Budgetary impact analysis of a primary care-based hepatitis C treatment program: Effects of 340B Drug Pricing Program

Assessing provider knowledge of the federal 340B Drug Pricing Program in a federally qualified health center

PURPOSE

The 340B Drug Pricing Program is important to healthcare organizations that serve vulnerable communities. However, it is unknown whether healthcare providers in these organizations understand the 340B program and how it supports enhanced patient services. This study aims to characterize the knowledge, attitudes, and beliefs of healthcare providers toward the 340B program in a multisite federally qualified health center (FQHC).

METHODS

This was a cross-sectional study. A 27-item survey designed to assess prescriber knowledge and perspectives toward the 340B program was developed and administered. Closed-ended items were summarized using descriptive statistics, and open-ended items were analyzed with qualitative methods.

RESULTS

A total of 198 healthcare providers with prescribing authority received the survey; of those, 65 (32.8%) participated. The majority of respondents (66.2%) were female; 41.5% were 35 years of age or younger, and 49.2% were physicians. The majority of respondents agreed that patients benefited from access to the organization's 340B pharmacies (95.0%) and that 340B pricing is important to consider when prescribing medications (78.3%). However, knowledge of the 340B program was limited, with only half of respondents (54.0%) able to correctly answer at least 4 of 7 knowledge-focused items. Reponses to a patient case suggested that some providers may be unfamiliar with which drugs are available at reduced prices.

CONCLUSION

The findings suggest that providers believe the 340B program benefits patients and the organization but often lack a complete understanding of the program. Future research should focus on prescriber education as a strategy to help organizations optimize their 340B programs and facilitate patient access to medications.

Assessing the Impact of the 340B Drug Pricing Program: A Scoping Review of the Empirical, Peer-Reviewed Literature

Policy Points The 340B Drug Pricing Program accounts for roughly 1 out of every 100 dollars spent in the $4.3 trillion US health care industry. Decisions affecting the program will have wide-ranging consequences throughout the US safety net. Our scoping review provides a roadmap of the questions being asked about the 340B program and an initial synthesis of the answers. The highest-quality evidence indicates that nonprofit, disproportionate share hospitals may be using the 340B program in margin-motivated ways, with inconsistent evidence for increased safety net engagement; however, this finding is not consistent across other hospital types and public health clinics, which face different incentive structures and reporting requirements.

CONTEXT

Despite remarkable growth and relevance of the 340B Drug Pricing Program to current health care practice and policy debate, academic literature examining 340B has lagged. The objectives of this scoping review were to summarize i) common research questions published about 340B, ii) what is empirically known about 340B and its implications, and iii) remaining knowledge gaps, all organized in a way that is informative to practitioners, researchers, and decision makers.

METHODS

We conducted a scoping review of the peer-reviewed, empirical 340B literature (database inception to March 2023). We categorized studies by suitability of their design for internal validity, type of covered entity studied, and motivation-by-scope category.

FINDINGS

The final yield included 44 peer-reviewed, empirical studies published between 2003 and 2023. We identified 15 frequently asked research questions in the literature, across 6 categories of inquiry-motivation (margin or mission) and scope (external, covered entity, and care delivery interface). Literature with greatest internal validity leaned toward evidence of margin-motivated behavior at the external environment and covered entity levels, with inconsistent findings supporting mission-motivated behavior at these levels; this was particularly the case among participating disproportionate share hospitals (DSHs). However, included case studies were unanimous in demonstrating positive effects of the 340B program for carrying out a provider's safety net mission.

CONCLUSIONS

In our scoping review of the 340B program, the highest-quality evidence indicates nonprofit, DSHs may be using the 340B program in margin-motivated ways, with inconsistent evidence for increased safety net engagement; however, this finding is not consistent across other hospital types and public health clinics, which face different incentive structures and reporting requirements. Future studies should examine heterogeneity by covered entity types (i.e., hospitals vs. public health clinics), characteristics, and time period of 340B enrollment. Our findings provide additional context to current health policy discussion regarding the 340B program.

Outcomes of the 340B Drug Pricing Program: A Scoping Review

Importance

The 340B Drug Pricing Program requires manufacturers to offer discounted drug prices to support safety net hospitals and clinics (covered entities) providing care to low-income populations. Amid expansion, the program has received criticism and calls for reform.

Objective

To assess the literature on the foundations of and outcomes associated with the 340B program.

Evidence Review

The databases searched in this scoping review included PubMed, Embase, EconLit, National Bureau of Economic Research (NBER), Westlaw, the Department of Health and Human Services Office of the Inspector General (HHS-OIG) website, the Government Accountability Office (GAO) website, and Google in February 2023 for peer-reviewed literature, legal publications, opinion pieces, and government agency and committee reports related to the 340B program.

Findings

Among a collected 900 documents, 289 met inclusion criteria: 83 articles from PubMed, 12 articles from Embase, 2 articles from EconLit, 1 article from NBER, 28 articles from Westlaw, 23 legislative history documents, 103 documents from Google, 11 GAO reports, and 26 HHS-OIG reports. Included literature pertained to 4 stakeholders in the 340B program: covered entities, pharmacies, pharmaceutical manufacturers, and patients. This literature showed that hospitals, clinics, and pharmacies generated revenue and manufacturers have forgone revenue from 340B discounted drugs. Audits of covered entities found low rates of compliance with 340B program requirements, whereas mixed evidence was uncovered on how covered entities used their 340B revenue, with some studies suggesting use to expand health care services for low-income populations and others to acquire physician practices and open sites in higher-income neighborhoods. These studies were hampered by a lack of transparency and reporting on the use of 340B revenue. Studies revealed patient benefits from access to expanded health care services, but there was mixed evidence on patient cost savings. Although the review identified considerable research on 340B hospitals, pharmacies, and patients, less research was found evaluating the 340B program's effect on nonhospital covered entities, drug pricing, and racial and ethnic minority groups.

Conclusions and Relevance

In this scoping review of the 340B program, we found that the 340B program was associated with financial benefits for hospitals, clinics, and pharmacies; improved access to health care services for patients; and substantial costs to manufacturers. Increased transparency regarding the use of 340B program revenue and strengthened rulemaking and enforcement authority for the Health Resources and Services Administration would support compliance and help ensure the 340B program achieves its intended purposes.

Evaluation of 340B prescription assistance program on healthcare use in chronic obstructive pulmonary disease

Background

The federal 340B drug program was designed to stretch scarce federal resources to provide more comprehensive services for more eligible patients. To help satisfy community needs, 340B Prescription Assistance Programs (PAPs) allow eligible patients to access medications at significantly reduced costs.

Objectives

To measure the impact of reduced-cost medications for chronic obstructive pulmonary disease (COPD) through a 340B PAP on all-cause hospitalizations and emergency department visits.

Methods

This multi-site, retrospective, single-sample, pre-post cohort study involved patients with COPD who used a 340B PAP to fill prescriptions for an inhaler or nebulizer between April 1, 2018, and June 30, 2019. Data from included subjects were evaluated and compared in the year before and after each individual patient's respective prescription fill in the 340B PAP. The primary outcome evaluated the impact of 340B PAP on all-cause hospitalizations and emergency department visits. Secondary outcomes evaluated the financial impact associated with program use. Wilcoxon signed-rank test was utilized to assess changes in the outcome measures.

Results

Data for 115 patients were included in the study. Use of the 340B PAP resulted in a significant reduction in the composite mean number of all-cause hospitalizations and emergency department visits (2.42 vs 1.66, Z = -3.12, p = 0.002). There was an estimated $1012.82 mean cost avoidance per patient due to reduction in healthcare utilization. Annual program-wide prescription cost savings for patients totaled $178,050.21.

Conclusions

This study suggested that access to reduced-cost medications through the federal 340B Drug Pricing Program was associated with a significant reduction in hospitalizations and emergency department visits for patients with COPD, decreasing patients' utilization of healthcare resources.

340B-Where Do We Go From Here?

This Viewpoint summarizes inefficiencies in the 340B program and provides suggestions for equitable reform that will potentially benefit patients.

Risks to the 340B Drug Pricing Program Related to Manufacturer Restrictions on Drug Availability

This Viewpoint documents the history, value, and success of the 340B Pricing Program, which is under threat from pharmaceutical corporations’ withdrawal and from a pending Supreme Court decision and offers 2 legislative fixes to address the concerns raised by the pharmaceutical companies.

Increasing Hepatitis C Screening in a Federally Qualified Health Center: A Quality Improvement Initiative

ABSTRACT

Hepatitis C virus (HCV) is a chronic infection that can lead to severe liver damage if left untreated. With increased availability and affordability of curative treatments, screening for HCV has become an important first step in reducing morbidity and mortality. At a rural federally qualified health center in North Carolina, two quality improvement initiatives-an electronic health record (EHR) prompt and educational flyers-were implemented to improve HCV screening rates. We compared the proportion of eligible patients born from 1945 to 1965 who received HCV screening before, during, and after the initiatives. HCV screening rates were highest during the two initiatives (30% and 39%, respectively). Screening rates fell in the 6-month period after the initiatives' conclusion (12%) but remained higher than at baseline (6%). Although HCV screening can increase with simple interventions, more durable solutions are needed to maintain screening coverage.

Implementation of a Hepatitis C Treatment Program Into a Primary Care Residency Clinic

BACKGROUND AND OBJECTIVES

Hepatitis C (HCV) is a commonly diagnosed disease state in primary care. Regimen simplification has made eradication possible with improvements in treatment and improved access through primary care physician (PCP) education. Little has been published discussing the role of resident physicians in the treatment of HCV. We implemented an HCV treatment program to increase access to HCV care, identify effective training methods, and examine the efficacy of resident physician treatment. Objectives were to increase the number of patients treated, improve resident confidence in ability to treat HCV, and increase the likelihood that they will continue to treat patients after graduation.

METHODS

A curriculum to train physicians to treat HCV was developed and implemented in a large family medicine residency program. This was a single-center implementation, with a retrospective chart review of patient data and anonymous survey of clinicians for curriculum assessment. We analyzed data using descriptive statistics.

RESULTS

The resident physician survey had a 92.3% response rate (n=36). Precurriculum, 94.4% of residents were not confident in their ability to treat HCV. After program implementation, 25% of residents were confident in treating HCV. The most effective educational interventions involved the multidisciplinary team. To date, 30 patients have started treatment since 2017. Of the patients who completed treatment, 23 patients achieved a virologic cure.

CONCLUSION

Treating patients for HCV at a residency clinic increased physician confidence in evaluating and addressing this chronic disease and resulted in a cure of all patients treated.

A comparison of medication access services at 340B and non-340B hospitals

BACKGROUND

For patients that face barriers to filling their prescriptions, the availability of medication access services at their site of care can mean the difference between receiving prescribed drug therapy, and undue interruptions in care. Hospitals often provide medication access services that are not reimbursed by payers; however, they can be challenging to sustain. The 340B Drug Pricing Program allows covered entities to generate savings through discounted pricing for certain outpatient medications, which can then be used to provide more comprehensive services, including medication access services.

OBJECTIVE

To characterize medication access services provided at hospitals that participate in the 340B Drug Pricing Program compared to hospitals that do not participate in the 340B Program.

METHODS

Primary questionnaire response data was collected from a national sample of Directors of Pharmacy at non-federal acute care hospitals from March 2019 to May 2019. American Hospital Association Data Viewer was used to collect demographic information on 1,531 hospitals. Hospitals were excluded if they had 199 beds or fewer, did not have a unique Medicare provider ID, were federally owned, were located outside the continental U.S., or were non-acute care hospitals that served niche patient populations. This study utilized a proportional stratified sampling strategy to administer an electronic questionnaire to 340B and non-340B hospitals to assess the number and type of medication access service offerings. A final randomized sample of 500 hospitals were administered the questionnaire, and data was collected through recorded responses in Qualtrics software.

RESULTS

340B hospitals provided a significantly higher average number of medication access services compared to non-340B hospitals (6.20 vs. 3.91, p = 0.0001), adjusted for differences in hospital size and ownership type. For all nine medication access services that were assessed, a higher percentage of 340B hospitals reported providing the service compared to non-340B hospitals. This difference was statistically significant for six out of nine programs assessed.

CONCLUSIONS

340B hospitals provided more medication access services, on average, than comparably sized non-340B hospitals, suggesting that hospitals participating in the 340B Drug Pricing Program may be better positioned to create and administer programs that support medication access services.

Evaluation of Risk Factors for Hepatitis C Virus Infection Among Philadelphia's Shelter-Bound, Homeless Population: Data from a Student-Run Hepatitis C Virus Screening Initiative

The objective was to assess risk factors for HCV specific to the shelter-bound homeless population of Philadelphia, Pennsylvania. This is a retrospective analysis of data obtained from 306 patients who received HCV antibody testing at 4 homeless shelters in Philadelphia between March 2017 and June 2019. Risk factors for HCV infection specific to this population were analyzed using Fischer exact tests. Fourteen (4.6%) of 306 patients screened positive for HCV infection. Risk factors for HCV infection among this shelter-bound homeless population included injection drug use, inhalation drug use, and tattoos obtained while incarcerated. Although an estimated 2.8% of the population of Philadelphia is infected with HCV, 4.6% of those screened in this program tested positive, highlighting the increased prevalence of HCV among the shelter-bound homeless population and the importance of assessing risks for HCV infection inherent to this specific population.

Epidemiological trend of hepatitis C-related liver events in Spain (2000-2015): A nationwide population-based study

OBJECTIVE

Analysis the epidemiological trends of hospital admissions, intra-hospital deaths, and costs related to chronic hepatitis C (CHC) taking into account four major clinical stages [compensated cirrhosis (CC), end-stage liver disease (ESLD), hepatocellular carcinoma (HCC), and liver transplantation (LT)] in Spain.

METHODS

Retrospective study in patients with chronic hepatitis C and a hospital admission in the Spanish Minimum Basic Data Set from 2000 to 2015. Outcome variables were admission, death, length of hospital stay and costs.

RESULTS

A total of 868,523 hospital admissions with CHC (25.5% CC, 25.3% ESLD, 8.6% HCC, and 2.5% LT) were identified. Overall rates of admission and mortality increased from 2000-2003 to 2004-2007, but after 2008, these rates stabilized and/or decreased. An upward trend was found for hospitalization percentage in CC (from 22.3% to 30%; p < 0.001), ESLD (from 23.9% to 27.1%; p < 0.001), HCC (from 7.4% to 11%; p < 0.001), and LT (from 0.07% to 0.10%; p = 0.003). An upward trend was also found for case fatality rate, except in ESLD (p = 0.944). Gender and age influenced the evolution of hospitalization rates and mortality differently. The length of hospital stay showed a significant downward trend in all strata analyzed (p < 0.001). Cost per patient had a significant upward trend (p < 0.001), except in LT, and a decrease from 2008-2011 to 2012-2015 in CC (p = 0.025), HCC (p < 0.001), and LT (p = 0.050) was found.

CONCLUSION

The initial upward trend of the disease burden in CHC has changed from 2000 to 2015 in Spain, improving in many parameters after 2004-2007, particularly in the 2012-2015 calendar period.