Promoting Innovative Approaches to Hepatitis C Care
A mere five percent of Medicaid account for nearly half of all Medicaid spending. One high-spend disease in particular, hepatitis C (HCV), disproportionately affects the Medicaid population, with an overall prevalence rate 7.5 times higher than among commercially insured members. Medicaid beneficiaries with HCV have three times higher inpatient admission rates, longer hospital stays and more than twice as many emergency department visits than Medicaid members who do not have HCV.
HCV affects more than five million Americans and causes more deaths in the U.S. than any other infectious disease. By itself, HCV is a dangerous disease; but those it affects often have multiple comorbidities including HIV, substance abuse and mental health disorders, further complicating their health. Their medical and daily life challenges are so intertwined that the traditional, siloed approach to treating disease rarely produces good outcomes. Caring for complex patients demands not only providing medical care, but also helping address their basic needs so they have a far better chance of complying with, and actually benefiting from, their treatment.
Traditional fee-for-service payment systems are also not always effective for the care of complex patients. Instead, in select cases, a value-based method that ties bundled payments to outcomes allows for more innovative and integrated approaches to meet their needs. In fact, experts at the Institute for Strategy and Competitiveness at Harvard University estimate that this the first time this type of program is being piloted to improve the care of one of the most complex patient populations: those with hepatitis C (HCV).
Challenges Facing HCV Patients
The fairly recent introduction of effective antiviral treatments that can cure HCV has been a game-changer. The difficulty lies in making sure patients have access and adhere to these extremely costly medications. Not only is the cost of noncompliance high in monetary terms, it also causes resistance to the medication and therefore, reduces treatment options.
Complying with HCV treatment—including showing up at doctor visits, having regular blood work and ultrasounds done, regularly taking medications—can be a challenge for vulnerable patients who may be homeless, lack transportation and food, and may be dealing with mental illness and substance abuse. Additionally, HCV is typically a symptomless condition, so patients may choose to ignore it and attend to more pressing problems.
Breaking Down the Barriers with Value-Based Care
To overcome the many obstacles patients are up against, physicians need flexibility to find the right mix of medical and social supports to focus on a patient’s individual circumstances and needs. That’s why bundled payments can be such a powerful approach to caring for the HCV population. Given the 95 percent cure rate of current HCV treatments, a successful outcome is now a patient being cured of the disease. To align a payment structure with a “cure” outcome, WellCare—through Care1st Health Plan of Arizona—and Maricopa Integrated Health System have launched a pilot program that gives physicians the freedom to innovate and provide care not typically covered under traditional payment systems. For instance, physicians have the authority to determine the best place for HCV patients to be examined and tested even if providers are out-of-network. This can help coordinate all care under one roof so patients don’t have to make multiple trips to different facilities, while the physician is better able to keep track of the patient’s status and progress.
The program also incentivizes physicians to address the patient’s other medical and non-medical issues. To help patients comply with their HCV therapy, physicians may need to confront substance abuse and mental health disorders, as well as connect them with case managers who can identify local services that can help meet basic needs such as food, housing, childcare and transportation assistance.
A payment system that extends care to engage with the clinical and daily needs of the patient both within and beyond the walls of the physician’s office is a necessary step in breaking down the barriers to HCV treatment compliance. It can save money and lives.
Kelly Munson is the executive vice president of Medicaid, WellCare Health Plans, Inc.
