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The American Journal of Managed Care February 2019
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Impact of Hepatitis C Virus and Insurance Coverage on Mortality
Haley Bush, MSPH; James Paik, PhD; Pegah Golabi, MD; Leyla de Avila, BA; Carey Escheik, BS; and Zobair M. Younossi, MD, MPH
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A. Mark Fendrick, MD; and Darrell George, BA
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Sachin H. Jain, MD, MBA
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Nirosha Mahendraratnam, PhD; Corinna Sorenson, PhD, MHSA, MPH; Elizabeth Richardson, MSc; Gregory W. Daniel, PhD, MPH, RPh; Lisabeth Buelt, MPH; Kimberly Westrich, MA; Jingyuan Qian, MPP; Hilary Campbell, PharmD, JD; Mark McClellan, MD, PhD; and Robert W. Dubois, MD, PhD
Medication Adherence as a Measure of the Quality of Care Provided by Physicians
Seth A. Seabury, PhD; J. Samantha Dougherty, PhD; and Jeff Sullivan, MS
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Anna D. Sinaiko, PhD, MPP; Shehnaz Alidina, SD, MPH; and Ateev Mehrotra, MD, MPH
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Thomas E. Kottke, MD, MSPH; Jason M. Gallagher, MBA; Marcia Lowry, MS; Pawan D. Patel, MD; Sachin Rauri, MS; Juliana O. Tillema, MPA; Jeanette Y. Ziegenfuss, PhD; Nicolaas P. Pronk, PhD, MA; and Susan M. Knudson, MA
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Impact of Hepatitis C Virus and Insurance Coverage on Mortality

Haley Bush, MSPH; James Paik, PhD; Pegah Golabi, MD; Leyla de Avila, BA; Carey Escheik, BS; and Zobair M. Younossi, MD, MPH
The Medicaid population has significantly higher hepatitis C virus (HCV) prevalence and mortality rates than patients with private insurance. These data must be considered when policy makers assess providing additional support to Medicaid programs for HCV elimination.

Objectives: To assess the association of payer status and mortality in hepatitis C virus (HCV)–infected patients.

Study Design: For this retrospective observational study, we used the National Health and Nutrition Examination Survey from 2000 to 2010. Adults with complete data on medical questionnaires, HCV RNA, insurance types, and mortality follow-ups were included.

Methods: We used Cox proportional hazards models to evaluate independent associations of insurance type with mortality in HCV-infected individuals. These models were rerun in the subset of HCV-positive subjects to determine the association of insurance type with mortality. The data used in this study predated the implementation of the Affordable Care Act.

Results: Among 19,452 eligible participants, 311 (1.4%) were HCV positive. HCV-positive patients were older, were more likely to be non-Hispanic black and male, and had higher prevalence of hypertension (all P <.001). HCV-positive patients were also less likely to have private insurance and more likely to be covered by Medicaid or be uninsured relative to HCV-negative patients (P <.001). Among HCV-positive patients, after adjustment for confounders, those with Medicaid coverage had an increased risk of mortality compared with those with private insurance (hazard ratio [HR], 6.31; 95% CI, 1.22-29.94) and uninsured individuals (HR, 8.83; 95% CI, 1.56-49.99).

Conclusions: Patients who have HCV are more likely to be uninsured or covered by Medicaid. HCV-positive patients with Medicaid have an increased mortality risk compared with those with private insurance. Given the high burden of HCV infection and adverse prognosis among individuals covered by Medicaid, policy makers must prioritize funding and supporting Medicaid programs.

Am J Manag Care. 2019;25(2):61-67
Takeaway Points
  • Hepatitis C virus (HCV) prevalence is significantly higher among patients with Medicaid compared with patients with private insurance and Medicare.
  • Medicaid patients who are infected with HCV have a higher risk of all-cause mortality than HCV-positive patients with private insurance coverage.
  • Policy makers should consider providing additional resources to Medicaid to cover all HCV-infected individuals.
In the United States, the estimated prevalence of individuals with hepatitis C virus (HCV) ranges from 5.2 million to 7.1 million.1-3 The majority of individuals infected with HCV were born between 1945 and 1964—the generation known as baby boomers—but there has been an increase in the number of infected individuals younger than 30 years due to intravenous drug use, which has contributed to a bimodal age distribution of HCV burden.4-6 If untreated, HCV can cause significant liver disease, making it the leading cause of cirrhosis, hepatocellular carcinoma, and liver transplantation in the United States.7-10 Until recently, the standard treatment for HCV was interferon based and had low sustained virologic response (SVR) rates, resulted in frequent adverse effects, and impaired patients’ health-related quality of life.11-13 However, new treatment regimens containing direct-acting antivirals (DAAs) boast cure rates higher than 96% and improve health-related quality of life during treatment and post SVR.14-17 Although the effectiveness of HCV treatment has steadily improved, these regimens have remained relatively expensive, with potential budgetary implications for payers.18 This issue is especially important to the Medicare and Medicaid programs because of the high burden of HCV infection in their covered populations.19,20 In fact, Medicare and Medicaid are currently the primary payers for the majority of HCV-associated cirrhosis hospitalizations.21 With the aging of the baby boomers with HCV and the high prevalence of HCV in the Medicare and Medicaid populations, the future ability of these programs to cover the cost of the new and more costly anti-HCV treatments can be challenging.

It is important to note that in the United States, the affordability of healthcare, especially medications, is largely dependent on insurance type. Some types of insurance cover nearly all the up-front costs of medications, whereas others require individuals to pay large sums of money for out-of-pocket expenditures. In this context, it is possible that insurance type may influence health outcomes by creating potential barriers to accessing beneficial treatment.19-22 This is especially relevant for the new anti-HCV regimens that have high efficacy but also substantial budgetary impact.17 In fact, these up-front costs of covering the new anti-HCV medications have led to substantial access restrictions by some payers, especially some states’ Medicaid programs.23 In this context, it is possible that the characteristics of patients with HCV covered by different types of insurance, coupled with their ease of access to treatment regimens, could potentially affect their outcomes. Therefore, the aim of our analysis was to use National Health and Nutrition Examination Survey (NHANES) data and linked mortality files to assess the burden and outcomes of HCV infection according to insurance coverage types in the United States.


Study Population

NHANES is a stratified, multistage probability sample representative of the noninstitutionalized civilian US population. The third NHANES was conducted in 1988-1994; beginning in 1999, the survey became a continuous program, with every 2 years representing 1 cycle. Each survey is composed of a home interview for demographic, socioeconomic, dietary, and health-related questions; a subsequent standardized physical examination; and laboratory tests from blood samples collected at a mobile examination center. Detailed descriptions of the plan and operation of each survey are available elsewhere.24 We used data from 5 NHANES cycles (2001-2010). To determine NHANES participants’ mortality status, we used the public-use Linked Mortality File, in which participants who were 18 years and older are linked to death records from the National Death Index through December 31, 2011.25 The eAppendix Figure (eAppendix available at represents the inclusion and exclusion criteria for the study population.

Collected Data and Definitions

Eligible participants were considered to have chronic hepatitis C (defined as HCV positive) if their serum tested positive for HCV RNA. Participants without HCV RNA were defined as HCV negative. Insurance types were categorized into 4 groups: (1) private insurance, including any military/state/government insurance; (2) Medicare; (3) Medicaid; and (4) uninsured. Patients with dual insurance (eg, private insurance and Medicare, Medicaid and Medicare) who could not be classified into a payer category were excluded. The following comorbidities were ascertained largely through the questionnaires completed by NHANES participants: history of arthritis, cancer, chronic obstructive pulmonary disease (COPD, which included either chronic bronchitis or emphysema), congestive heart disease (CHD), ischemic heart disease (IHD), kidney failure, and stroke.

Other clinical variables were defined as follows. Obesity was defined as a body mass index of 30 kg/m2 or greater, and type 2 diabetes (T2D) was defined as a fasting glucose value of 126 mg/dL or greater or current use of oral hypoglycemic and/or insulin. A diagnosis of hypertension (HTN) required a mean systolic blood pressure of 140 mm Hg or greater, mean diastolic blood pressure of 90 mm Hg or greater, or current use of an antihypertensive. Hypercholesterolemia was defined as a total serum cholesterol of 200 mg/dL or greater, a low-density lipoprotein of 130 mg/dL or greater, current use of an antihyperlipidemic drug, or a high-density lipoprotein (HDL) of 40 mg/dL or less in men or 50 mg/dL or less in women. A diagnosis of metabolic syndrome was defined as having at least 3 of the following26: waist circumference greater than 102 cm in men or 88 cm in women, fasting plasma glucose greater than 110 mg/dL, blood pressure greater than 130/85 mm Hg, elevated triglycerides greater than 150 mg/dL, and HDL of 40 mg/dL or less in men or 50 mg/dL or less in women.

Participants’ age, race/ethnicity, sex, military service, college degree, marital status, employment, excessive alcohol consumption (if more than 20 g per day in men and more than 10 g per day in women), smoking status, and poverty income ratio (PIR) were based on self-reported data from the NHANES in-home interview.

Of note, the data used in this study predated the implementation of the Affordable Care Act (ACA).

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