The Trouble with California’s Hep C Strategy

January 27, 2020

Good intentions are having unintended consequences for hepatitis C patients in California. 

Hepatitis C, an infectious disease that affects 629,000 Californians, damages the liver over time through inflammation and scarring.  If left untreated, it can lead to liver cancer or cirrhosis.  

Innovative medicine can now cure the disease, benefitting both individual patients and public health.  In fact, California was one of the first states to embrace curative treatments for Medicaid beneficiaries.  The state’s Medi-Cal program expanded coverage for hepatitis C cures in 2015.

But program logistics have created an unforeseen treatment barrier.  Medi-Cal pays its managed care organizations a weekly, per-patient amount to cover the cost of curative treatment.  The problem? Different hepatitis C cures require different treatment periods. Some regimens can be completed in as few as eight weeks, while others take 12.  

In other words, Medi-Cal’s payment structure unintentionally incentivizes managed care organizations to opt for the longer regimen.  More weeks of treatment equal more weeks’ worth of payment. 

The issue of longer treatments being more lucrative has at least two unintended consequences.  

First, it drives up costs.  Some patients on the 12-week regimen could likely be treated more quickly and at less expense to taxpayers.  

Second, it muddles the medical decision of which regimen a patient should take.  Whether dictated by efficacy, side effects or lifestyle, choice among treatments belongs to the individual patient and his or her physician.  

Medi-Cal is right to save lives and curb the public health impact of hepatitis C.  But that doesn’t have to mean sacrificing individualized care or undermining physician-patient decision making.  By reevaluating Medicaid reimbursement policy, state officials could strike a balance that protects access, the physician-patient relationship and patients’ health.

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