VA Overhauls Approach to Care for Veterans With Hepatitis C : Page 2 of 3

July 26, 2016


Increased competition may be beginning to drive the price down, however. Merck & Co joined the fray in early 2016, offering a new hepatitis C treatment called Zepatier (elbasvir and grazoprevir) at a list price of $54,600 for a 12-week regimen.

Dr Aronsohn predicts that, as new hepatitis C regimens are released onto the market, competition will drive prices down, making the costs associated with HCV treatment more sustainable for systems like the VA.

In the meantime, although the bulk use of these medications has allowed the VA to negotiate discounted pricing, it still spent $696 million on new hepatitis C drugs (17% of the VA’s total pharmacy budget) last year alone. 

In fiscal year 2015, the total cost to the VA of treating 30,936 veterans with HCV was $1.2 billion, according to David Ross, MD, PhD, MBI, director of HIV, Hepatitis, and Public Health Pathogens Programs for the Veterans Health Administration. Based on current treatment rates, the VA expected to treat between 42,000 and 50,000 veterans in fiscal year 2016, and the drug costs alone would have totaled between $753 and 880 million.

As of the March expansion in HCV coverage, VA says that it anticipates that spending on hepatitis C drugs will total ~$1 billion as many more veterans will be started on HCV treatment. Fortunately, Congress has increased funding to the VA to support this spending increase for the current fiscal year. But whether this support from Congress will continue into the next fiscal year remains to be seen. The VA has reportedly requested $1.5 billion in its budget for 2017 to support HCV treatments and clinical resources.


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Remaining Challenges

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. 

hepatitis CTo 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.