prevention and management programs Outreach and referral to clinicians Education, including health education Coalitions and advocacy to address SDOH Community engagement

9 What structures make this work? From ACOs to Accountable Care Communities Who is the integrator in each community? Health departments? Community based organizations? How are gaps filled and standard of care assured? Ryan White-like program? Or expansion of the mission of Ryan White? Address issues system doesn t Serve those federal/state policy has left behind Serve as integrator

10 What will it take? Holding systems and officials accountable as part of the triple aim Making a return on investment case Mobilizing communities Adapting existing programs to new realities Partnering across institutional lines in ways public health has not done in the past