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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.

Lost to Follow-Up and Yield

SLTC results for each strata and scenario are presented in Figures 2, 3, and 4. The figures show the number of patients lost after each step; fewer patients lost indicates a more efficient process. In baseline, 12% of Medicaid, 6% of Medicare, and 4% of commercial patients are lost before treatment. Across all insurance types, most patients are lost after RNA testing. For reflex and consolidated, 4.0% and 0.7%, respectively, are lost before treatment for Medicaid, 2.0% and 0.5% for Medicare, and 1.0% and 0.3% for commercial patients.

Yield and total lost results are presented in the Table. Yield incorporates both HCV prevalence in the screened population and the likelihood of loss. High yields therefore result from high prevalence, screening process efficiency, or both. Baseline yields are 0.5%, 0.7%, and 0.2% for Medicaid, Medicare, and commercial patients, respectively. The higher efficiency of the reflex and consolidated models translates into higher yields; reflex yields are 3.5%, 3.1%, and 0.9%, respectively, and 4.9%, 4.4%, and 1.2% in consolidated.

Conditional yield describes the efficiency of the screening process for chronically infected patients. Baseline conditional yields are 4%, 9%, and 5% for Medicaid, Medicare, and commercial, respectively, increasing to 28%, 44%, and 22% in reflex and 31%, 49%, and 24% in consolidated.


The Table also presents total costs, total screening costs, screening costs per patient treated, and the cost to identify 1 additional patient and link them to care. We used undiscounted costs in our model; therefore, our cost results represent an upper bound.

Total costs are driven by the total treated, and in baseline are highest for Medicare ($3.1 million) and lowest for commercial ($1.0 million); total costs increase substantially for reflex and consolidated, ranging from $3.8 million to $15.1 million and $5.3 million to $21.0 million, respectively. Although commercial has the lowest total screening cost, it also treats the fewest patients, leading to higher per person costs. In baseline, the cost per person treated is $7843 for Medicaid, $4833 for Medicare, and $14,176 for commercial.

For baseline, the cost to identify 1 additional chronically infected patient and link them to care is highest in the commercial population ($2546) and lowest in the Medicare population ($1539), but Medicaid sees the largest reductions in that cost when the process is collapsed from baseline to reflex or consolidated.

Alternative Analyses

Three alternative analyses were conducted: (1) “fixed prevalence,” which assumed the same HCV Ab+ prevalence across insurance types; (2) “no genotype,” which removed genotype testing; and (3) “no sobriety requirements,” which removed sobriety requirements. Results for alternative analyses are presented in the eAppendix.

“Fixed prevalence” allows us to compare the efficiency of the SLTC process across insurance types while holding constant population disease prevalence. Commercial has the highest per person costs in the main analysis, but Medicaid and commercial costs are similar in the fixed prevalence analysis, suggesting that lower per person costs in Medicaid are driven primarily by higher prevalence.

Although genotype testing is still recommended in HCV treatment guidelines, “no genotype” explores the impact of removing genotype testing, which may be possible with pangenotypic therapies. Because genotype testing occurs during the same visit as fibrosis staging, removing it reduces per person costs by $351 but does not reduce visits.

“No sobriety requirements” removes a barrier to treatment initiation that occurs late in the SLTC process and affects only the Medicaid population. Removing sobriety testing reduces screening costs by $48 per drug test.

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