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The American Journal of Managed Care Special Issue: HCV
Real-World Outcomes of Ledipasvir/Sofosbuvir in Treatment-Naïve Patients With Hepatitis C
Zobair M. Younossi, MD, MPH, FACG, AGAF, FAASLD; Haesuk Park, PhD; Stuart C. Gordon, MD; John R. Ferguson; Aijaz Ahmed, MD; Douglas Dieterich, MD; and Sammy Saab, MD, MPH
Sofosbuvir Initial Therapy Abandonment and Manufacturer Coupons in a Commercially Insured Population
Taruja D. Karmarkar, MHS; Catherine I. Starner, PharmD; Yang Qiu, MS; Kirsten Tiberg, RPh; and Patrick P. Gleason, PharmD
Improving HCV Cure Rates in HIV-Coinfected Patients - A Real-World Perspective
Seetha Lakshmi, MD; Maria Alcaide, MD; Ana M. Palacio, MD, MPH; Mohammed Shaikhomer, MD; Abigail L. Alexander, MS; Genevieve Gill-Wiehl, BA; Aman Pandey, BS; Kunal Patel, BS; Dushyantha Jayaweera, MD; and Maria Del Pilar Hernandez, MD
Does Patient Cost Sharing for HCV Drugs Make Sense?
Darius N. Lakdawalla, PhD; Mark T. Linthicum, MPP; and Jacqueline Vanderpuye-Orgle, PhD
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A Way Out of the Dismal Arithmetic of Hepatitis C Treatment
Jay Bhattacharya, MD, PhD, Center for Primary Care and Outcomes Research, Stanford University School of Medicine; Guest Editor-in-Chief for the HCV special issue of The American Journal of Managed
The Wider Public Health Value of HCV Treatment Accrued by Liver Transplant Recipients
Anupam B. Jena, MD, PhD; Warren Stevens, PhD; Yuri Sanchez Gonzalez, PhD; Steven E. Marx, PharmD; Timothy Juday, PhD; Darius N. Lakdawalla, PhD; and Tomas J. Philipson, PhD
Costs and Spillover Effects of Private Insurers' Coverage of Hepatitis C Treatment
Gigi A. Moreno, PhD; Karen Mulligan, PhD; Caroline Huber, MPH; Mark T. Linthicum, MPP; David Dreyfus, DBA; Timothy Juday, PhD; Steven E. Marx, PharmD; Yuri Sanchez Gonzalez, PhD; Ron Brookmeyer, PhD; and Darius N. Lakdawalla, PhD
Coverage for Hepatitis C Drugs in Medicare Part D
Jeah Kyoungrae Jung, PhD; Roger Feldman, PhD; Chelim Cheong, PhD; Ping Du, MD, PhD; and Douglas Leslie, PhD

A Way Out of the Dismal Arithmetic of Hepatitis C Treatment

Jay Bhattacharya, MD, PhD, Center for Primary Care and Outcomes Research, Stanford University School of Medicine; Guest Editor-in-Chief for the HCV special issue of The American Journal of Managed
This special issue presents important new peer-reviewed research, covering issues ranging from access and the out-of-pocket costs of a treatment course, to the real-world consequences-both economic and clinical-of failing to treat.
Am J Manag Care. 2016;22(5 Spec Issue No. 6):SP183-SP184
Although the medical prospects facing patients with hepatitis C virus (HCV) have never been better, the prospect of gaining access to a cure is another matter for many patients. About 2.7 million Americans suffer from chronic HCV, with 170 million worldwide.1 After decades of research and billions of dollars in investment, we now have a definitive treatment—direct-acting antivirals (DAAs)—that can cure this serious illness.2 Better still, the pills are relatively cheap to produce and future improvements in production technology are likely to make them even cheaper in the future.3
Despite this obviously great news for patients with HCV, there is good reason to worry about the high costs of DAA treatment: the average cost for a complete 12-week course of one such treatment is $84,000.4 At this price, many insurers are reluctant to provide full access to DAAs for all patients with HCV; Medicaid programs provide only limited access.5
This special issue of The American Journal of Managed Care presents important new peer-reviewed research about the consequences of this dismal arithmetic of HCV treatment. The papers cover ground ranging from the out-of-pocket costs of a DAA treatment course to the real-world consequences—both economic and clinical—of failing to treat.
A paper by Jung et al6 documents substantial out-of-pocket costs for patients with HCV on Medicare. They show that such patients face up to almost $11,000 in out-of-pocket costs for a complete course of treatment with DAAs. Even low-income patients with HCV who qualify for low-income subsidies from the federal government can face out-of-pocket costs of up to $1200 for a course of treatment. Another paper, by Karmarkar et al,7 shows that insurance coverage greatly increases adherence to therapy; conversely, high out-of-pocket costs greatly increase the likelihood of prematurely abandoning therapy.
Two papers document the clinical effects of DAAs on disparate populations in the real world. Younossi et al8 find that the high rate of cures observed in clinical trials of patients with HCV are realized in real-world practices for treatment-naïve patients. In contrast, Lakshmi et al9 find that cure rates with DAAs are lower in a population coinfected with HIV and HCV than what would be expected based on the clinical trial data. They argue that improved adherence to therapy, including follow-up clinic visits, greatly increases the probability of a cure in this population.
Multiple papers also document the considerable direct and indirect benefits that would come from universal coverage for DAA treatment. Moreno et al10 calculate savings over a longer period, and find that curing patients with HCV would save billions of healthcare dollars that would otherwise be spent on traditional therapies in the coming decades in the absence of curative treatment with DAAs. Jena et al11 identify an unanticipated boon from HCV cures: treatment with DAAs benefits non-HCV patients with liver failure who are awaiting transplant by reducing wait times and mortality rates.  This happens because curing patients with HCV reduces the number of those patients who will need a transplant. Finally, Linthicum et al12 calculate that a strategy of widespread screening of patients for HCV, combined with treatment to cure with DAAs at an early stage of the disease, generates nearly $1 trillion in social benefit.
Together, this collection of research makes a strong case that providing patients with HCV with access to curative treatment at an affordable price would create enormous benefits for both the patients and for society at large. Two commentaries13,14 also published in this special issue argue that given these facts, insurance should cover these drugs and that patients with HCV should face little or no cost sharing to access treatment. Although this notion makes sense given the benefits of DAA treatment for all patients with HCV, there is still a risk of higher insurance premiums if insurers follow this advice.

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