Program cuts medication costs for hep C patients
CMs focus on appropriate management of the diseases
In the first year of a disease management program to promote effective treatment for hepatitis C, BlueCross BlueShield of Tennessee was able to cut medication costs for the treatment of the disease by $1.63 million.
The savings were generated by ensuring that physicians conduct genotype blood tests that indicate the recommended length of treatment and by working with members with hepatitis C to ensure that they complete their full medication regimen, says Beverly Franklin-Thompson, PharmD, regional pharmacy director for the Chattanooga-based health plan.
The purpose of the disease management program is to make sure patients are getting appropriate treatment regimens for the appropriate amount of time, says Jocelyn Bryant, RN, MSN, CCM, supervising clinical project manager.
Case managers in the health plan work with the members and their physicians to implement strategies to make sure that the members receive appropriate management of the disease, Bryant says.
"Treatment for hepatitis C is not well tolerated and can result in flu-like symptoms, depression, and diabetes. People who are taking medication for the disease can feel pretty miserable," she adds.
The health plan developed the program several years ago when data analysis indicated an uptick in the number of people receiving treatment for hepatitis C, Franklin-Thompson says.
"It wasn't so much that the acute cases were increasing, but there was an increase in the people who had been infected in the past and were becoming symptomatic and were realizing they have the diagnosis," Franklin-Thompson says.
Patients with hepatitis C often are asymptomatic for many years after the initial infection, she adds.
"The symptoms begin to appear 10 to 15 years later and include fatigue, joint pain, sore muscles, and jaundice," she says.
The health plan analyzes pharmacy claims each month to identify members who are receiving prescriptions for hepatitis C treatment.
Case managers call the members' prescribing physicians to verify the diagnoses and the dates they began treatment and to obtain clinical information about the patients.
When the program began, the case managers determined that physicians were not ordering genotype blood tests because they didn't understand the importance of the test in developing a treatment plan.
The genotype blood test determines the strain of hepatitis C that infects the patient, which will determine the length of treatment.
Different genotypes require different lengths of therapy. For instance, genotype 1 is the most difficult to treat and requires 48 weeks of therapy; genotype 2 requires 24 weeks of treatment.
"The nurse case managers began educating the physicians about the importance of the genotype blood type test early in the treatment and notifying them that the health plan covers the cost of the tests," Franklin-Thompson says.
After the patients have been receiving treatment for a few weeks, the case managers call them and conduct an assessment and provide information about the disease and the treatment regimen, Bryant says.
They work with the member and the physician to develop a plan of care.
The case managers educate the members about possible medication side effects and the need to take the medications as directed.
They contact the members every 30 days for up to six months, and longer if necessary, working with them to help them comply with their treatment plan. In the 12th week of treatment, the case managers contact the members' physicians to determine the result of the viral load tests, which indicate whether the medications are working.
"The unique aspect of this program is that we are conducting outreach to the patient and the physician instead of waiting for them to contact us," Bryant says.
The case managers offer suggestions on how to manage side effects, which can include fatigue, nausea, and depression.
They help the members access other resources within the health plan or in the community and link them to community support groups that can help them cope with the condition.
"The main issue with members is the side effects. The case managers emphasize that they should not stop taking the drug until they complete the treatment regimen. Some patients stop the therapy because of side effects. Others stop because of the cost of the drug. We try to intervene and prevent that from happening," Franklin-Thompson says.
If patients stop the therapy because of side effects, they have to start the treatment course over and take the medication for the full 24 or 48 weeks, she says.
"We want to ensure that they take the full course of treatment so they have the best opportunity for success," Franklin-Thompson says.