Medicaid Policymaker Approaches to Prior Authorization Policies for Direct-Acting Antivirals for the Treatment of Hepatitis C Virus

Abstract

Research Objective: In response to the high cost of direct‐acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV), many Medicaid agencies implemented prior authorization (PA) policies designed to restrict access based on advanced liver disease, prescriber specialty, and/or substance use disorder history. Although PA policies have since been loosened, we have limited insight about the association between PA policies and DAA uptake, and factors impacting Medicaid agency policy decisions. In this mixed‐methods study evaluating the uptake of DAAs in four New England Medicaid programs, the objective of this analysis is to understand how and why the external context supports and impedes DAA uptake and the specific PA policies Medicaid agencies adopt. Study Design: Qualitative, recorded videoconference interviews were conducted between November 2020 and January 2021 using a semi‐structured interview guide. Key domains of inquiry included: 1) the PA policies adopted and why; 2) the systems and structures established to support these policies; and 3) factors that facilitate and impede policy implementation. Rapid qualitative analysis techniques were used to identify content and themes within the interviews. We compared results across states defined by relative uptake of DAAs (i.e., high versus low). DAA uptake was defined in the quantitative analysis as annually between 2014 and 2017. High uptake was defined as >10% uptake annually for all four years of the study. Population Studied: Interviews were conducted with the pharmacy director and other senior administrators responsible for setting medication PA policies from Medicaid agencies in four New England states. Two to three individuals were interviewed per state (N=11). Principal Findings: One state had high DAA uptake relative to the other three states. The interviews explored eight topic areas with only one emerging as varied between the high and low uptake states: the high uptake state did not have managed care organizations (MCOs); all low‐uptake states did. All states consulted with multiple internal stakeholders such as the Medicaid agency’s pharmacy team, drug utilization review board, medical director, and/or senior agency staff. All states consulted with multiple external stakeholders such as clinicians, academic institutions, departments of health, national and professional organizations, pharmacy benefit manager or fiscal agent, and/or MCOs. Supplemental rebates were leveraged by all states. Only one state implemented a specialized PA process for the DAAs. Conclusions: Overall, there were few differences in DAA PA policies and the development process between high and low‐uptake states but there were differences with respect to presence of MCOs. This suggests that variation in DAA uptake may be less driven by PA policies than by provider‐ and possibly patient‐level factors. Implications for Policy or Practice: To understand the variation in DAA uptake in Medicaid it is necessary to explore contextual factors beyond PA policy, such as provider‐ and possibly patient‐level factors. This research suggests there may be differences in how PA policies are mediated at the provider level. Understanding the broader context for medication uptake can allow Medicaid agencies to ensure they are achieving intended utilization patterns among their membership.