The Promise and the Challenge
Here's the promise: There is a cure, a complete cure in a short 12 weeks, for hepatitis C virus (HCV), which the Centers for Disease Control and Prevention estimates afflicts between 2.7 and 3.9 million Americans, and which is a leading cause of liver cancer and other devastating health complications. This new class of HCV drugs, which are much easier on the human body and virtually free of side effects, attacks the virus directly and can reduce the viral load to zero when taken correctly.
As with so many things in healthcare, this promise comes with challenges. First, the price tag can be steep--nearly $100,000 for a full 12-week course. But weigh this against the down-the-line medical and lost-productivity costs, not to mention human toll, associated with hepatitis C (HCV) infection, which can cause chronic liver infection, cirrhosis, cancer and the need for a liver transplant. In 2014, there were nearly 20,000 deaths in the U.S. with HCV infection as an underlying or contributing cause.
And, although treatment often comes in the form of a single pill taken once a day--simple, right?--people's lives are complicated. Medicine is only as effective as an individual's ability to take it properly, and Americans in general have a poor record here. Nearly three out of four people in the U.S. report that they do not always take their medication as directed. If the HCV regimen is started and abandoned, a great deal of money is being wasted--something the healthcare industry can ill afford.
For those suffering from HCV infection, many obstacles can stand in the way of taking medications as directed. What if you don't have stable housing and have nowhere to store the pills? What if you are elderly, asthmatic, live in a fourth-floor walk-up and cannot get to the pharmacy to fill your prescription? What if the medication interacts poorly with the HIV medication that is sustaining your life? Or, what if, fearing stigma of a disease often contracted by sharing needles, you secret the medication away and fail to refill it?
Collaborating Towards a Cure
Here's a question: How can we ensure that if we use such a costly medicine to treat people with HCV infection, including some of society's most vulnerable, they will follow the regimen day in and day out--and emerge disease-free? A novel partnership in New York City, where an estimated 150,000 people have HCV infection, is aiming to find out and provide a blueprint for others.
The effort, called Project INSPIRE* NYC, is funded by an almost $10 million Health Care Innovation Award from the Centers for Medicare & Medicaid Services (CMS). It focuses on collaboration, integrated care and care coordination that is so crucial for a population often burdened with other chronic illnesses and medications, and living without a strong social or family safety net. Now in the second year of a three-year HCIA award, the project reaches out to patients at risk for HCV infection in the Bronx and Manhattan, using an integrated model of care in which primary care providers collaborate with specialized care coordinators, and peer navigators to enroll people with HCV infection, then educate and guide them through the treatment process.
This government-provider-payer collaboration is a terrific example of what needs to be done to sustain comprehensive and effective care for a vulnerable population. The New York City Department of Health and Mental Hygiene developed this project to target communities with the highest prevalence of HCV infection. The Health Department is working in partnership with Montefiore and the Mount Sinai Health System, which administer the treatments and provide care coordination, to implement the project. Partners also include two not-for-profit health insurance companies--including my organization, VNSNY CHOICE Health Plans, through its SelectHealth Special Needs Plan--which cover the cost of treatment, recognizing that the true value of the treatment lies not just in delivering the medication but in ensuring that it is taken appropriately.
Those covered by our plan, SelectHealth, are Medicaid-eligible New Yorkers with HIV, and, while they are used to being compliant with therapy regimens, they are often living in vulnerable circumstances and can be overwhelmed by adding another medicine to their already long list. "Our Medicaid population includes a sizeable number of people with psychosocial challenges that make it difficult to stick to a three-month medication protocol," explains Dr. Jay Dobkin, SelectHealth's Medical Director.
SelectHealth has already had over 400 of its members successfully complete treatment with new HCV drugs. These successes are made possible by care coordination and other supportive services, as is being demonstrated by Project INSPIRE. Our Pharmacy Services program actively encourages robust communication among the patient, care provider and the patient's dispensing pharmacy to ensure that prescriptions are being filled and refilled in a timely manner and that contraindications (including with certain HIV and OTC medications) are observed. For homebound patients, we encourage and monitor home delivery. We have fielded questions from patients accustomed to older HCV therapies that had to be refrigerated, on how to store new meds (answer: at room temperature). And, we recognize the need for patient education, including for patients who have tried older, injectable medications, and fear that regimen's same tremendous commitment and wide array of difficult-to-manage side effects.
Creating a Sustainable Model
Project INSPIRE offers a model that is right for the times in this era of value-based purchasing in healthcare--focusing the financial equation on health outcomes rather than individual encounters. The cure's $100,000 price tag, then, must be justified by the outcomes determined and achieved by Project INSPIRE. That includes making sure each person who begins the treatment completes it, , and carefully studying the costs offset by achieving a complete cure--including the considerable costs of liver transplants and treatments for liver cancer and end-stage liver failure.
"Paying for medical and pharmacy costs is a good investment in the long-term health of our members--and also a Medicaid requirement," says Eli Camhi, Vice President & General Manager of SelectHealth. "We're modeling a new way of reimbursing that pays not only for the medication, but also helps the patient with medication adherence and provides the care coordination services needed to support this vulnerable population. The HCIA dollars get you off the ground and allow evaluation of the intervention, but when the award funding goes away, CMS doesn't want to see the initiative end. They want to know that there's a financial commitment through understanding what this partnership has learned, in order to make sure that the model can be sustained."
Eli notes that if the project's positive early reports hold up, it can lead the way on a model that may eventually be adopted across the country. CMS could recommend that Medicare and Medicaid plans cover the cost of care coordination for patients undergoing treatment for HCV infection.
"We know the new treatments work," he notes. "Our goal is to be sure our members complete the treatment and get cured."
*INSPIRE stands for Innovate & Network to Stop HCV & Prevent complications via Integrating care, Responding to needs and Engaging patients & providers.
The project described was supported by Grant Number 1C1CMS331330 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. Preliminary results may or may not be consistent with or confirmed by the findings of the independent evaluation contractor.