VA Overhauls Approach to Care for Veterans With Hepatitis C : Page 2 of 2
According to Dr Aronsohn, there are other difficulties that need to be addressed beyond just cost of care to ensure sustainable access to HCV treatment among veterans. For one, a lack of disease awareness means that many adults in the US, including veterans, may have been infected with HCV but are not aware of it. Therefore, improved efforts to identify and diagnose the virus in these individuals are crucial.
To overcome the challenges associated with lack of awareness, Dr Aronsohn said, the model of success is HIV. The one thing that has been done well is creating awareness of the disease over time. “That needs to happen with hepatitis C,” he said, “and that’s one of the ways to get patients to understand their risk factors and to know when they need to be advocates for themselves.” For its part, VA is working to improve disease awareness for HCV through educational resources for veterans provided on its website.
The second key challenge is the linkage from diagnosis to care. Patients who have been diagnosed need to be able to find providers equipped to treat the illness. Yet, the dramatic increase in the numbers of those receiving or seeking treatment makes this a tall order. The rate of new treatment starts in the VA was about 100 per week prior to 2014, according to Dr Ross. One year ago, the rate had increased to approximately 570 per week. Currently, the rate is approximately 1130 per week.
To address this increase in demand, beginning in 2014, the VA deployed Veterans Integrated Service Network (VISN) Hepatitis C Innovation Teams (HITs). Through the implementation of systems redesign strategies, these teams have assessed and worked to address local gaps in care for veterans with the disease.
The VA also offers the Veterans Choice Program, which allows eligible veterans to receive care from non-VA facilities and providers. Eligible individuals include those who have been waiting more than 30 days for medical care within the VA system or who live more than 40 miles away from the nearest VA medical care facility or face another travel burden that prevents them from receiving care at a VA medical care facility.
To address geographic constraints for those who choose to receive treatment within the VA health system, the VA has adopted a model developed by Sanjeev Arora, MD, at the University of New Mexico called Project ECHO (Extension of Community Health Outcomes). The VA’s version is called SCAN (Specialty Care Access Network)/ECHO.
This tele-consultation model uses case-based learning to train primary care providers at outpatient clinics to evaluate and treat patients, allowing veterans in rural locations to receive treatment at a VA facility close to where they live, rather than to travel for hours to a VA medical center.
SCAN/ECHO has been highly successful, according to Dr Ross. Wait times for treatment decreased by 75%, and cure rates for patients treated through this program are equivalent to the rates for patients treated by specialists.
Dr Aronsohn, who leads the ECHO-Chicago Hepatitis C management team, pointed out that programs like this are going to be essential moving forward because of the high rates of HCV infection—both among veterans and among the general population. “It’s just not feasible that they’re all going to get in to see specialists and be managed by specialists,” he said. “That care is going to have to be shifted to the primary care setting.”
Even with improved efforts to connect veterans with the care they require, many veterans with HCV have conditions that may limit the ability to be treated effectively, such as substance use that impairs adherence, serious mental illness, documented non-adherence to medical appointments or treatment, unstable/uncontrolled medical comorbidities, or a lack of engagement in care, Dr Ross pointed out. Still others choose to decline treatment.
The VA is taking steps to increase the availability of treating providers and outreach staff and is scaling up efforts to reach out to patients who fall into these categories so that they, too, can benefit from treatment when appropriate.
Lessons To Be Learned
According to Dr Ross, the success of the VA, in large part, has been due to the utilization of interdisciplinary clinical teams that integrate treatment, aggressive case management, mental health support, and clinical pharmacy expertise.
The use of a population health cascade of care model to determine which patients have been tested, diagnosed, linked to care, evaluated, treated, or cured, allows targeted interventions to improve access and quality at each stage of the cascade. In addition, electronic registries and dashboards allow near real-time reporting and analysis on various access and quality measures.
Bringing care to the patient through SCAN/ECHO and other telehealth initiatives improves access, and evidence-based standards with flexibility for clinical judgment enhance outcomes. Last, but certainly not least, Dr Ross added, the thorough integration of clinical pharmacists at all levels is critical for ensuring appropriate therapy.
So what can other health care systems potentially learn from the VA’s large-scale approach to expanding HCV treatment to all veterans?
“There are huge disparities in our country as far as access to these medications, so the VA is a really nice model,” Dr Aronsohn said, noting that the VA is accomplishing what the medical community, patient advocates, and patients have hoped would take place across the country and around the world. “Whatever way they’ve been able to do this to make [the expanded coverage] happen is something that other systems should really pay a lot of attention to,” he added.
At the same time, Dr Aronsohn acknowledges the challenges for systems outside the VA. The cost benefits associated with HCV tend to pay off over the course of years, he explained, because savings are achieved through the prevention of the complications that arise during the end stages of liver disease. But patients tend to change payers and insurance policies fairly often, so why would a payer want to spend $100,000 for a beneficiary’s treatment when that same individual could very well be covered by someone else in 5 years?
“The VA is a little bit of a different population: because people tend to stay in the VA for a longer period of time, they are actually able to realize the cost benefits down the road with this population.”