The AIDS Institute HCV Testing and Coverage – Impact of Health Care Reform Carl Schmid Deputy Executive Director The AIDS Institute Washington, DC July 10, 2014
Outline • Why Hepatitis Screening is Important • The USPSTF • Hepatitis C Testing Grade • Prevention and the ACA • Coverage by each payer Medicare • Private Insurance • Medicaid • • Next Steps The AIDS Institute
Why HCV Testing is Important Source: Yehia BR, Schranz AJ, Umscheid CA, Lo Re V III (2014) The Treatment Cascade for Chronic Hepatitis C Virus Infection in the United States: A Systematic Review and Meta-Analysis. PLoS ONE 9(7): e101554. doi:10.1371/journal.pone.0101554 The AIDS Institute
US Preventive Services Task Force (USPSTF) Sponsored by Agency for Healthcare Research and Quality • (AHRQ) at the HHS Leading independent panel of private-sector experts in • prevention and primary care “Conducts rigorous, impartial assessments” of evidence for • effectiveness of clinical preventive services, including screening, counseling, and preventive medications Key to coverage determinations, particularly in health reform • implementation The AIDS Institute
USPSTF Grades Grade Definition Suggestions for Practice A USPSTF recommends the service. There is a high Offer or provide this service. certainty that the net benefit is substantial. B USPSTF recommends the service. There is a high Offer or provide this service. certainty that the net benefit is moderate or there is a moderate certainty that the net benefit is moderate to substantial. C USPSTF recommends against routinely providing the Offer or provide this service only service. There may be considerations that support if other considerations support providing the service in an individual patient. There is at offering or providing the service least moderate certainty that the net benefit is small. to an individual patient. (Previously no recommendation for/against). D USPSTF recommends against the service. There is no Discourage the use of this moderate or high certainty that the service has no net service. benefit or that the harms outweigh the benefits. I USPSTF concludes that the current evidence is insufficient Read the clinical considerations of the USPSTF Recommendation Statement to assess the balance of benefits and harms of the Statement. If the service is offered, service. Evidence is lacking, of poor quality, or patients should understand the conflicting, and the balance of benefits and harms uncertainty about the balance of The AIDS Institute cannot be determined. benefits and harms.
USPSTF Grade A & B Recommendations (Partial List) • Alcohol misuse counseling • Gonorrhea screening* • Blood pressure screening • Healthy diet counseling* • Cervical cancer screening • Hepatitis B & C screening* • Chlamydial infection • HIV Screening • STI counseling* screening* • Cholesterol abnormalities* • Syphilis screening* • Colorectal cancer screening* • Tobacco counseling & • Depression screening screening * For “at risk” or certain sub -populations only (e.g. pregnant women, 50+) The AIDS Institute
USPSTF & HCV Screening • Prior to June 2013, USPSTF grades were: “ D ” – against screening adults not at-risk; and • “ I ” – insufficient evidence for or against screening adults at high • risk • In July 2012, USPTF proposed revisions: “B” – in favor of screening at-risk adults • “C” – against screening adults not at-risk, but recognizing • possibility of individual indications where testing would be appropriate. The AIDS Institute
USPSTF & HCV Screening • CDC Issued Revised testing recommendations in August 2012 • “Adults born during 1945 -1965 should receive one-time testing for HCV without prior ascertainment of HCV risk.” • In reaction, and after much advocacy and new data USPSTF reconsidered its recommendation The AIDS Institute
USPSTF & HCV Screening • Final recommendation is a “B” grade • One-time screening of adults born 1945-1965 (Baby Boomers, ages 49-69) • Screening for people who are at risk of HCV infection. • Persons at continued risk should be screened “periodically.” • Published in June 2013 The AIDS Institute
Who is “At Risk for HCV?” According to the USPSTF “at risk” for HCV is defined as : “persons with a current or past history of illicit injection drug use; and • persons who have a history of receiving a blood transfusion prior to 1992.” • USPSTF also cites as additional risk factors: Long-term hemodialysis • Being born to an HCV-infected mother • Incarceration • Intranasal drug use • Getting an unregulated tattoo, and other percutaneous exposures. • The AIDS Institute
The ACA & Preventive Services While much of the focus has been on expanded • coverage for care and treatment through private insurance plans & Medicaid, the ACA includes preventive services-for people who have coverage: Medicare • Private Insurance • Medicaid • Based on USPSTF grades • The AIDS Institute
Medicare • Covers Preventive services with USPSTF “A” and “B” grades • Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) • Covered by Medicare after national coverage determination (NCD) process • The ACA removed any beneficiary cost sharing • Medicare initiated NCD process in September 2013 and issued proposed NCD in March 2014 for HCV testing • During comment period, many comments received urging Medicare coverage per USPSTF recommendation The AIDS Institute
Medicare • Coverage Determination finalized June 2014 • Medicare now covers HCV screening with no cost-sharing: • One-time screening of adults born 1945-1965 (Baby Boomers) • Screening for people who are at risk of HCV infection; annual screening for people whose risk is ongoing. • Medicare defines risk as “current or past illicit drug use” or having had a blood transfusion prior to 1992 • Only in primary care settings The AIDS Institute
Private Insurance • Under the ACA most plans required to cover A & B Services, without cost-sharing (Began September 2010) • Applies to plans inside and outside of the marketplace (unless grandfathered) • Beginning the new plan year starting on or after June 30, 2014 (one year after the new USPSTF recommendation), plans will be required to cover HCV screening • One-time screening of adults born 1945-1965 (Baby Boomers) • Periodic screening for people who are at risk of HCV infection The AIDS Institute
Private Insurance and Health Reform Non-grandfathered private individual and small group plans (inside and outside of exchanges) must provide 10 categories of Essential Health Benefits (EHB): • Prescription drugs • Ambulatory patient services • Rehabilitative and habilitative • Emergency services services and devices • Hospitalization • Laboratory services • Maternity and newborn care • Preventive and wellness services • Mental health and substance use and chronic disease management disorder services, including • Pediatric services, including oral behavioral health treatment and vision care “A” & “B” graded USPSTF services are also included through the preventive benefit category, as are other services. The AIDS Institute
Traditional Medicaid • Must cover medically necessary HCV testing under Social Security Act • State decision to cover other HCV testing if not medically necessary, such as one-time screening in Baby Boomer age- group • CA, NY, OR and TX report that they cover “routine” HCV testing • FL does not The AIDS Institute
Traditional Medicaid • ACA incentivizes states to cover USPSTF “A” & “B” services -- 1% increase in federal match for cost of covering all “A” & “B” and other preventive services • Began January 1, 2013 • States that fully align their Medicaid expansion package with traditional Medicaid will need to add these services • Participating so far: CA, CO, HI, KY, NH, NJ, NV, NY, OH, WI The AIDS Institute
Medicaid Expansion • ACA envisioned all states would expand their Medicaid programs to include those up to 138% FPL • Supreme Court decision made expansion a state decision • Many states remain undecided or against but hope to see a phasing in of acceptance as with Medicaid and CHIP in the past The AIDS Institute
State Decisions on Medicaid Expansion Source: Center on Budget and Policy Priorities. “Status of the ACA Medicaid Expansion” http://www.cbpp.org/files/status-of-the-ACA-medicaid-expansion-after-supreme-court- ruling.pdf, accessed June 19, 2014. The AIDS Institute
Medicaid Expansion • Expanded Medicaid plans (Alternative Benchmark Plans) beginning January 1, 2014 • Required to cover all “A” and “B” grade services • Through the essential health benefits preventative service category • No cost sharing • In states that opt to expand Medicaid, enrollees in newly covered group will have access to HCV screening at no cost: • If at higher risk for HCV, or • Born between 1945 and 1965 – one-time testing The AIDS Institute
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