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New Incentives for Hepatitis C Treatment

Keywords: Hepatitis C, Incentives

Overview

A financial incentive program to improve appointment attendance at a safety-net hospital-based primary care HCV treatment program.

Innovator

Kristen Lee MD

Editor

Meg Krasne MPH

Location

Boston Medical Center, Boston MA

Organizational Context

  •  The intervention was implemented by the Boston Medical Center (BMC) Primary Care Hepatitis C Treatment Program.
  • The BMC Primary Care HCV Treatment Program was established in 2015 in an effort to address the specific needs of HCV patients so that they can receive timely treatment and support

  • The program consists of the following:
    -13 primary care HCV providers (physicians, nurse practitioners, and residents, 4 of whom see the majority of the patients) internally trained to treat HCV. This training includes completion of online modules provided by the American Association for the Study of Liver Disease or by University of Washington and shadowing a HCV specialist for 1 clinic session.
    -A social worker: follows patients longitudinally and addresses patients’ psychosocial issues by providing education and counseling for HCV, exploring barriers to successful completion of treatment (housing, transportation issues, food insecurity), and connecting patients to behavioral health or addiction specialists if needed
    -A clinical pharmacist: provides medication teaching to patients and safety monitoring while on treatment
    -A pharmacy liaison: works to obtain prior authorization for HCV medication.

  • The BMC Primary Care HCV Treatment Program’s no show rate (# missed appointments/total # appointments scheduled) was 40% during its first few years, much higher than the adult primary care practice’s no show rate which was 25%. 
  • The Primary Care HCV Treatment Program members decided to try an intervention to improve appointment attendance so that more patients get treatment for their disease.

Macro Context

  • 340B drug pricing monetarily incentivizes medical centers to treat hepatitis C in their patient population

Population Served

  • BMC is a large safety net hospital, and Medicare/Medicaid pay for 90% of HCV medication costs in BMC's population
  • 10% of the patient population at BMC has HCV infection, much higher than the 2% prevalence in the United States’ general population. 
  • While some patients with HCV at BMC received care for HCV in specialty clinics (gastrointestinal or infectious disease), there remained many patients who had trouble accessing the necessary care to treat their disease. 

Project Research & Planning

  • After identifying the need to improve appointment attendance, team considered QI projects around patient navigation and case management, but they felt the social worker was providing these services well. 
  • The social worker mentioned that patients had reported not coming to clinic for financial reasons (unable to miss work, issues with transportation, no childcare available). 
  • They thus decided to try a financial incentive program. While financial incentives had not been implemented elsewhere for HCV treatment as far as the team was aware, they have been shown to be effective in care for HIV, substance use disorders, and smoking cessation
  • As data collection was key to the intervention, a research assistant was hired. This person helped to collect and analyze the data during the pilot, and assisted the team in conducting interviews with both hospital stakeholders (to learn their thoughts on the sustainability, feasibility, ethics, and acceptability of the intervention) and patients (to hear about their experience with the intervention).
  • The team decided to forego a randomized control trial and provided gift cards to all patients who attended appointments with a HCV provider. They consulted the BMC legal team, who advised them that it was not illegal to provide financial incentives to patients when it is promoting access to care and that hospital policy stipulated the maximum amount to give is $15 per visit and $75 maximum annually.
  • They chose to conduct the pilot from April through June 2017, as there would be fewer weather problems and holidays to inhibit attendance.  

Funding

  • A grant from the Boston University Center for Implementation and Improvement Science for a pilot project providing $15 gift cards to patients who attend their scheduled appointments with HCV providers. 

Training

  • The 13 primary care HCV providers (physicians, nurse practitioners, and residents), 4 of whom see the majority of the patients were internally trained to treat HCV. 
  • This training includes completion of online modules provided by the American Association for the Study of Liver Disease or by University of Washington and shadowing a HCV specialist for 1 clinic session. 

Tech Involved

Epic

Team Members

  • Attending physicians & residents
  • Nurse practitioners
  • Social Worker
  • Clinical Pharmacist

Daily Workflow Steps

The typical hepatitis C clinic workflow:

  • The social worker received referrals to the program via EMR from several different sources within BMC (primary care providers, the lab when a new case is identified). Patients are also referred from the community (addiction rehab, halfway housing, etc.).
  • They see a physician for an initial evaluation, during which mode of disease contraction, potential treatment, and level of motivation for treatment are discussed. 
  • They then receive outpatient testing to evaluate extent of disease (ultrasound and fibroscan of the liver), and they subsequently return to clinic to discuss test results and make the decision whether or not to treat.
  • Typically, it takes a week or two for prior authorization to be approved (since 2016, all patients have been approved), at which time the patient meets with the clinical pharmacist to receive education around taking Harvoni and potential side effects/interactions, a calendar of treatment, and a prescription to receive the medication (if getting medication through BMC pharmacy, they receive their first bottle at the appointment). 
  • The clinical pharmacist calls the patient at week 2 and sees the patient in clinic at week 4 to take labs. 3 months after treatment, patients come to see the physician to check for cure and receive more education.

The financial incentive pilot workflow:

  • The social worker contacts the patient to set up an appointment with a physician and tells the patient that he or she will receive a $15 gift card at the appointment. When the patient arrives at the appointment, the physician gives the patient the gift card. For patients not seeing one of the four main hepatitis C physicians, the social worker gives the patient the gift card. Providing the gift card is included in the patient’s chart. 
  • Note: not all patients scheduled their appointments with the social worker, so a portion of patients who received the gift card at the appointment were unaware of it prior to attending the appointment.

Budget

$14,000

  • The pilot's cost of $14,000 included $5,000 for the cost of the gift cards, the salary of a research assistant (helps with submitting paperwork, collecting and analyzing data).

Status

  • The intervention has been completed. 
  • The three-month intervention served as a pilot, and the program is working with BMC to explore the potential for a long-term intervention. 
  • They have presented data to a high-level administrator, who thinks the data is convincing.  
  • They are looking into the financial data to see if increasing attendance translated into increased drug prescription, and they plan meeting with the legal team to explore legality of future interventions if the funding were to come from BMC.

Outcomes

  • The key outcome was clinic attendance rate (# appointments attended/total # appointments schedules) for HCV provider visits in the BMC Primary Care HCV Treatment Program.

    • 98 patients were scheduled for visits during this intervention.

    • Data analysis showed that patient attendance increased from 61% in April-June 2016 to 73% in April-June 2017 with the incentive, (78% if only counting patients informed of the incentive by the social worker in the analysis).

  • More complex analysis was also performed. 
    • A logistic regression, controlling for age, sex, race, and insurance type, showed that odds of a patient attending a visit during the intervention in 2017 was 2.05 times the odds of a patient attending a visit during the same 3-month period in 2016 (CI 1.25-3.36, p=0.005). 
    • An interrupted time series analysis was also performed and showed that the effect of the intervention was independent of larger trends over the study period. 

Future Outcomes

  • Dr. Lee's team is looking into the financial data to see if increasing attendance translated into increased drug prescription, and they plan meeting with the legal team to explore legality of future interventions if the funding were to come from BMC.

Benefits

  • The intervention promoted access to treatment service for more HCV patients. 
  • Further, engagement with these specially trained HCV providers in primary care creates increased access to health benefits for other medical problems and improved engagement with the medical system. 
    • For example, patients attending appointments increases their likelihood of engaging in healthcare maintenance such as vaccinations (hepatitis A and B immunizations) and screens.
  • A presumed benefit (which has not been measured) is that hospital system benefits monetarily from increased drug prescription.

Unique Challenges

  • There is a lot of uncertainty around 340B drug pricing and potential future changes to reimbursement. 
  • Therefore, it is unclear what the best solution will be in the future and how engaged the hospital system will be in this systems changeAdd paragraph text here.

Personnel Challenges

  • Initially, the social worker was somewhat overwhelmed with the new tasks related to the intervention. 
  • In addition to scheduling appointments and calling patients to remind them, the intervention required that the social worker also remind providers to give gift cards, keep track of gift cards, give out some gift cards herself, and collect data around appointment attendance.

Glossary

Mass Health: a health insurance program for Massachusetts residents that are eligible for Medicaid and Childrens Health Insurance Program (CHIP).
https://www.mass.gov/topics/masshealth

340B Drug Pricing: ‘covered entities’, or providers such as safety net hospitals that treat the nation’s most vulnerable populations, receive specific medications (including hepatitis C drugs) at a discounted price from drug companies, but insurance companies are charged at market price, allowing for the hospital to keep the margin. In April 2016, eligible hospitals no longer received this benefit for medications prescribed to patients insured by MassHealth.
https://www.340bhealth.org/340b-resources/340b-program/overview/

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