United States faces biggest burden of hepatitis C treatment costs before 2020

The cost of treating hepatitis C (HCV) is likely to decline dramatically over the next decade in the United States, not because of cuts in drug prices but because the population in need of treatment will shrink by 2020 as a majority of patients will already have been treated, according to research by Jagpreet Chhatwal of Massachusetts General Hospital and colleagues presented at the 2015 AASLD Liver Meeting in San Francisco last month.

HCV spending peaked in the United States in 2015 at $21 billion and will decline to around $4 billion per year in 2020, Chhatwal estimates. Approximately 80% of spending ($17 billion) in 2015 went toward direct-acting antivirals, mainly sofosbuvir (Sovaldi) and sofosbuvir/ledipasvir (Harvoni). By 2020 the cost of direct-acting antiviral treatment will fall to $2 billion due to the declining number of people in need of treatment.

The model assumes that in the period between 2003 and 2010 – prior to the introduction of direct-acting antiviral treatment – the prevalence of hepatitis C in the United States was around 2.7 million. It also assumes that the number of people with chronic hepatitis C infection will fall to around 1 million by 2020 as a result of either successful treatment or death. Of these, 70% will be unaware of their infection. Furthermore, the numbers with advanced fibrosis or cirrhosis – those in urgent need of treatment – will fall from around 400,000 in 2015 to less than 100,000 by 2020.

However, the model’s estimates all rely on hepatitis C prevalence estimates derived from the US National Health and Nutrition Survey (NHANES). A recent systematic review of published studies by Brian Edlin of Weill Cornell Medical College, New York, puts the number of Americans with chronic HCV infection at 3.5 million. Edlin and colleagues note that the NHANES study excludes the homeless, the huge US incarcerated population, anyone on active military service, people in hospital or nursing homes and those living on Indian reservations. The number infected might be as high as 4.6 million, the authors conclude.

Jagpreet Chhatwal and colleagues estimate that it would cost $106 billion to make HCV a rare disease over the next 25 years. This number is critically dependent on HCV prevalence and drug costs. They argue that this cost is substantially cheaper than the cost of HIV treatment and prevention during the period of 2011 to 2015 ($144 billion). However Chhatwal’s estimate of HIV prevention and treatment costs includes US support for the Global Fund to Fight AIDS, Tuberculosis and Malaria, which is money spent outside the United States on HIV prevention and treatment.

Another research group presenting at the 2015 Liver Meeting asked whether spending on hepatitis C treatment at current prices represented value for money compared to some other health interventions. They found a very large net benefit relative to some other expensive health intervention – including reducing greenhouse gas emissions – but also showed that hepatitis C treatment could consume 7% of all health care expenditure and 70% of prescription drug costs over an unspecified period in order to cure 2.7 million people.

In view of this huge burden of cost, can US health payers avoid prioritising some groups of patients for treatment? Jagpreet Chhatwal and colleagues concluded that it would be necessary to continue prioritising people with more advanced liver disease for treatment until 2022, assuming that around 150,000 people a year undergo direct-acting antiviral treatment, as in 2014. But if treatment numbers stay at the level seen in 2015 – around 280,000 – prioritisation might cease to be necessary after 2018. And raising the number of people treated to 400,000 would do away with the need for patient prioritisation after 2016. Achieving this level of treatment coverage would also have a substantial impact on the number of liver-related deaths and decompensated cirrhosis in the longer term, they project, when compared to treating 280,000 a year.

Although these long-term cost savings are often held up as the rationale for expanding treatment to people with less advanced liver disease, another study of treatment costs in the VA system found that the shorter-term cost burden of hepatitis care might also be diminished with greatest effect by treating people in the earlier stages of disease.

Jennifer Kramer of the VA Medical Center, Houston, found the largest cost burden in the VA system’s hepatitis care was associated with cirrhosis and decompensated cirrhosis. Using medical costs data for 17,134 of 140,169 patients with chronic hepatitis C, demographically matched with the same number of VA patients without hepatitis C, they calculated the incremental cost of progression through six stages of liver disease, from an APRI score of < 1 (representing minimal fibrosis) to decompensated cirrhosis, hepatocellular carcinoma and liver transplant. They went on to calculate the proportional and total costs of each stage of liver disease to the Veterans Health Administration. Almost half the cost (45%) was taken up with treatment of patients with cirrhosis or decompensated cirrhosis, and a further 22% by patients with APRI of > 1.77 (roughly correlating with F3 fibrosis). These findings suggest that the largest cost savings would be achieved by prioritising the treatment of patients with F3 fibrosis and above, but the researchers concluded that more studies are needed to assess the cost effectiveness and health benefits of targeted treatment.

Yet, under the patchwork system in the US, which includes private insurance, Medicaid for low-income people and Medicare for seniors, the payer that incurs the cost of treatment today may not be the one to benefit from long-term savings in the future.