Transcript No Slide Title

Management of Hepatitis C:
An Unprecedented Challenge for Corrections
Brad Livingston
Executive Director,
Texas Department of Criminal Justice
Lannette Linthicum, MD, CCHP-A, FACP
Director, Health Services Division
Texas Department of Criminal Justice
ASCA/CCHA Meeting – September 11, 2014 – Phoenix, AZ
Overview
• Briefly describe the Texas Department of Criminal Justice,
and its healthcare system – Brad Livingston
• Briefly describe the burden of Hepatitis C Virus (HCV) in
the Texas Department of Criminal Justice – Dr. Lannette
Linthicum
• Provide an overview of the challenges in managing HCV
in a large prison system – Dr. Lannette Linthicum
• Describe strategies used to manage HCV – Dr. Lannette
Linthicum
• Discuss the financial impact of HCV on TDCJ
Correctional Managed Health Care Appropriations – Brad
Livingston
• Review future options to consider for HCV managementBrad Livingston and Dr. Lannette Linthicum
Large Patient Population
• TDCJ prison population in Fiscal Year (FY) 2013
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–
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1.
265,009 adults under community supervision
150,784 incarcerated
71,713 admissions
72,071 releases
87,000 under parole supervision
Fiscal Year 2013 Statistical Report. Texas Department of Criminal Justice.
Texas Department of Criminal Justice
• Largest state prison
system in US
• 109 facilities
• 150,784 incarcerated
– 92% male
– 8% female
DH
JN
BC, KN
N3
FB, WR
LC, JM
RH
TH, RS
JA
LN
SY
DL
WL, DW
BR
JT
BM
RB, NE
JD HJ
VS
GV, HT,
AH, MV,
LM,
WM,
N2
RZ
• Average age 38 years
TH
• Healthcare Expenditures
$513,915,671
B1, B2, CO, ND, MI
BY
N1, HB
BH
HD, SV
FE
N5, LH
EA
BL
HV, WY, E1, E2,
DU, NF, GR
BB
CV
LJ, LT, HI
P1 &
C & HM
P2
TI
– Range 16-91 years
– 19% ≥ 50 years
TO
CM CL
SM
KY
BJ,
BA, ST
AJ
J1, J2, J3, J4
R1, R2, R3 , DA
SB
TE
HF
CY
ML
TL
GL
LC
BX
DB
N6
GG
NI & NH
N4
SO
WI
RL
RV
CN
CG
HG
Prison Health Care Expenditures
• Spending increased in 41 states with median
growth of 13 percent from 2007-2011
• Spending totaled $7.7 billion in fiscal 2011
nationwide
• Number of older offenders, who typically
require more expensive care, increased in
all but two of the 42 states that submitted
data
State Prison Health Care Spending. An examination. Pew Charitable Trusts and MacArthur Foundation. July
2014. www.pewstates.org/healthcarespending
High Burden of Hepatitis in Texas Prisons
• Prevalence rates:
- General US
population 1-1.5%
- Prison populations
16-41%
- TDCJ population
29%
1. Correctional Facilities and Viral Hepatitis. CDC. http://www.cdc.gov/hepatitis/Settings/corrections.htm
2. Messina JP, et al. Global distribution and prevalence of hepatitis C virus genotypes. Hepatology. Article first published
online: 28 JUL 2014. DOI: 10.1002/hep.27259.
High Burden of Hepatitis in US Prisons
Binswanger A, et al. Prevalence of chronic medical conditions among jail and prison offenders in the USA compared with the
general population. J Epidemiol Community Health 2009;63:912-919.
TDCJ Population with End Stage Liver Disease
End Stage Liver Disease is defined as
patients with: ascites, hepatic
encephalopathy, esophageal varices,
significant cirrhosis or liver cancer.
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Hepatitis is a Leading Cause of Death
in State Prisons
Mortality in local jails and state prisons, 2001-2011 – Statistical Tables. US Department of Justice. Office of Justice Programs.
Bureau of Justice Statistics. August 2013, NCJ 242186.
Challenges Managing HCV
Challenges
Strategies
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Large population &
correctional system
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Centers of excellence
Technology (e.g., EHR, telemedicine)
Clinical guidelines
Administrative practices (e.g., Medical Hold)
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High burden of chronic
disease
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Health screenings
Chronic care clinic
Specialty clinics (e.g., HIV, HCV, ESLD)
•
Changing and complex
standards of care
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Collaboration with university providers & subject matter experts
Special task force / workgroups
Multi-disciplinary approach to care
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Rising drug costs and
budget limitations
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Drug purchasing initiatives (e.g., 340B)
Strict formulary controls
Use of clinical guidelines
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Continuity of care and
linkage to care
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Technology (e.g., EHR, telemedicine)
TCOOMMI programs (e.g., case management, continuity of care and
MRIS)
Peer education programs
Complex therapies completed during incarceration whenever possible
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Major Pharmaceutical Cost Drivers
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HIV
Psychotropic agents
Chronic hepatitis C
Chronic care medications
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‒
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Dialysis agents
Cardiovascular agents
Antidiabetic agents
Respiratory agents
Correctional Managed Care
Evolution of HCV Drug Therapy in Texas
Sector
Peginterferon
+ Ribavirin
PEG/RBV +
Boceprevir
PEG/RBV +
Sofosbuvir
UTMB
$8,480
$25,310
$62,240
Texas Tech
$8,620
$77,420
$80,730
• HCV genotype 1
- PEG and RBV used prior to treatment advances
- Currently PEG, RBV, and Boceprevir used
- HCV treatment evolving rapidly & sofosbuvir
recommended for most patients
• 2013 CMHCC guideline currently under review
• Significant increase in HCV drug costs expected
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Potential Impact HCV Drug Cost
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Future Strategies
• Prioritize drug use
• Establish partnerships with 340B eligible entities so
savings may be used to increase access to care
• Leverage technology
– Use of EHRs and “Meaningful Use” requirements to
improve linkage to care
– Use telemedicine to reduce nonmedical expenses
• Close knowledge gaps
• Plan now for providing treatment with new agents and
drugs in the pipeline
Future Strategies (Cont.)
• Develop and implement policies and strategies that provide
for and address the unique needs of offenders with HCV
– Corrections specific recommendations in national guidelines,
reports, position statements, etc.
– Expansion of Medicaid to include offenders and nondisabled adults
without children to reduce the financial burden on state
government and prison budgets
– Less stringent criteria for meeting requirements for compassionate
release from prison (e.g., medical or geriatric parole)
• Approach HCV from a societal perspective
Questions?