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The American Journal of Managed Care August 2018
Impact of a Medical Home Model on Costs and Utilization Among Comorbid HIV-Positive Medicaid Patients
Paul Crits-Christoph, PhD; Robert Gallop, PhD; Elizabeth Noll, PhD; Aileen Rothbard, ScD; Caroline K. Diehl, BS; Mary Beth Connolly Gibbons, PhD; Robert Gross, MD, MSCE; and Karin V. Rhodes, MD, MS
Choosing Wisely Clinical Decision Support Adherence and Associated Inpatient Outcomes
Andrew M. Heekin, PhD; John Kontor, MD; Harry C. Sax, MD; Michelle S. Keller, MPH; Anne Wellington, BA; and Scott Weingarten, MD
Precision Medicine and Sharing Medical Data in Real Time: Opportunities and Barriers
Y. Tony Yang, ScD, and Brian Chen, PhD, JD
Levers to Reduce Use of Unnecessary Services: Creating Needed Headroom to Enhance Spending on Evidence-Based Care
Michael Budros, MPH, MPP, and A. Mark Fendrick, MD
From the Editorial Board: Michael E. Chernew, PhD
Michael E. Chernew, PhD
Optimizing Number and Timing of Appointment Reminders: A Randomized Trial
John F. Steiner, MD, MPH; Michael R. Shainline, MS, MBA; Jennifer Z. Dahlgren, MS; Alan Kroll, MSPT, MBA; and Stan Xu, PhD
Impact of After-Hours Telemedicine on Hospitalizations in a Skilled Nursing Facility
David Chess, MD; John J. Whitman, MBA; Diane Croll, DNP; and Richard Stefanacci, DO
Baseline and Postfusion Opioid Burden for Patients With Low Back Pain
Kevin L. Ong, PhD; Kirsten E. Stoner, PhD; B. Min Yun, PhD; Edmund Lau, MS; and Avram A. Edidin, PhD
Patient and Physician Predictors of Hyperlipidemia Screening and Statin Prescription
Sneha Kannan, MD; David A. Asch, MD, MBA; Gregory W. Kurtzman, BA; Steve Honeywell Jr, BS; Susan C. Day, MD, MPH; and Mitesh S. Patel, MD, MBA, MS
Currently Reading
Evaluating HCV Screening, Linkage to Care, and Treatment Across Insurers
Karen Mulligan, PhD; Jeffrey Sullivan, MS; Lara Yoon, MPH; Jacki Chou, MPP, MPL; and Karen Van Nuys, PhD
Medicare Advantage Enrollees’ Use of Nursing Homes: Trends and Nursing Home Characteristics
Hye-Young Jung, PhD; Qijuan Li, PhD; Momotazur Rahman, PhD; and Vincent Mor, PhD

Evaluating HCV Screening, Linkage to Care, and Treatment Across Insurers

Karen Mulligan, PhD; Jeffrey Sullivan, MS; Lara Yoon, MPH; Jacki Chou, MPP, MPL; and Karen Van Nuys, PhD
An optimized hepatitis C virus screening and linkage-to-care process reduces the number of patients lost to follow-up and improves linkage to care for Medicare, Medicaid, and commercially insured patients.
Model Scenarios

The baseline scenario previously described requires at least 4 visits before chronically infected patients receive a treatment recommendation (Figure 1). We also estimated reflex and consolidated scenarios in which chronically infected patients require a minimum of 3 or 2 visits, respectively, before treatment recommendation. All stages of the SLTC process in baseline are included in reflex and consolidated, but they are condensed to varying degrees. Beyond the treatment decision step, the 3 scenarios are identical.

Baseline includes the SLTC steps recommended in current HCV guidelines, with each step in the process requiring a separate visit and only specialists providing genotype testing, fibrosis staging, and treatment decisions. Baseline thus requires 4 visits for a chronically infected patient to receive a treatment recommendation and is the least efficient scenario.

Reflex also includes the SLTC steps recommended in current HCV guidelines, but reflexes antibody and RNA testing so that 2 blood samples are collected from a single draw at the first visit and if the first is Ab+, the second is automatically tested for HCV RNA.17,18 Thus, the process can be completed in 3 visits rather than 4.

Reflex also eliminates the specialist visit for less clinically complex patients who can be effectively managed by primary care physicians (PCPs). To be conservative, we assumed that only patients with fibrosis scores below F2 can be managed by PCPs, which resulted in 60% of patients requiring a specialist visit.19

Consolidated represents a hypothetical best-case scenario in which all tests are reflexed and a specialist visit is not required for patients with fibrosis scores below F2. This scenario requires at least 2 visits for chronically infected patients to receive a treatment decision and provides the fewest opportunities for patients to be lost.

Although pangenotypic treatment is now available, guidelines still recommend genotype testing, and all 3 scenarios include it. Genotype testing can also be used to guide treatment for patients who do not receive pangenotypic treatment. To reflex noninvasive fibrosis staging, diagnostic tests using a blood draw (eg, AST [aspartate aminotransferase] to Platelet Ratio Index or FibroTest) would be required.20 Although these may be uncommon as the primary means for fibrosis staging in current practice, they are feasible. Current HCV treatment guidelines recommend combined blood- and image-based fibrosis testing, so our consolidated scenario should be considered exploratory, as an estimate of potential benefits from an SLTC process that minimizes patient visits.3

Model Outcomes

We estimated several outcomes for each scenario and insurance type: number of patients lost at each stage, yield (percentage of patients entering the model who complete the process and initiate treatment), conditional yield (percentage of patients with chronic HCV who complete the process and initiate treatment), and several cost outcomes. Total screening costs include the cost of antibody testing, RNA testing, genotype testing, fibrosis staging, and, when relevant, specialist and sobriety costs. Total costs include screening costs plus the cost of treatment. We assumed that treatment cost equals the wholesale acquisition cost of sofosbuvir 400 mg/velpatasvir 100 mg (Epclusa) discounted by 46%.3 To estimate the cost to identify and link 1 additional patient to care, we calculated the number of patients screened to yield 1 patient in the genotype/fibrosis step of the model and calculated the cost of antibody and RNA testing for those patients. This outcome provides an additional measure of efficiency of the SLTC process prior to receiving a treatment recommendation and is independent of the number of patients treated. Other outcomes are presented in the eAppendix, including cost per person screened, timing-related results, and yield conditional on the number of Ab+ patients.

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