As clinicians, we must advocate for our patients; currently, that role involves the considerable task of educating insurers, many of whom are focused firmly on the fibrosis score. We must diligently insist that third-party payers recognize the potential for HCV-related complications to affect a patient’s health
Norah Terrault, MD, MPH - 3/13/2015 More from this author
In the current era of direct-acting antivirals, one of the most common challenges facing patients with HCV infection is access to therapy. Despite an impressive new array of highly effective, highly tolerable treatments, I see patients struggle with insurance providers over coverage for these expensive drugs. How can we as clinicians maximize our patients’ potential to gain access to these life-altering therapeutics?
Expanded Screening for HCV-Related Complications
The AASLD-IDSA guidance includes a list of liver-related complications and extrahepatic diseases that qualify patients for high priority treatment. In my practice, we have instituted routine additional screening based on that list to help seek out potentially hidden risk factors for disease complications. For example, we now screen every patient with HCV infection for cryoglobulins. Cyroglobulinemia can have obvious end-organ manifestations such as vasculitis or renal failure. However, patients who have cyroglobulins without immediate symptoms are still at risk for developing complications in the near future. Thus, we seek to document any evidence of cryoglobulins and highlight the associated risk for developing extrahepatic manifestations. In addition, we perform a urinalysis on all patients to look for evidence of proteinuria or microscopic hematuria. Of importance, there are HCV-related renal diseases that are not cryo related, including membranous glomerulonephritis. Performing routine urinalysis ensures that we are able to document such conditions when prescribing HCV medications.
Diabetes is easily screened for and is an obvious complication of HCV infection. We also screen for insulin resistance in all patients, as well as hemoglobin A1c. We have been surprised to find evidence of insulin resistance among thin patients who do not fit the typical profile of prediabetes. In addition, some patients have evidence of skin manifestations of HCV disease, such as lichen planus. Many of these patients have already received dermatologic diagnoses, but as hepatologists, we are able to link these conditions to HCV infection and help make it clear to the insurer that their disease is having additional complications.
A common complication of HCV infection is fatigue. Documenting fatigue is more difficult, as it can have many causes and is challenging to quantify. In my practice, we ask our patients to provide examples of how fatigue is affecting their ability to work and play. For example, we document any instances where patients have taken medications to improve energy, such as amphetamine and dextroamphetamine. We are also actively exploring tools that will help us to better characterize fatigue, such as a patient questionnaire.
Finally, we document cofactors that might give us concern for accelerated disease progression. These include HIV coinfection and risk factors for fatty liver, such as obesity and metabolic syndrome. In addition to the hepatic and extrahepatic manifestations of HCV, these cofactors help us provide a complete picture of each patient’s current and future risk for disease complications.
Acting as Patient Advocates
You may be wondering how much all of this additional screening has helped our patients receive approval for therapy. Unfortunately, it has thus far had only a modest affect. However, I am hopeful that as we continue to perform more comprehensive evaluations of each patient, we will see improved access to treatment. As clinicians, we must advocate for our patients; currently, that role involves the considerable task of educating insurers, many of whom are focused firmly on the fibrosis score. We must diligently insist that third-party payers recognize the potential for HCV-related complications to affect a patient’s health.
Your Thoughts?
Have you considered expanding your approach to screening patients with HCV infection for extrahepatic manifestations and related complications? I invite readers to post their opinions and experiences on improving patient access to therapy in the comments section below.
In the current era of direct-acting antivirals, one of the most common challenges facing patients with HCV infection is access to therapy. Despite an impressive new array of highly effective, highly tolerable treatments, I see patients struggle with insurance providers over coverage for these expensive drugs. How can we as clinicians maximize our patients’ potential to gain access to these life-altering therapeutics?
Expanded Screening for HCV-Related Complications
The AASLD-IDSA guidance includes a list of liver-related complications and extrahepatic diseases that qualify patients for high priority treatment. In my practice, we have instituted routine additional screening based on that list to help seek out potentially hidden risk factors for disease complications. For example, we now screen every patient with HCV infection for cryoglobulins. Cyroglobulinemia can have obvious end-organ manifestations such as vasculitis or renal failure. However, patients who have cyroglobulins without immediate symptoms are still at risk for developing complications in the near future. Thus, we seek to document any evidence of cryoglobulins and highlight the associated risk for developing extrahepatic manifestations. In addition, we perform a urinalysis on all patients to look for evidence of proteinuria or microscopic hematuria. Of importance, there are HCV-related renal diseases that are not cryo related, including membranous glomerulonephritis. Performing routine urinalysis ensures that we are able to document such conditions when prescribing HCV medications.
Diabetes is easily screened for and is an obvious complication of HCV infection. We also screen for insulin resistance in all patients, as well as hemoglobin A1c. We have been surprised to find evidence of insulin resistance among thin patients who do not fit the typical profile of prediabetes. In addition, some patients have evidence of skin manifestations of HCV disease, such as lichen planus. Many of these patients have already received dermatologic diagnoses, but as hepatologists, we are able to link these conditions to HCV infection and help make it clear to the insurer that their disease is having additional complications.
A common complication of HCV infection is fatigue. Documenting fatigue is more difficult, as it can have many causes and is challenging to quantify. In my practice, we ask our patients to provide examples of how fatigue is affecting their ability to work and play. For example, we document any instances where patients have taken medications to improve energy, such as amphetamine and dextroamphetamine. We are also actively exploring tools that will help us to better characterize fatigue, such as a patient questionnaire.
Finally, we document cofactors that might give us concern for accelerated disease progression. These include HIV coinfection and risk factors for fatty liver, such as obesity and metabolic syndrome. In addition to the hepatic and extrahepatic manifestations of HCV, these cofactors help us provide a complete picture of each patient’s current and future risk for disease complications.
Acting as Patient Advocates
You may be wondering how much all of this additional screening has helped our patients receive approval for therapy. Unfortunately, it has thus far had only a modest affect. However, I am hopeful that as we continue to perform more comprehensive evaluations of each patient, we will see improved access to treatment. As clinicians, we must advocate for our patients; currently, that role involves the considerable task of educating insurers, many of whom are focused firmly on the fibrosis score. We must diligently insist that third-party payers recognize the potential for HCV-related complications to affect a patient’s health.
Your Thoughts?
Have you considered expanding your approach to screening patients with HCV infection for extrahepatic manifestations and related complications? I invite readers to post their opinions and experiences on improving patient access to therapy in the comments section below.
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