Systems Approach Improving Outcomes in Hepatitis C

A newer therapy for the treatment of hepatitis C has prompted the U.S. Preventative Services Task Force to consider new guidelines for the virus and other health systems to adopt more beneficial services for patients affected.

The Task Force reviewed hepatitis C screening in 2013, but revisited its recommendations in 2019 as a result of new therapies known as “direct acting antivirals” (DAAs), which have been shown to eliminate the virus from most infected persons, according to Stephen Parodi, MD, chairman of the Council of Accountable Physician Practices (CAPP) Board, EVP of External Affairs, Communications, and Brand at The Permanente Federation, and associate executive director for The Permanente Medical Group (TPMG).

“Previously, the treatments available for hepatitis C were quite toxic and not very effective. The DAAs are expensive, estimating $1,000 a pill, but are one-time therapies,” Parodi says.

After reviewing evidence, benefits, and harms of DAAs, the Task Force grades the service under review. If the Task Force assigns a service a grade of A or B, then insurers must follow new guidelines of covering the service with $0 copay. Congress added this preventive benefit as section 2713 of the ACA in 2010, and it applies to all group and individual health issuers, says Parodi.

This new guideline could affect millions of Americans.

According to Parodi, nearly 2.4 million Americans are infected with hepatitis C, and the CDC estimates that one in 30 baby boomers is infected with the virus. In Louisiana alone, 90,000 people are known to be living with hepatitis C.

“The CDC recommends testing for Americans born between 1945 and 1965,” he says. “Testing is important because most people don’t experience early symptoms to know they have the virus. By treating the patient before liver cirrhosis, it stops the progress of the disease and the patient is less likely to develop liver cancer.”

“Screening in an integrated system, such as those in CAPP groups and at The Permanente Medical Groups (TPMG), have shown such promising results,” he says. “At the Mid-Atlantic Permanente Medical Group, the hepatis C screening program uses electronic health record alerts, care coordinators for each patient, and lab testing that has resulted in screening 72% of baby boomers for hepatitis C (more than 173,000 patients since 2014). This has led to earlier treatment for more than 2,500 patients with hepatitis C.”

Related: The First Hep C Value-Based Bundled Payment Plan

The Permanente Medical Group (TPMG) in Northern California also integrates research and advanced technology to systematically encourage baby boomers to get tested and to screen them when they are already at appointments. When patients are diagnosed, a multidisciplinary team dedicated to Hepatitis C matches them to a treatment place and manages their care.

Parodi says CAPP is also working toward the care of patients with the virus.

CAPP is a multi-specialty group that shares a commitment to building systems of care that are coordinated, patient-centered, prevention-oriented, physician-led and data-driven. CAPP members work closely with a care team to treat patients with a diversity of medical conditions. By working in a system, CAPP uses data from the electronic health record to increase the evidence base for preventative and therapeutic purposes. Hepatitis C is one of the latest diseases where this approach is having a significant impact, he says.

For example, the Hepatitis C Clinic at Louisiana-based Ochsner Medical Center, a CAPP member, offers comprehensive care for patients diagnosed with the virus.

“Through a multidisciplinary, collaborative approach, the clinic’s team creates personalized care plans for patients,” he says. “They work to start hepatitis C treatment faster by organizing lab and imaging studies before their first clinic appointment with a specialist. The specialist, the advanced practice provider (APP), recommends a personalized treatment plan in that first visit. Most patients’ prescriptions are available that same day at the Ochsner Specialty Pharmacy. A minority of patients need more tests before their first treatment. At the clinic, a hepatologist is always available.”

In addition, the clinic team helps patients navigate care and their insurance authorization process, reducing one of the biggest headaches for patients. Team members also provide help with copays and finances, as necessary.

“The Clinic allows patients to maintain their quality of life, receive excellent care with fewer visits, and avoid liver biopsies with on-site FibroScans,” says Parodi. “The clinic staff is a comprehensive team of experts who stay updated on evolving treatments. This team is dedicated full time to hepatitis C patients.”

At TPMG 12,000 patients have been treated since 2011 with DAA within a broader scope of treatment and based on a personalized treatment plan designed between the physician and their patient  Within this population an estimated 2,300 patients avoided cirrhosis, 500 avoided a liver transplant, and 250 avoided eventual death.

“Healthcare executives should be interested because of the significant cost associated with the hepatitis C medications themselves as well as the case management needed to ensure adherence and virologic success with this potentially curative therapy,” he says. “The upfront investment in a comprehensive case management system for hepatitis C will increase the chances of cure and reduce the long-term consequences related to hep C which includes the risk for developing end stage liver disease related to cirrhosis and hepatocellular cancer.  Those overall aims help the individual patient and the health system at large.”

He adds there are other disease states that will be addressed by the taskforce in the future due to their regular assessments on evidence for preventive services and grading the evidence of benefits and harms. Often outside organizations, such as professional societies or associations, nominate services for the Task Force to review.

Briana Contreras is associate editor of Managed Healthcare Executive.