Is Your Health Plan Supporting the Best Value-Based Care for Chronic HCV Infection?

The approvals of new therapies and treatment combinations for chronic hepatitis C virus (HCV) infection from 2013 and now into 2016 have ushered in new paradigms for treatment,1 offering a much needed potential cure for some patient populations but accompanied with substantial cost challenges. Due to these rapid therapeutic developments and numerous costly options, achieving value-based care in the management of chronic HCV infection has become one of the most complex challenges facing health plans today. Many health plans were hit unexpectedly with the rapid increase in use of these highly effective agents and were unprepared for the tremendous financial impact. The targeted population was larger than anticipated and treatment with these agents stood to break the budgets of health plans. Some health plans, struggling with high prices for these therapies, responded with restricted access formularies, bringing them under scrutiny with state investigations.2

Today, there is more than one safe and effective treatment approach available for chronic HCV infection, so the focus is increasingly on optimizing value. An estimated 2.7 to 3.9 million people in the United States are chronically infected with HCV.3 For this large population, a major challenge is determining who will benefit from treatment, and how do we support the use of the most safe and effective treatments, including a potential for cure, for the lowest price? Only two years ago, we didn’t have the choices we have today. The best available treatment was $84,000 for a 12-week course.4 With today’s options, many patients may be treated and potentially cured for much less than this.

Payers are seeking and adopting a variety of strategies for clinical and financial management of specialty drugs for chronic HCV infection:5

  • Identify preferred agents for coverage
  • Track response to therapy (viral load)
  • Limit continued treatment to patients showing response to therapy
  • Require a specific fibrosis score (most require >3)

Which of these strategies are best for optimizing health outcomes and spend? What else can be done?

Since clinicians can choose from multiple available treatment approaches and a variety of different parameters are considered to determine who will benefit from treatment, many plans want to know the best way to leverage tools such as formularies and utilization management approaches. The best outcomes don’t come randomly. Health plans need the right program to get the best outcomes. Health plans can reduce a great deal of complexity by working with a Center of Excellence for Hepatitis C. Best practices include following treatment protocols based on American Association for the Study of Liver Diseases (AASLD) guidelines, using appropriately structured formulary and prior authorization approaches that bring together the right information to support appropriate use at the best price, monitoring outcomes, and supporting adherence.

Structured programs focused on patient outcomes are essential in ensuring best practices. The Argus Health Center of Excellence for Hepatitis C works in collaboration with our clients to help identify opportunities for care improvement. We help formulate patient-specific treatment plans and monitor utilization patterns to help align patient care with current guidelines and known best practices. These approaches can help health plans support the use of the most effective therapy for populations at the best price.

As the treatment paradigm for HCV infection continues to evolve, we need new ways to use real world data to shape the future of HCV infection treatment. Argus Health is developing ways to use claims and other sources of data to help answer the question many health plans are wondering about: For the price paid for novel agents, do patients experience the expected benefits? We know that what is seen in the controlled environment of a clinical trial is not always what is seen when a drug is commercialized. Do we experience in the real-world setting what is expected?

By combining the right data, we have the ability to analyze sub-populations and help identify who should receive treatment for chronic HCV infection (those who are most likely to benefit), who should not receive treatment (those unlikely to receive benefit), see what the cure rate is for those treated, and optimize treatments while controlling spend.

Learning from this real world experience, Argus Health is finding new insights that may help refine best practices and evidence-based standards of care for the future treatment of HCV. Stay tuned for future reports sharing what we are learning from the detailed analyses as part of our ongoing support for health plans seeking the best value-based care for members with chronic HCV infection.



1 Hepatitis Central. Medications to treat hepatitis C – a timeline. Accessed May 22, 2016

2 Bloomberg. New York said to probe insurers over hepatitis C drugs. Published March 2, 2016. Accessed May 23, 2016.

3 Centers for Disease Control and Prevention. Hepatitis C FAQs for the Health Professionals. Accessed May 23, 2016.

4The Washington Post. New hepatitis C drugs are costing Medicare billions. Published March 29, 2015. Accessed May 23, 2016.

5EMD Serono. EMD Serono Specialty Digest™ 12th Edition. Accessed May 23, 2016.