Comparative Evaluation of State-Level Subscription-Based Payment Models for Hepatitis C Drugs

BACKGROUND: Subscription-based payment models (SBPMs) have been adopted to expand access to hepatitis C virus (HCV) treatment within Medicaid programs. OBJECTIVE: To evaluate the impact of SBPMs on HCV screening, RNA testing, and direct-acting antiviral (DAA) uptake among Medicaid Managed Care enrollees in Louisiana and Washington, and to identify factors associated with differential policy effects. RESEARCH DESIGN: Quasi-experimental study using the synthetic control method to compare outcomes in Louisiana and Washington-the only states implementing SBPMs in July 2019-with weighted combinations of 14 control states. SUBJECTS: Adults aged 18-64 years or older enrolled in Medicaid Managed Care between January 2018 and December 2022. MEASURES: Monthly HCV screening, RNA testing, DAA initiation, and refill rates identified from payer-complete closed claims. RESULTS: Louisiana SBPM was associated with significant increases in RNA testing (+35.2/100,000 persons/mo), DAA initiation (+7.8/1000 patients/mo), and DAA refills (+24.4/1000 patients/mo; all P=0.07). Gains were broad-based across subgroups and geographically consistent. Washington SBPM was associated with nonsignificant screening changes and significant declines in DAA initiation (-3.6/1000 patients/mo) and refills (-12.9/1000 patients/mo; P=0.07), with uniformly negative or null subgroup effects. CONCLUSIONS: SBPM yielded markedly different outcomes across states. Louisiana gains likely reflect convergence with recent Medicaid expansion and prior removal of DAA restrictions, generating a large treatment-eligible pool at implementation. Washington earlier expansion (2014) and fibrosis-restriction removal (2016) may have already addressed this demand. As the federal government invests $12.3 billion in HCV elimination with SBPM as a central mechanism, payment reform must be paired with comprehensive strategies-including provider engagement, screening infrastructure, and patient navigation-to achieve elimination goals.