Do Medicaid Expenditures Increase After Adults Exit Permanent Supportive Housing?

The effects of homelessness and permanent supportive housing (PSH) on health care utilization have been well documented. Prior research on the association between PSH entry and Medicaid expenditures have indicated that such housing support could result in savings to Medicaid programs; however, whether changes occur in health care use and expenditures after individuals exit PSH is unknown. If efficiency gains from PSH persist after the individual leaves PSH, the savings to payers such as Medicaid may continue even after the costs to provide housing for a PSH recipient have ended. We used linked Medicaid and housing data from Pennsylvania to examine changes in the level and composition of Medicaid expenditures for 580 adult enrollees during the 12 months before and after exit from PSH adjusting for relevant covariates. In adjusted analyses, we estimated that monthly spending declined by $200.32 (95% CI: $323.50, $75.15) in the first quarter post-exit and by $267.63 (95% CI: $406.10, $127.10) in the third quarter. Our findings suggest that PSH may have sustained budgetary benefits to state Medicaid agencies even for beneficiaries exiting the program. However, more research is needed to understand if these reductions in expenditures last beyond 12 months and do not reflect under-use of care that may be important for managing health over the long-term.

Caring for Family Caregivers: Perceptions of CARE Act Compliance and Implementation

BACKGROUND

The Caregiver Advise, Record, Enable (CARE) Act encourages inclusion of family caregivers in the hospitalization process for patients. Translating the state laws into meaningful changes within the health care delivery system can be challenging and requires time. This study sought to examine early compliance with and implementation of the CARE Act reported by hospitals in the Commonwealth of Pennsylvania.

METHODS

We sent an online survey to hospital executives in Pennsylvania in 2017. Descriptive statistics were computed to examine hospital characteristics and used to assess compliance and implementation of the CARE Act tenets.

RESULTS

Most hospitals reported that changes have been and are being made to comply with the CARE Act (90.9%). Hospital executives reported that the family caregiver designation is available in 63.6% of the hospitals and notification of patient discharge is available in 45.5%. Hospital executives reported that family caregiver education and instruction is occurring in 31.8% of all inpatient stays. Hospital executives indicated that they are still developing processes to comply with the legislation and to integrate family caregivers into hospital systems and processes.

CONCLUSIONS

Our findings suggest that hospitals are complying with the legislation, while fully operationalizing the components of the CARE Act is a work in progress.

Five-Year Outcomes Among Medicaid-Enrolled Children With In Utero Opioid Exposure

The health of women and children affected by opioid use disorder is a priority for state Medicaid programs. Little is known about longer-term outcomes among Medicaid-enrolled children exposed to opioids in utero. We examined well-child visit use and diagnoses of pediatric complex chronic conditions in the first five years of life among children with opioid exposure, tobacco exposure, or neither exposure in utero. The sample consisted of 82,329 maternal-child dyads in the Pennsylvania Medicaid program in which the children were born in the period 2008-11 and followed up for five years. Children with in utero opioid exposure had a lower predicted probability of recommended well-child visit use at age fifteen months (42.1 percent) compared to those with tobacco exposure (54.1 percent) and those with neither exposure (55.7 percent). Children with in utero opioid exposure had a predicted probability of being diagnosed with a pediatric complex chronic condition similar to that among children with tobacco exposure and those with neither exposure (20.4 percent, 18.7 percent, and 20.2 percent, respectively). Our findings were consistent when we examined a subgroup of opioid-exposed children identified as having neonatal opioid withdrawal symptoms.

New evidence of state variation in Medicaid payment policies for dual Medicare-Medicaid enrollees

OBJECTIVE

To develop the first longitudinal database of state Medicaid policies for paying the cost sharing in Medicare Part B for services provided to dual Medicare-Medicaid enrollees ("duals") and an index summarizing the impact of these policies on payments for physician office services.

DATA SOURCES

Medicaid policy data collected from electronic sources and inquiries with states.

STUDY DESIGN

We constructed a national database of Medicaid payment policies for the period 2004-2018, consolidating information from online Medicaid policy documents, state laws, and policy data reported to us by state Medicaid programs. Using this database and state Medicaid fee schedules, we constructed a Medicaid payment index for duals. This index represented the proportion of the Medicare allowed amount that physicians would expect to be paid from Medicare and Medicaid for a subset of physician office services (evaluation and management services) based on annual state payment policies and Medicaid fee schedules.

PRINCIPAL FINDINGS

In 2018, 42 states had policies to limit Medicaid payments of Medicare cost sharing when Medicaid's fee schedule was lower than Medicare's-an increase from 36 such states in 2004. In the preponderance of states with these policies, combined Medicare and Medicaid payments for evaluation and management services provided to duals averaged 78 percent of the Medicare allowed amount for these services, reflecting relatively low Medicaid fee schedules in these states. In 2013 and 2014, physicians who qualified for the Affordable Care Act's Medicaid "fee bump" were paid 100 percent of the Medicare allowed amount for these services.

CONCLUSIONS

Medicaid programs vary across states and over time in their payments of cost sharing for physician office services provided to duals. Our database and index can facilitate monitoring of these policies and research on the consequences of policy changes for duals.

Vape Shop Proliferation and Noncompliance in Pennsylvania: A Pre- and Post-tax Analysis

Background:

The growing use of electronic nicotine delivery systems (ENDS) among adolescents is a public health concern. Taxation of these products is a viable approach to reduce ENDS use, particularly among adolescents. Opponents of taxation posit that it puts specialty retailers (ie, vape shops) out of business, thereby reducing availability of ENDS for adult smokers seeking harm reduction. Pennsylvania enacted substantial ENDS taxes in October 2016. This study sought to examine (1) the prevalence of Pennsylvania vape shops before and after ENDS taxes were enacted and (2) ENDS retail licensing compliance among vape shops.

Methods:

We employed standardized searches for vape shops in Pennsylvania on the Yelp business-listing platform a month prior to and for 18 consecutive months following the imposition of ENDS taxes. We then compared listings to a public database of ENDS-related retail licenses to determine compliance status.

Results:

The number of listed vape shops increased in a linear fashion by a magnitude of 23%. In addition, when we compared a final listing of retailers to data from the state tax authority, we found roughly a quarter (22%-29%) of vape shops to be noncompliant with maintaining a valid ENDS retail license.

Conclusions:

Overall, ENDS taxation in Pennsylvania has not appeared to reduce prevalence of vape shops as anticipated. However, stricter enforcement of the tax law is necessary to ensure compliance among retailers. These findings have implications for implementation and enforcement of ENDS tax policy nationwide, including states that currently lack such policies.

Home- and Community-Based Provider Preparation for Pennsylvania's Managed Long-term Services and Supports

As Pennsylvania implements its managed long-term services and supports program, we explore how home- and community-based providers are preparing for and perceiving the transition through an online survey. We summarize responses and conduct chi-square analysis to measure differences between select provider groups. Despite high levels of uncertainty about program impact, over 84% of respondents plan to participate. We found that providers in the first implementation phase had more strategic and operational discussions with MCOs than the other two phases (p < .03). As program rollout continues, we anticipate changes in MCO-provider conversation frequency and topics based upon implementation zone.

A Multisite Case Study of Caregiver Advise, Record, Enable Act Implementation

BACKGROUND AND OBJECTIVES

The Commonwealth of Pennsylvania passed the Caregiver Advise, Record, Enable (CARE) Act on April 20, 2016. We designed a study to explore early implementation at a large, integrated delivery financing system. Our goal was to assess the effects of system-level decisions on unit implementation and the incorporation of the CARE Act's three components into routine care delivery.

RESEARCH DESIGN AND METHODS

We conducted a multisite, ethnographic case study at three different hospitals' medical-surgical units. We conducted observations and semi-structured interview to understand the implementation process and the approach to caregiver identification, notification, and education. We used thematic analysis to code interviews and observations and linked findings to the Promoting Action on Research Implementation in Health Services framework.

RESULTS

Organizational context and electronic health record capability were instrumental to the CARE Act implementation and integration into workflow. The implementation team used a decentralized strategy and a variety of communication modes, relying on local hospital units to train staff and make the changes. We found that the system facilitated the CARE Act implementation by placing emphasis on the documentation and charting to demonstrate compliance with the legal requirements.

DISCUSSION AND IMPLICATIONS

General acute hospitals will be making or have made similar decisions on how to operationalize the regulatory components and demonstrate compliance with the CARE Act. This study can help to inform others as they design and improve their compliance and implementation strategies.

JUUL on Twitter: Analyzing Tweets About Use of a New Nicotine Delivery System

BACKGROUND

Initial reports suggest that JUUL, a popular e-cigarette, is being used in schools and other locations in which cigarette smoking is illegal or discouraged. However, there is little scholarly research documenting this. We aimed to make a systematic analysis of JUUL use themes and sentiment on Twitter.

METHODS

Data were collected from Twitter's Filtered Streams Application Programming Interface from April 12, 2018 to May 10, 2018. This yielded 67,934 tweets, from which a random sample of 2% was selected for coding. The final dataset included 1209 tweets. Inter-rater reliability ranged κ = 0.64-0.85.

RESULTS

The majority (71.5%) of tweets expressed positive sentiment toward JUUL. JUUL use in places where cigarette smoking is illegal or discouraged appeared in 111 tweets (9.2%); approximately one-third of these tweets referring to using the device in school. Nearly 20% of tweets mentioned using the device at home and/or directly in front of responsible adults.

CONCLUSIONS

This study confirms anecdotal reports of JUUL use in places where cigarette smoking is illegal or discouraged. Positive sentiment about use of JUUL suggests that the product is being normalized among young people. It may be valuable for educators to discuss the addictive nature of nicotine delivered through JUUL with younger populations.

Work Performance Among Informal Caregivers: A Review of the Literature

Objectives: To examine the association between informal caregiving and caregiver work performance. Method: A systematized review of the literature. Results: We found that caregiving has an adverse impact on work performance: caregivers experience substantial work disruptions and negative work performance outcomes, and these findings were consistent across measures. Our synthesis suggests that caregivers miss a significant amount of work and have reductions in productivity due to their caregiving responsibilities. However, significant methodological limitations with the reviewed studies make systematic interpretations and causal determinations challenging. Discussion: Examining the effect of caregiving on work performance is critical to better understand the full impact of caregiving, especially as demand for caregivers increases as the population ages. This comprehensive review suggests that caregiving has a significant negative impact on work performance, although methodological challenges remain in this area of science. These findings should inform both public policy development and workplace benefits design.

I wake up and hit the JUUL: Analyzing Twitter for JUUL nicotine effects and dependence

BACKGROUND

JUUL-a novel electronic nicotine delivery system (ENDS)-comprises most of the ENDS market share. Additionally, JUUL has a high nicotine content and utilizes a patented nicotine salt formulation aimed to speed absorption. Many JUUL users are not aware of the nicotine content and therefore may not be expecting acute nicotine effects or potential for dependence. This study sought to analyze Twitter messages ("tweets") regarding nicotine, symptoms of dependence, and withdrawal related to JUUL use.

METHODS

Data were collected from Twitter's Filtered Streams interface 4/11-6/16/2018 by retrieving tweets matching the terms "juul," "juuls," and "juuling" that also used words consistent with nicotine effects, symptoms of dependence, and withdrawal. A random 5% subsample (n = 1986) was coded by 2 independent coders. Cohen's κ for inter-rater reliability ranged 0.62-1.00 for all coded variables. Tweets were assessed using a qualitative content analysis approach.

RESULTS

A total of 335 tweets mentioned dependence-related themes, including use upon waking and compulsion to use. A total of 189 tweets mentioned themes related to nicotine, with almost 15% of these tweets describing physical effects. Additionally, 42 tweets mentioned themes related to quitting JUUL and/or withdrawal from JUUL.

DISCUSSION

This qualitative analysis suggests that users of JUUL are experiencing symptoms of nicotine exposure and dependence. Considering the high nicotine content of JUUL and the rising popularity among young people, more research around initiation of and dependence on JUUL, as well as the impact of recent FDA policy changes, should be conducted.

Do Family Caregivers Offset Healthcare Costs for Older Adults? A Mapping Review on the Costs of Care for Older Adults With Versus Without Caregivers

BACKGROUND AND OBJECTIVES

Older adults face significant long-term care and health care costs. But some of these costs can potentially be offset through family caregivers who may serve as substitutes for formal care or directly improve the care recipient's health and reduce health care utilization and expenditures. This article reviews the current literature to determine whether it is possible through existing work to compare the costs of care for individuals with versus without family caregivers and, if not, where the data, measurement, and other methodological challenges lie.

RESEARCH DESIGN AND METHODS

A mapping review of published works containing information on health care utilization and expenditures and caregiving was conducted. A narrative approach was used to review and identify methodological challenges in the literature.

RESULTS

Our review identified 47 articles that met our criteria and had information on caregiving and health care costs or utilization. Although findings were mixed, for the most part, having a family caregiver was associated with reduced health care utilization and a decreased risk of institutionalization however, the precise difference in health care expenditures for individuals with caregivers compared to those without was rarely examined, and findings were inconsistent across articles reviewed.

DISCUSSION AND IMPLICATIONS

The number of family caregivers providing care to loved ones is expected to grow with the aging of the Baby Boomers. Various programs and policies have been proposed to support these caregivers, but they could be costly. These costs can potentially be offset if family caregivers reduce health care spending. More research is needed, however, to quantify the savings stemming from family caregiving.

Medicare Shared Savings Program ACO network comprehensiveness and patient panel stability

OBJECTIVES

The current Medicare Shared Savings Program (MSSP) accountable care organization (ACO) attribution methodology creates unpredictability for ACOs that are developing and deploying strategic initiatives aimed at improving value. The goal of this study is to determine if ACO network comprehensiveness is associated with the stability of assigned Medicare beneficiaries from 2013 to 2014.

STUDY DESIGN

We utilized a beneficiary-level logistic regression model to determine association of network comprehensiveness with stable attribution to an MSSP ACO.

METHODS

Using 2013 and 2014 Medicare fee-for-service beneficiary and provider files, we developed a measure of network comprehensiveness based on 2013 provider contracts, determined beneficiary attribution, and generated market-level measures. Additional population and quality measures were obtained from the US Census and the ACO Public Use File.

RESULTS

Of the 1,317,858 observed beneficiaries, 84.38% were attributed to the same ACO in 2013 and 2014, and mean (SD) ACO network comprehensiveness was 0.30 (0.20). We found that a 0.10 increase in network comprehensiveness score significantly increased the odds of remaining attributed to the same ACO by 4.5% (P = .001). Patient panel stability was significantly associated with improved diabetes (P = .01) and hypertension (P = .02) control, timely access to care (P = .001), and delivery of health education (P = .03) over the 2-year period.

CONCLUSIONS

The comprehensiveness of an MSSP ACO's contracted provider network is associated with stable patient assignment year to year. Patient panel stability may aid in the longitudinal management of some conditions.

Caregiver health literacy predicting healthcare communication and system navigation difficulty

INTRODUCTION

The role of caregiver health literacy in predicting difficulty communicating with health care professionals and navigating services and supports for older adults was examined and informed by the health literacy skills framework (Squiers, Peinade, Berkman, Boudewyns, & McCormack, 2012).

METHOD

Secondary analyses of cross-sectional data from the Pittsburgh Regional Caregivers Survey in 2017 were conducted. A total of 761 caregivers of older adults reported communicating with health care providers and accessing services and supports. Health care provider communication and navigation of services and supports (HCNS) was assessed through self-report questions on communication about needs of the care recipient and caregiver, and the ability to locate and arrange services and supports for the care recipient. Health literacy was assessed with self-report questions on confidence filling out forms, need for help with reading information, and comprehension with written information. A logistic regression was conducted to determine the relationship between health literacy and high HCNS difficulty while controlling for demographic and contextual caregiving characteristics.

RESULTS

A fifth of the caregivers demonstrated low health literacy (n = 150, 19.7%). For a caregiver with low health literacy, the odds of having high levels of difficulty with HCNS was 2.52 times larger than the odds for a caregiver with adequate health literacy while controlling for demographic and contextual caregiving factors (odds ratio = 2.52, 95% confidence interval [1.57, 4.06]; p < .001).

DISCUSSION

Findings demonstrate that poor caregiver health literacy is an important factor associated with HCNS difficulty. The health literacy of caregivers should be considered for assessments and interventions designed to identify and reduce the difficulty caregivers experience with HCNS. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Toward Real-Time Infoveillance of Twitter Health Messages

There is growing interest in conducting public health research using data from social media. In particular, Twitter "infoveillance" has demonstrated utility across health contexts. However, rigorous and reproducible methodologies for using Twitter data in public health are not yet well articulated, particularly those related to content analysis, which is a highly popular approach. In 2014, we gathered an interdisciplinary team of health science researchers, computer scientists, and methodologists to begin implementing an open-source framework for real-time infoveillance of Twitter health messages (RITHM). Through this process, we documented common challenges and novel solutions to inform future work in real-time Twitter data collection and subsequent human coding. The RITHM framework allows researchers and practitioners to use well-planned and reproducible processes in retrieving, storing, filtering, subsampling, and formatting data for health topics of interest. Further considerations for human coding of Twitter data include coder selection and training, data representation, codebook development and refinement, and monitoring coding accuracy and productivity. We illustrate methodological considerations through practical examples from formative work related to hookah tobacco smoking, and we reference essential methods literature related to understanding and using Twitter data.

Comparison of toxicant load from waterpipe and cigarette tobacco smoking among young adults in the USA

OBJECTIVES

To form population-level comparisons of total smoke volume, tar, carbon monoxide and nicotine consumed from waterpipe tobacco smoking (WTS) and cigarette smoking using data from a nationally representative sample of smokers and non-smokers aged 18-30 years.

METHODS

In March and April 2013, we surveyed a nationally representative sample of 3254 US young adults to assess the frequency and volume of WTS and cigarette smoking. We used Monte Carlo analyses with 5000 repetitions to estimate the proportions of toxicants originating from WTS and cigarette smoking. Analyses incorporated survey weights and used recent meta-analytic data to estimate toxicant exposures associated with WTS and cigarette smoking.

RESULTS

Compared with the additive estimates of WTS and cigarette smoking combined, 54.9% (95% CI 37.5% to 72.2%) of smoke volume was attributed to WTS. The proportions of tar attributable to WTS was 20.8% (95% CI 6.5% to 35.2%), carbon monoxide 10.3% (95% CI 3.3% to 17.3%) and nicotine 2.4% (95% CI 0.9% to 3.8%).

CONCLUSIONS

WTS accounted for over half of the tobacco smoke volume consumed among young US adult waterpipe and cigarette smokers. Toxicant exposures to tar, carbon monoxide and nicotine were lower, but still substantial, for WTS alone compared with WTS and cigarette smoking. Public health and policy interventions to reduce harm from tobacco smoking in young US adults should explicitly address WTS toxicant exposures.

Pennsylvania policymakers' knowledge, attitudes and likelihood for action regarding waterpipe tobacco smoking and electronic nicotine delivery systems

INTRODUCTION

Use of waterpipe tobacco smoking (WTS, or hookah smoking) and electronic nicotine delivery systems (ENDS, such as e-cigarettes) is rapidly increasing. However, legislatures have been slow to update policy measures related to them. Therefore, we aimed to assess knowledge, attitudes and likelihood to take future action regarding WTS and ENDS among Pennsylvania legislators.

METHODS

We approached all Standing Members of key Pennsylvania House and Senate health and welfare committees to complete a survey about substances of abuse, including WTS and ENDS. Closed-ended knowledge, attitude and action items used a 100-point scale. Responses to open-ended items were assessed using thematic analysis by three independently working researchers.

RESULTS

We received responses from 13 of 27 eligible policymakers (48%). Participants answered a mean of only 27% (SD=20%) of knowledge items correctly. When asked to rank by priority eight issues in substance abuse, WTS ranked eighth (least urgent) and ENDS ranked fifth. Participants reported low likelihood to introduce legislation on WTS (mean=29, median=25) and/or ENDS (mean=28, median=10). Thematic analysis revealed that participants readily acknowledged lack of understanding of WTS and ENDS, and were eager for additional information.

CONCLUSIONS

Policymakers exhibit a lack of knowledge concerning newer forms of tobacco and nicotine delivery systems and consider them to be relatively low legislative priorities. However, respondents expressed a desire for more information, suggesting the potential for public health entities to promote effective policy development via improved dissemination of information.

Changing Structures and Processes to Support Family Caregivers of Seriously Ill Patients

BACKGROUND

Although family caregivers provide a significant portion of health and support services to adults with serious illness, they are often marginalized by existing healthcare systems and procedures.

OBJECTIVE

We examine the role of caregivers in existing systems of care, identify needed changes in structures and processes, and describe how these changes might be monitored and assessed and who should be accountable for implementing them.

DESIGN

Based on a broad assessment of the caregiving literature, the recent National Academy of Sciences Report on family caregiving, and descriptive data from two national surveys, we describe structural and process barriers that limit caregivers' ability to provide effective care.

SUBJECTS

To describe the unique challenges and impacts of caring for seriously ill patients, we report data from a nationally representative sample of older adults and their caregivers (National Health and Aging Trends Study [NHATS]; National Study of Caregiving [NSOC]) to identify the prevalence and impact on family caregivers of seriously ill patients who have high needs for support and are high cost to the healthcare system.

MEASUREMENTS

Standardized measures of patient status and caregiver roles and impacts are used.

RESULTS

Multiple structural and process barriers limit the ability of caregivers to provide effective care. These issues are exacerbated for the more than 13 million caregivers who provide care and support to 9 million seriously ill older adults.

CONCLUSIONS

Fundamental changes are needed in the way we identify, assess, and support caregivers. Educational and workforce development reforms are needed to enhance the competencies of healthcare and long-term service providers to effectively engage caregivers.

Caregiver Integration During Discharge Planning for Older Adults to Reduce Resource Use: A Metaanalysis

OBJECTIVES

To determine the effect of integrating informal caregivers into discharge planning on postdischarge cost and resource use in older adults.

DESIGN

A systematic review and metaanalysis of randomized controlled trials that examine the effect of discharge planning with caregiver integration begun before discharge on healthcare cost and resource use outcomes. MEDLINE, EMBASE, and the Cochrane Library databases were searched for all English-language articles published between 1990 and April 2016.

SETTING

Hospital or skilled nursing facility.

PARTICIPANTS

Older adults with informal caregivers discharged to a community setting.

MEASUREMENTS

Readmission rates, length of and time to post-discharge rehospitalizations, costs of postdischarge care.

RESULTS

Of 10,715 abstracts identified, 15 studies met the inclusion criteria. Eleven studies provided sufficient detail to calculate readmission rates for treatment and control participants. Discharge planning interventions with caregiver integration were associated with a 25% fewer readmissions at 90 days (relative risk (RR) = 0.75, 95% confidence interval (CI) = 0.62-0.91) and 24% fewer readmissions at 180 days (RR = 0.76, 95% CI = 0.64-0.90). The majority of studies reported statistically significant shorter time to readmission, shorter rehospitalization, and lower costs of postdischarge care among discharge planning interventions with caregiver integration.

CONCLUSION

For older adults discharged to a community setting, the integration of caregivers into the discharge planning process reduces the risk of hospital readmission.

Paid sick days and stay-at-home behavior for influenza

Access to paid sick days (PSD) differs by workplace size, race/ethnicity, gender, and income in the United States. It is not known to what extent decisions to stay home from work when sick with infectious illnesses such as influenza depend on PSD access, and whether access impacts certain demographic groups more than others. We examined demographic and workplace characteristics (including access to PSD) associated with employees' decisions to stay home from work for their own or a child's illness. Linking the 2009 Medical Expenditure Panel Survey (MEPS) consolidated data file to the medical conditions file, we used multivariate Poisson regression models with robust variance estimates to identify factors associated with missed work for an employee's own or a child's illness/injury, influenza-like-illness (ILI), and influenza. Controlling for gender, race/ethnicity, education, and income, access to PSD was associated with a higher probability of staying home for an employee's own illness/injury, ILI, or influenza, and for a child's illness/injury. Hispanic ethnicity was associated with a lower prevalence of staying home for the employee's own or a child's illness compared to non-Hispanic Whites. Access to PSD was associated with a significantly greater increase in the probability of staying home among Hispanics than among non-Hispanic Whites. Women had a significantly higher probability of staying home for their child's illness compared to men, suggesting that women remain the primary caregivers for ill children. Our results indicate that PSD access is important to encourage employees to stay home from work when sick with ILI or influenza. Also, PSD access may be important to enable stay-at-home behavior among Hispanics. We conclude that access to PSD is likely to reduce the spread of disease in workplaces by increasing the rate at which sick employees stay home from work, and reduce the economic burden of staying home on minorities, women, and families.

Long-term disease and economic outcomes of prior authorization criteria for Hepatitis C treatment in Pennsylvania Medicaid

BACKGROUND

Several highly effective but costly therapies for hepatitis C virus (HCV) are available. As a consequence of their high price, 36 state Medicaid programs limited treatment coverage to patients with more advanced HCV stages. States have only limited information available to predict the long-term impact of these decisions.

METHODS

We adapted a validated hepatitis C microsimulation model to the Pennsylvania Medicaid population to estimate the existing HCV prevalence in Pennsylvania Medicaid and estimate the impact of various HCV drug coverage policies on disease outcomes and costs. Outcome measures included rates of advanced-stage HCV outcomes and treatment and disease costs in both Medicaid and Medicare.

RESULTS

We estimated that 46,700 individuals in Pennsylvania Medicaid were infected with HCV in 2015, 33% of whom were still undiagnosed. By expanding treatment to include mild fibrosis stage (Metavir F2), Pennsylvania Medicaid will spend an additional $273 million on medications in the next decade with no substantial reduction in the incidence of liver cancer or liver-related death. Medicaid patients who are not eligible for treatment under restricted policies would get treatment once they transition to the Medicare program, which would incur 10% reduction in HCV-related costs due to early treatment in Medicaid. Further expanding treatment to patients with early fibrosis stages (F0 or F1) would cost Medicaid an additional $693 million during the next decade but would reduce the number of individuals in need of treatment in Medicare by 46% and decrease Medicare treatment costs by 23%. In some scenarios, outcomes could worsen with eligibility expansion if there is inadequate capacity to treat all patients.

CONCLUSIONS AND RELEVANCE

Expansion of HCV treatment coverage to less severe stages of liver disease may not substantially improve liver related outcomes for patients in Pennsylvania Medicaid in scenarios in which coverage through Medicare is widely available.