Comparative Evaluation of State-Level Subscription-Based Payment Models for Hepatitis C Drugs.

BACKGROUND

Subscription-based payment models (SBPMs) have been adopted to expand access to hepatitis C virus (HCV) treatment within Medicaid programs.

OBJECTIVE

To evaluate the impact of SBPMs on HCV screening, RNA testing, and direct-acting antiviral (DAA) uptake among Medicaid Managed Care enrollees in Louisiana and Washington, and to identify factors associated with differential policy effects.

RESEARCH

DESIGN

Quasi-experimental study using the synthetic control method to compare outcomes in Louisiana and Washington-the only states implementing SBPMs in July 2019-with weighted combinations of 14 control states.

SUBJECTS: Adults aged 18-64 years or older enrolled in Medicaid Managed Care between January 2018 and December 2022.

MEASURES: Monthly HCV screening, RNA testing, DAA initiation, and refill rates identified from payer-complete closed claims.

RESULTS

Louisiana SBPM was associated with significant increases in RNA testing (+35.2/100,000 persons/mo), DAA initiation (+7.8/1000 patients/mo), and DAA refills (+24.4/1000 patients/mo; all P=0.07). Gains were broad-based across subgroups and geographically consistent. Washington SBPM was associated with nonsignificant screening changes and significant declines in DAA initiation (-3.6/1000 patients/mo) and refills (-12.9/1000 patients/mo; P=0.07), with uniformly negative or null subgroup effects.

CONCLUSIONS

SBPM yielded markedly different outcomes across states. Louisiana gains likely reflect convergence with recent Medicaid expansion and prior removal of DAA restrictions, generating a large treatment-eligible pool at implementation. Washington earlier expansion (2014) and fibrosis-restriction removal (2016) may have already addressed this demand. As the federal government invests $12.3 billion in HCV elimination with SBPM as a central mechanism, payment reform must be paired with comprehensive strategies-including provider engagement, screening infrastructure, and patient navigation-to achieve elimination goals.