Medicare gives primary care permission to increase hepatitis C testing

June 3, 2014

CMS has announced that Medicare will cover hepatitis C virus testing for adults.The ruling specifies that covered testing must be ordered by a primary care provider.

The Centers for Medicare and Medicaid Services (CMS) has announced that Medicare will cover hepatitis C virus (HCV) testing for adults, in a statement released June 2.

The testing will include a single screening for adults born between 1945 and 1965, and repeat screenings for adults considered high risk due to drug use or a blood transfusion prior to 1992. Disabled adults with Medicare under the age of 65 are eligible for the testing. The ruling specifies that covered testing must be ordered by a primary care provider.

“As preventive services gain recognition of their potential to improve the health status of the individual, we believe the primary care provider is in the unique position to provide a comprehensive and coordinated approach to Medicare beneficiaries' health care and this coordinated approach will help ensure the best outcomes for these services,” CMS said in a response to commenters who questioned whether testing should be expanded to other practitioners and medical settings. “Other provider specialties may provide patient care in other settings but do not offer care in the context of being the coordinator of the patient's healthcare needs, not limited by problem origin or diagnosis.”   

The statement also specifies that “emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, clinics providing a limited focus of health care services, and hospice are examples of settings not considered primary care settings under this definition.”

Increased attention to HCV testing began late in 2013 after the U.S. Preventive Services Task Force recommended that all Baby Boomers be tested regardless of risk factors, because 4.3% of people between 40 and 49 years old have the virus.

At the same time, the debate over the high cost of HCV treatment also became a factor as two new drugs were released last year. Sovaldi costs $1,000 per pill, $84,000 for a 12-week treatment regimen or $168,000 for a 24-week treatment regimen. Olysio, another new HCV treatment, costs $800 per pill, with treatments lasting 24 to 48 weeks. Because only 11% of all HCV patients develop liver cirrhosis within 20 years, many question whether the high cost of treatment is worth it.

The nonprofit organization National Coalition of Health Care, recently launched the Campaign for Sustainable Rx Pricing, which aims to find affordable solutions for expensive treatments such as Solvaldi. “Escalating drug prices are forcing all of us, whether families, employers and drug plans, to make impossible choices,” says Larry McNeely, policy director for the National Coalition of Health Care. 

“When faced with a $1000 a pill or $100,000 a year price tag, families, patients and plans are forced to consider everything.  But what’s really needed is a new path that can reward innovation without completely busting the budgets of families, employers, and public institutions,” McNeely says.