Today, one of the most important global public health challenges is represented by the hepatitis C virus (HCV), which imposes a dramatically relevant burden in terms of morbidity and mortality in many parts of the world. For this reason, the health sectors of the different countries have designed and implemented various HCV prevention, control, and treatment programs . According to the World Health Organization (WHO), 399,000 people die annually from HCV and its complications, such as cirrhosis and liver cancer. this represents a major source of concern for health policy and decision makers .
There are effective therapies for HCV patients worldwide, which has raised hopes of improving the management and cure process of these patients . With the emergence of new viral treatments such as direct-acting antivirals (DAAs), the health sectors of the different countries are working to provide treatment to these people in order to increase their quality of life (QL) and prevent complications related to the disease .
economic burden generated by hvc
vhc is responsible for a huge economic burden for the countries of the world . direct costs (related to medical expenses for hepatic and extrahepatic complications of hvc) as well as indirect costs (incurred from impaired quality of life and lost work productivity due to disability) have become a real worldwide challenge [6, 7]. in particular , according to a recent systematic review and meta-analysis of 102 studies, extrahepatic complications such as diabetes (occurring in 15% of patients) and depression (occurring in approximately 25% of patients) patients) are the main drivers of such a relevant economic burden. Due to financial restrictions, the health systems of many countries, in many cases, are not able to cover most of the costs generated by the treatment of these patients . Direct, indirect, cumulative, and lifetime costs of HCV vary by setting and health system adopted; Estimates calculated for different countries are reported in Table 1 [9,10,11,12,13,14,15,16,17,18,19].
the role of insurance programs
The economic-financial crises, the increase in the incidence rates of HCV infection, the availability of new biomedical technologies and the increase in personnel costs are the main factors that have limited the allocation of funds for the health sector and, as such, decisions and health policies. -those responsible are not able to attend to all the health needs of the population in order to satisfy them adequately .
As a result, many patients face serious problems in adequately managing and treating their disease. this has prevented the establishment of universal financial protection for these patients from the health sectors. meanwhile, rising out-of-pocket expenses have made it harder for poor people to meet their health-related needs .
Patient adherence to pharmacological treatment and the use of effective medications in the management of HCV disease are of crucial importance for decision makers and health policies. despite the effectiveness of daas , drug prices are high and many patients cannot afford these costs. therefore, many of them cannot use these drugs and the treatment process faces serious challenges .
who reported in 2013 on trends in country policies and programs related to hepatitis. In this report, many countries have referred to medicines for the treatment of HCV patients for activities such as drug subsidies, but one of the things that health decision and policy makers need to take into account is the lack of insurance coverage for these patients. in developed and developing countries, insurers do not, in fact, play an important role in helping/helping hcv patients .
Studies show that globally, insurance coverage for HCV patients is inadequate, as many patients are still not covered by insurance programs. this issue and the economic conditions of the countries represent very serious challenges to ensure an effective treatment [25, 26].
Insurers have a very important role to play in supporting the health sector in building financial resources and helping people offset financial catastrophe by offering support. Health insurance should improve the HCV disease treatment process and play a more proactive role in facilitating this process , ensuring, for example, continuity between HCV screening and healthcare (so-called HCV screening). and linkage to care or sltc). continuum or cascade of care, which includes different subsequent steps, namely: diagnosis, linkage to care, retention in care, prescription of antiretroviral therapy and sustained virological response/viral suppression) .
Medical expenses are causing poverty and financial catastrophe for patients and their families , and payment increases from the start. unfortunately, in hcv patients, the increased oop has made treatment problematic . On the other hand, those who have been insured have been able to enjoy good antiviral treatment and, in addition to recovery, this will reduce the economic burden generated by HCV .
the need for consolidation and integration of the various insurance programs
There are various insurance providers, whether public or commercial, offering a variety of programs and plans, such as public government programs for employees, or for urban and rural areas/settings, and government-provided catastrophic health insurance or commercial health insurance. insurance programs. As such, it is very important to create an alliance for insurance administrators, to meet different health needs, specific populations and reduce costs, while providing high quality health care services. consolidation and integration of payers and providers, leading to a “mosaic of insurance programs” can result in increased value and clinical safety on a sustainable basis. “In a typical integrated network, payers stipulate a framework by which provider groups agree to serve a specific population of patients with the goal of meeting or exceeding a predetermined set of quality and cost benchmarks. the integration model encourages health organizations to offer value to patients and reduce the excessive use of treatments” .
insurers must understand the conditions of the disease and the treatment of patients. Many insurance companies are unwilling to participate in the treatment of HCV patients due to their high costs. meanwhile, some health care policy and decision makers seem to have overlooked the importance of treating these patients and are indifferent to them .
due to the economic conditions of the countries and the crises that affect the health system every day, the negotiation with insurance managers is increasingly essential. If we want to reach the goal of eliminating/eradicating HCV by the year 2030 , in addition to the Ministry of Health (MOH), other organizations, such as insurance companies, must be the main trustees that provide health care services to patients. patients .
treatment and adherence to patients are not complete unless the cost of treatment for them is lower and affordable and the treatment provides these patients with better control and prevention conditions. reducing this disease, especially by increasing the use of injectable medications, can be very effective in improving the general health of the population .
obstacles and barriers for insurers in guaranteeing access to treatment for hcv patients
There are different obstacles and barriers to guarantee access to treatment for patients with HCV. For example, there is a gap between health policy and decision makers and insurance administrators/providers, and this could be a serious warning for the treatment of HCV patients. this gap may be due to different goals, objectives and perspectives (public health and social point of view versus commercial purposes).
To cope with the high costs of new DAA regimens, some insurers are restricting access to medications, setting selective criteria for reimbursement. gowda and colleagues  conducted a prospective cohort study among US HCV patients. The authors found that outright denials of DAA regimes by insurers have remained high and have increased over time.
It should be emphasized that the health department is not a closed system and has to use the high and effective potential of insurance programs. insurers that offer support to target groups and beneficiaries can play a very valuable role in the treatment process. Health policy and decision makers can support HCV treatment by communicating effectively with insurers .
opportunities for insurers
The most important and greatest help available today to ensure HCV treatment is to implement plans to reduce costs and support patients. Of course, it should not be forgotten that insurers have a benefit in addition to their support for the health plan, which must also be addressed by policy and decision makers. governments can grant them concessions to obtain insurance and provide insurance companies with incentives to support patients for greater economic-financial coverage . In the United States, Medicaid reimbursement  for therapies necessary for the proper management and treatment of HCV infection has increased from $723 million to $2.35 billion in the period 2012-2015. significant variations in the medicaid reimbursement scheme for daas could be detected between states in 2014 that became even more apparent in 2015. expansion states were characterized by a greater increase in daas reimbursement by individual with hcv infection relative to no-expansion or late-expansion states, adjusting for pre-expansion reimbursement. In conclusion, approximately one-third of states contributed more than 5-15% of pharmacy reimbursements to DAAS. therefore, new health care policies are urgently needed to ensure coverage of an increasing number of expensive drugs required for the effective treatment of an increasing number of patients.
Furthermore, according to a mathematical model analysis , the pricing scheme for medicines for the treatment of HCV infection appears to follow a value-based model, with a fairly constant proportion of costs by achieved a sustained virological response over a period of 25 years. This leads to the paradoxical enigma that health systems are challenged by the economic-financial problems that arise from the high resource utilization of these new drugs despite their cost-effectiveness  and their short-term and long-term efficacy. health benefits. therefore, synergy between different stakeholders (pharmaceutical industries, health care payers and insurance providers) should be sought and established to find innovative drug pricing schemes to manage all HCV patients.
It was estimated that treating all medicaid-eligible patients , regardless of fibrotic stage, resulted in significantly fewer liver transplants and cases of cirrhosis, hepatocellular carcinoma, and hcv-related deaths, as well as years of significantly additional life and quality. -years of life adjusted per patient. Treatment of all chronic HCV Medicaid patients was projected to result in significant cost savings and a reduction in total costs of care. however, the “treat all” strategy appears promising and cost-effective, if adequately supported by new financing and payment schemes, such as cost-sharing mechanisms , such as plan premiums, deductibles, copays, and coinsurance . , among others .
the functions of the different insurance programs
The role of health insurance programs is recognized as an important contribution to the health sector and should be used to promote and improve health plans. insurers can guarantee drug treatment and management to many poor people who cannot receive health services, and governments can diversify their packages of health care services. Insurers, in addition to maintaining and increasing their own interests, try to increase their social status as patrons of patients.
However, discrepancies exist between public and private/commercial insurance providers. such discrepancies could be due to economic factors. for example, mukka et al. , in a retrospective study of 160 HCV patients, found that privately insured patients were more likely to receive treatment compared with publicly assisted patients. vu and colleagues  performed a multivariable regression analysis and found that the predictors of fewer steps in the authorization cascade were having insurance without health insurance and being HCV without genotype 2. In the survival analysis, insurance without health insurance and mid-range fibrosis were significantly associated with fewer days to authorization approval.
on the other hand, the role of private/commercial insurance providers can be positive. Moreno and colleagues  have modeled the costs and indirect effects of private insurer coverage and found that, with expanded HCV treatment coverage, private payers can reduce medical expenses and, over a 20-year period, years, they may even experience overall savings. , also generating positive indirect effects for insurers such as Medicare.