Viral Hepatitis in Hawai‘i – Differing Perspectives
IV. Perspectives of Administraors and Health Care Plans
B. Hepatitis and Private Insurance Companies:
Tarquin Collis MD and Joseph Humphrey MD
pp. 12-13
Although there are significant administrative differences when working with various private insurance providers, the common goal from a physician’s standpoint is to provide excellence in patient care. Access to care, working effectively with primary care providers, maximizing cure rates, and developing data management and decision support tools were identified as important issues in treating patients with hepatitis from different private insurance perspectives (Kaiser Permanente and HMSA). Table 3 summarizes the various administrative and health plan perspectives regarding hepatitis treatment options.
Access to Care
Access to and delivery of care is a significant problem in Hawai‘i for patients with hepatitis B and C, due in part to limited access to specialists. As previously described, this access is particularly difficult for high risk populations. Various community screening programs can increase the number of patients screened for hepatitis, including the “3 for Life” program, which has been a successful community-based HBV testing and vaccination program targeting the Asian/Pacific Islander American population. The program, which first started in San Francisco in 2004 and has expanded to other major US cities including Honolulu, is an accessible, affordable, and sustainable model to increase HBV awareness, testing, and prevention.
The Hepatitis C Clinic was established at Kaiser Permanente in Honolulu in 2003 and is currently staffed by the medical director (an infectious diseases specialist), an internist, a clinical pharmacist, a nurse practitioner, and a registered nurse. The clinic provides care for Kaiser members on O‘ahu and Kaua‘i with HCV infection, and will begin providing care for Kaiser members on the Big Island in 2010. The clinic has an aggressive approach to HCV treatment, which is a conscious decision based on the fact that many of the clinic’s patients have significant social and economic barriers that effectively preclude liver transplantation as an option should their liver disease worsen as a result of ongoing HCV infection. The clinic employs a number of treatment approaches that help it maintain substantially higher rates of virologic cure than would be expected given the challenging treatment population that it serves. A unique aspect of working at Kaiser as a specialist is the ability to provide cutting edge care for patients outside the context of the often adversarial relationship between a doctor or patient and private insurance companies. At Kaiser Permanente, specialists have been granted the opportunity to dispense HCV-infected patients the medicine that they need, for the duration of treatment necessary, and to use the tests that in the physician’s judgment are appropriate to guide patient care without the concern that a third-party payer will deem the recommended medical care inappropriate or overly expensive.
Working Effectively with Primary Care Providers
Because the field of hepatitis C, like that of HIV infection, is a relatively young one, and because advances in hepatitis C treatment have evolved at a rapid pace, many practicing primary care providers are unaware of the details of HCV related medical care and the very real possibility of cure for many patients. Most internists, family practitioners, and nurse practitioners have limited knowledge of the important roles of HCV genotypic and viral load testing in predicting response to treatment, and have little firsthand experience with hepatitis C treatment and its attendant side effects.
At Kaiser, there is a well-established framework to assist frontline caregivers in learning about HCV infection and treatment. In addition to talks and grand rounds offered to medical and nursing staff, the Kaiser Permanente Hepatitis C Treatment Guidelines is a document made available on Kaiser’s intranet which provides an evidence-based, up-to-date, and extensively referenced overview of hepatitis C epidemiology and natural history, and reviews the clinic’s approach to treatment and side effect management. This guideline is updated annually to reflect the newest research in the field.
Another approach the Kaiser clinic has taken to assist frontline physicians with their HCV-infected patients is through efforts at targeted population management. One of the benefits of a “closed” patient population that is cared for through an electronically integrated care delivery system such as Kaiser’s is the capacity to efficiently create comprehensive databases of Kaiser members in order to improve their health care. For example, the clinic team systematically reviews a database of known HCV-infected Kaiser members who have not been seen in consultation, and identifies patients who are newly diagnosed with hepatitis C, whose labs or radiology studies suggest undiagnosed cirrhosis/advanced liver disease, or who have easy-to-cure Hepatitis C genotypes. Through Kaiser’s email system, physicians caring for these patients can be contacted directly and offered consultation for the patients in question. This method has been highly successful and has already resulted in the cure of many patients who might otherwise have come to the clinic’s attention only after becoming too sick to receive interferon-based care. Kaiser’s hepatitis C clinic has a similar database that is used to automate the screening for liver cancer for hepatitis C-infected patients with advanced liver disease. These unique opportunities for proactive population management are a particularly exciting part of Kaiser’s practice, and provide unique forms of assistance for frontline medical providers and their patients in ways that are well outside the realm of the reactive, referral-based model of specialty care as it is generally practiced in the United States.
Maximizing Cure Rates
The hepatitis C clinic at Kaiser maintains a separate, highly detailed electronic database on all of the patients who have been seen in consultation, allowing a better understanding of the demographics of patient population, and providing regular updates on clinic treatment outcomes. From the standpoint of potential virologic cure, the patient population that Kaiser manages is quite difficult to treat. For example, as of September 2007, of the patients who have completed a full course of HCV therapy at our clinic, 78% had either stage 3 or 4 hepatic fibrosis and nearly 20% had failed one or more courses of interferon HCV treatment prior to receiving care at the hepatitis C clinic. In addition significant co-morbidities including HIV co-infection, end stage renal disease, morbid obesity, and active social and psychiatric issues were present in a significant number of patients.
Despite a patient population whose profile includes many factors mitigating against the chances of cure, the intent-to-treat, genotype specific rates of cure with HCV treatment at Kaiser are equal to or better than those of the licensing trial of pegylated interferon alfa-2a, which is the form of pegylated interferon used at the Kaiser clinic.22 In that licensing trial, the patient population represented young, treatment-naïve patients, of whom only 12% had stage 3 or 4 fibrosis. An important part of Kaiser’s success in achieving rates of cure that are much higher than would be predicted for the population served involves an integrated treatment approach that includes: thorough pre-treatment counseling; aggressive, multifaceted patient support by the treatment team once treatment starts; and the minimization of dose-reductions during treatment through the use of erythropoietin and, when needed, blood transfusion and growth colony stimulating factors. Hence, the rates of treatment discontinuation and dose-reduction during therapy are extremely low, translating to much higher rates of cure than would be possible otherwise. In addition, Kaiser Permanente has given the clinic the liberty to employ several approaches to HCV treatment that are not currently reimbursed by private insurance in Hawai‘i , but which are supported by recent clinical trials and are in common use in university academic HCV treatment centers. These include the use of high dose (weight-based) ribavirin for significantly obese patients,23 the use of prolonged courses of HCV treatment based on detectable HCV viral loads at week 4 of treatment,24-25 and the use of daily dosed “consensus” interferon (Intergen) for selected patients who are not responding to pegylated interferon therapies.26-27
At the Hawai‘i Medical Service Association (HMSA), hepatitis C treatments for its members require prior authorization except for HMSA Quest members that have State mandated benefits. HMSA hepatitis C policy is based on national guidelines with input from local experts. HMSA’s research policy allows coverage of usual covered costs for members who are enrolled in studies sponsored by recognized institutions such as the National Institutes of Health (NIH), Veterans Administration (VA), and more. All hepatitis B treatments are covered, and immunization coverage for adults currently follows CDC recommendation.
There are a number of ongoing drug trials supported by the pharmaceutical industry to test new drugs or new combinations of medication. The contribution of these clinical trials is often overlooked in our community. The medications must meet the standards of the US Federal Drug Administration and are provided at no charge by the companies. Clinical trials sponsored by centers such as the Liver Center and Infections Limited Hawai‘i have saved our communities millions of dollars in therapy and made treatment available for patients who might otherwise not be able to afford it.
Data Management and Decision Support
Partnering with HMSA Foundation, the University of Hawai‘i Telehealth Research Institute, and community health centers, the Liver Center at Hawai‘i Medical Center East is developing a hepatitis B and C telemedicine system to provide quality care in the primary care setting. The “3 for Life” and the Hepatitis Support Network of Hawai‘i screening programs allowing tracking and monitoring from detection to outcome, and improves communication and coordination among the state health department, specialty pharmacies, health plans, specialists, and primary care providers. There are over 300 patients registered in the database. The objectives of this program are primary care education for hepatitis, telemedicine information and consultation services, and establishment of a comprehensive disease management program for hepatitis that includes a registry, decision support and care monitoring, tracking, reminders for hepatitis B immunizations, survey tools, educational material, report generator, graphs of labs, and secure email. Obstacles to improving these services are resistance from primary care providers to change their systems, HIPAA privacy rules, multi-system integration, software development, overall implementation, and adequate funding and personnel. Data collection and ongoing analysis are important aspects for the evaluation and management of hepatitis. There is an ongoing need for comprehensive registries or electronic medical records reporting systems that would allow for rapid analysis of patient databases for hepatitis and its complications.
