Rural Americans Still Lack Access to Syringe Exchange Programs

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

The HEAL Blog  covers the expansion of Syringe Exchange programs as an effective and proven method of Harm Reduction to prevent the spread of HIV and Hepatitis C (HCV). While there have been some notable successes over the past few years, especially in states where rural transmission of both HIV and HCV is increasing, the stark reality is that these areas largely lack access to the Syringe Exchange programs that could help to stanch the spread of deadly diseases that are easily spread through sharing and reusing needles.

A new report from the Centers for Disease Control and Prevention (CDC), decreases in HIV diagnoses in People Who Inject Drugs (PWIDs) indicate success in HIV prevention. However, emerging behavioral and demographic trends could reverse this success (Wejner, et al, 2016). In terms of demographics of PWIDs, both African-Americans and Hispanic populations have seen consistent and rapid downward trends in all three areas: HIV diagnoses among PWIDs, those who shared syringes to inject drugs, and people who reported injecting drugs for the first time. Whites, but urban and non-urban, however, did not fare well in these measures.

In both Urban and Non-Urban settings, new HIV diagnoses amongst white PWIDs saw a slight increase; the same is true of whites who shared syringes to inject drugs; whites made up over 50% of people who reporting injecting drugs for the first time. This shouldn’t come as a big shock to those who have been following drug usage trends – the abuse of opioid prescription drugs and heroin in rural and suburban areas has spiked significantly, over the past twenty years, as we have covered in previous posts – areas where the population tends to skew heavily to the White.

Sign reading, "HIV Needle Exchange"

Indiana Needle Exchange

While Syringe Exchange Programs (SEPs) have grown more common in urban areas, people living in largely rural states, rural areas, and suburban areas have again fared poorly in this regard. A 2015 report from the CDC surveyed 153 SEP directors (out of the then 204, in March 2014), and found that only 9% of SEPs were in Suburban areas and only 20% in Rural areas (Des Jarlais, et al., 2015). The areas hardest hit by the increase in PWIDs – the Northeast, South, and Midwest – had a total of 11 SEPs in Rural areas; the West, by comparison, had 18 in Rural areas. While this data is from 2013, and more SEPs have been opened, it is difficult to get a definitive count of the number of operative SEPs.

From a health emergency perspective, we have a White HIV crisis brewing in rural and suburban America. Beyond the issues related to PWIDs, there is also the increase risk of sexual transmission from PWIDs to those who do not inject drugs. Whites have consistently represented the largest number of new infections, since the beginning of the epidemic (not to be confused with the disproportionate rate of infection amongst minority groups), and for the first time in 2014, White PWIDs had more HIV diagnoses than any other racial or ethnic population in the country (Sun, 2016). State and Federal laws – especially in rural states – continue to present barriers to establishing and funding SEPs in areas that are the hardest hit.

One of the most frustrating aspects of reporting healthcare statistics is the reporting lag; the references used in this post present data that is at least two years old. This problem exists because of the time it takes for states to finalize data, in addition to the time it takes for peer reviewing before publication. While there were 204 operating SEPs in the U.S. in 2013/2014, it’s now 2016, and we could use some updated numbers.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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The 2016 Election, and What This May Mean for Healthcare

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

The passage of the Affordable Care Act (ACA), also known as Obamacare, included a provision that gave states the option to expand Medicaid coverage in order to cover citizens whose incomes were above the Federal Poverty Level (FPL), but whose incomes still present a significant barrier to purchasing health insurance. Of the 50 United States and the District of Columbia, 32 states (including DC) have opted to expand their Medicaid programs. Nineteen states have opted not to expand access.

Expanding access to Medicaid is an essential piece of the ACA, as it was designed to help increase the number of people with access to affordable healthcare. Because the ACA envisioned low-income people receiving coverage through Medicaid, it does not provide financial assistance to people below poverty for other coverage options. As a result, in states that do not expand Medicaid, many adults fall into a ”coverage gap” of having incomes above Medicaid eligibility limits, but below the lower limit for Marketplace premium tax credits (Garfield & Damico, 2016). Since the expansion of Medicaid under the ACA, 73,137,154 Americans were enrolled in Medicaid/CHIP as of August 2016 (Henry J. Kaiser Family Foundation, 2016).

There are an estimated 2.6 million Americans who currently fall into that coverage gap, and of the states that did not expand Medicaid, four states represent 64% of those people (TX – 26%, FL – 18%, GA – 12%, NC – 8%). When looking at the geographic distribution of those 2.6 million Americans, 91% are in the American South (Garfield & Damico, 2016). Demographically, 46% are White non-Hispanics, 18% are Hispanic, and 31% are Black, and over half are middle-aged (age 35-54) or near elderly (55 to 64). Additionally, the majority of people in the coverage gap are in poor working families.

Donald J. Trump

Photo Source: NBC News

President-elect, Donald J. Trump, as well as the incoming Republican-led Congress and Senate, have openly stated that their first priority, at the beginning of the next legislative session, is the repeal of the ACA. There are very few comprehensive plans being proffered to replace the ACA, and healthcare professionals, providers, payers, patients, and advocates, alike, are currently unsure about the future of the expansion, and whether or not that aspect of the ACA will be retained in the forthcoming repeal.

It bodes poorly for those existing people infected with viral hepatitis, especially Hepatitis C (HCV), who stand to lose coverage if the Medicaid expansion does not survive the repeal, even with the existence of drug manufacturer and private Patient Assistance Programs (PAPs). In order for those PAPs to be accessed, however, people must first know about them; without the aid of social workers, healthcare aides, and advocates, people living with HCV are unlikely to find out about these PAPs, unless this information is provided to them by a doctor or nurse.

An additional concern exists for those recipients of the Ryan White Program. Over the past eight years, HIV/AIDS advocates and policy wonks have been in a near-constant debate about whether to reopen the Ryan White Care Act for reauthorization to address some of the ways in which the current law has not necessarily aged well, in terms of keeping up with newer treatments, costs, and funding paradigms. The concern over the past five years has been that the Republican-controlled Congress would “gut” the bill, cutting out many of the provisions upon which organizations and patients have come to rely. With repealing the ACA having played such a large role in this year’s election, concerns about reopening the act are likely to deepen, rather than abate. It is important to note that many states include HCV therapies under their AIDS Drug Assistance Program’s drug formularies.

The HEAL Blog  will pay close attention to both programs, as well as other HIV and HCV-related issues throughout 2017.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Voluntary Involuntary Opioid Abuse Treatment

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

Kicking an opioid drug abuse habit is one of the most difficult habits to break. So difficult is the prospect of quitting that reports are coming out of Massachusetts indicating that some people facing opioid-related drug charges are asking judges to lock them up – inside a treatment program center for 90 days from which they cannot leave.

These requests are in response to several issues, not the least of which include overcrowded treatment programs with long waitlists that reject patients whose insurance will not adequately compensate the cost of inpatient treatment, often the only way to ensure that those undergoing treatment cannot gain access to heroin or other opioid drugs while attempting to detox. In 2016, roughly 8,000 people will be committed to substance abuse treatment in MA, up 40% from five years ago (Brown, 2016).

Technically, a patient cannot request their own involuntary committal; it requires a close relative, probation officer, or emergency room doctor (or other official) to petition the court on your behalf. If you agree not to oppose the petition, a judge is likely to approve the petition. If a judge agrees to the involuntary commitment, that’s a bed in an inpatient facility paid for by the state, rather than the patient or private insurance, and for a length of treatment longer than for which most insurance programs are willing to pay.

Vivitrol for Opiod Dependence

Photo Source: Vivitrol.com

Treatment prospects are much less diverse for those already incarcerated. The Federal government recently approved spending more than $23 million to fund treatment projects that include giving monthly injections of Vivitrol (Alkermes, Inc.) – a blocker that attaches to certain opioid receptors in the brain and blocks the pleasurable feelings associated with taking opioids (Alkermes, nd.b) – to inmates in an attempt to break the cycle of opioid addiction. Eight states (Arizona, Colorado, Illinois, North Carolina, Rhode Island, Vermont, Wisconsin, and Wyoming) are the recipients of these grants – $2.8 – $3 million over three years (Associated Press, 2016). Each of these states intends to utilize these services to patients in different ways, and at different points in their respective sentences.

In addition to these states, the West Virginia Division of Corrections (DOC) has started a pilot program where it offers an injection of Vivitrol to its soon-to-be-released inmates struggling with opioid addiction. WV, along with neighboring OH and KY, have been incredibly hard hit by opioid abuse. One drawback of this pilot program is that the DOC does not follow up on offenders after they have served their entire sentence, so no information is available on the recovery efforts of six of the participants. This creates a problem with the program, as there is no evidence of its efficacy outside of the incarceration or parole period (Holdren, 2016). Additionally, there are simply not enough treatment centers who provide Vivitrol injections in WV, and those that exist are inconveniently located to those located in some of the hardest hit counties and locations, requiring patients to make 1.5- to 3-hour roundtrips to treatment receive injections.

The primary issue with Vivitrol is the cost – between $1,000 and $1,300 per injection on a monthly basis (Johnson, 2016). For inmates enrolled in Medicaid, Vivitrol injections cost just $3 (in WV); those not on Medicaid must pay their insurance’s prescription fee or foot the entire $1,300 on their own. Alkermes does offer a Patient Assistance Program, which offers co-pay assistance up to $500 each month (Alkermes, n.d.a). Additionally, because the drug is relatively new, there is little evidence, yet, that use of Vivitrol proves effective in the long-term. What data there is, however, points to excellent results.

References

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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The Negative Impact of Opioid Drugs Upon Children and Young Adults

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

In early November 2016, a conference held at Xavier University in Ohio drawing hundreds of doctors, nurses, social workers, and addiction specialists began releasing shocking (though unsurprising) data related to the prescription opioid and heroin epidemic’s negative impact on children and teenagers. The findings indicate what many in healthcare already knew: we are at risk of creating a generation of children whose lives are fundamentally altered for the worse by addiction.

In the past few months, HEAL Blog has doggedly followed the unrelenting opioid-fueled devastation in the state of Ohio, and we have frequently brought to the fore the plight of children whose lives are have been put at risk due to their caretakers’ substance addiction and abuse. What we haven’t yet really covered has been the growing risk posed to children and teens whose access to opioids is made possible by their caretakers.

A study released in the Journal of the American Medical Association (JAMA) Pediatrics showed a 165% increase in opioid poisonings in children from 1997 to 2012 (Luthra, 2016). The rate of toddlers hospitalized more than doubled, and teens were found to be increasingly at risk of overdose (both intentional and unintentional) because they gained access to their parents’ prescription opioids without their knowledge. Both of these issues point to the need to better address overprescribing of opioid drugs, as well as to better stress the need for safer storage of prescription drugs.

Roughly 1 in 10 high school students admit to taking prescription opioid drugs for nonmedical reasons (McCabe, West, Boyd, 2013; Luthra, 2016), and roughly 40% say they got those drugs from their own prior prescriptions (Fortuna, Robbins, Caiola, Joynt, Halterman, 2016). This suggests that (1.) parents are not properly securing their own prescriptions and (2.) parents are not properly monitoring their children’s use and disposal of prescriptions. These suppositions raise questions about whether or not parents whose children or teens overdose should (or do) face negligence charges.

Prescribing guidelines continue to be tightened, as the U.S. Centers for Disease Control & Prevention (CDC) and the U.S. Food & Drug Administration (FDA) have both attempted to get physicians to limit prescriptions to shorter periods, and there is little evidence that imposing penalties upon people who fail to properly store or dispose of medications will have any appreciable impact on the adult behaviors. The concern, however, is whether or not those penalties will result in lower levels of abuse and poisoning on the part of children and teens.

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Hepatitis C and Aging

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award

By: Marcus J. Hopkins, Blogger

While we, here at HEAL Blog, have spent much of the year focusing on the vast increase in new Hepatitis C (HCV) infections amongst the Injection Drug User (IDU) population, what often gets left out of that picture is the effect that Chronic HCV has upon the aging Baby Boomer population. According to the U.S. Centers for Disease Control and Prevention (CDC), of the estimated 3.2 million people chronically infected with HCV in the U.S., approximately 75% were born between 1945–1965 – Baby Boomers (CDC, 2015). As such, the Community Access National Network (CANN) will be hosting a panel on HCV and Aging this December 08, 2016, in Washington, D.C.

BORN 1945-1965? CDC recommends you get a blood test for Hepatitis C

Photo Source: Examiner

Baby Boomers have faced significant risks that make them more likely to have been infected with HCV, not the least of which includes blood transfusions received prior to 1990, when routine screening for HCV became the norm. Additionally, because HCV may take many years to manifest, many people are unaware that they are infected, with estimates ranging from 45% – 85% (CDC, 2015). Additionally, recent CDC reports indicate that HCV kills more Americans than any other infectious disease (CDC, 2016), despite being a curable condition. Roughly half HCV-infected patients often fail to receive appropriate treatment, because they are unaware that they are infected.

For those patients who are aware of their condition, there is often fear associated with HCV treatments. HCV treatment has long been considered one of the least tolerated therapies in medicine, with older Pegylated interferon-based treatments requiring long regimens that left patients sick and unable to function. With the introduction of the Direct Acting Agents (DAAs), Sovaldi (Gilead) and Olysio (Janssen), in 2013, these concerns related to the tolerability of drugs were largely mitigated. In 2013, there were two DAAs specifically aimed at treating HCV; in November 2016, there are now nine different drugs on the market to treat various genotypes of HCV – Sovaldi, Olysio, Harvoni (Gilead), Viekira Pak (AbbVie), Daklinza (Bristol-Myers Squibb), Technivie (AbbVie), Zepatier (Merck), Epclusa (Gilead), and Viekira XR (AbbVie). Epclusa, released in July 2016, is also the first pan-genotypic DAA that can treat HCV across all genotypes. These HCV DAAs are not only more easily tolerated, but also have shorter treatment times (between 12-24 weeks, with current testing for 8-week courses).

Though the tolerability of HCV treatments has been largely addressed with these newer DAAs, new concerns have risen regard the cost of the regimens, ranging from $54,000 – $94,500 for twelve weeks of treatment (Zepatier and Harvoni, respectively). In addition, Medicaid, Medicare, Ryan White, and private insurers alike have imposed strict Prior Authorization pre-requisites for approving these treatments, many of which include waiting until liver fibrosis scores (scarring levels) have reached a certain severity before they will approve a patient for these regimens. These pre-requisites often include a daunting amount of paperwork that must be filed, several denials, and abstinence from various activities for extended periods before considerations will even begin to be made. These barriers prevent many Baby Boomers from receiving life-saving treatments that should be routine, but because of cost-related issues are often not.

Despite these concerns, testing for HCV is still not a requirement in emergent care situations, regardless of recommendations by the CDC. With HCV being the leading cause of infectious disease-related deaths, it is imperative that we, as a nation, take better care of our seniors, and all become more aware of the risks posed by Chronic HCV.

 

References:

  • Centers for Disease Control and Prevention. (2015, May 31). Viral Hepatitis – CDC Recommendations for Specific Populations and Settings. Atlanta, GA: Centers for Disease Control and Prevention: National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention: Division of Viral Hepatitis. Retrieved from: http://www.cdc.gov/hepatitis/populations/1945-1965.htm
  • Centers for Disease Control and Prevention. (2016, May 04). Hepatitis C Kills More Americans than Any Other Infectious Disease. Atlanta, GA: Centers for Disease Control and Prevention: Newsroom. Retrieved from: http://www.cdc.gov/media/releases/2016/p0504-hepc-mortality.html

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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An Argument Against “Pain”

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award

By: Marcus J. Hopkins, Blogger

Last week, I posted a link from The Week, about John Oliver’s take on the prescription opioid epidemic. In his NSFW video, he does a largely comprehensive retrospective of how America became quickly addicted to opioid painkillers as the “go to” pain remedy beginning in the late-1990s, of course with his trademark British fire, ire, and expletive-laden delivery. Generally, this type of post generates a few laughs from my friends and agreeing comments from healthcare professionals who understand the scope of the epidemic. This time, however, I was surprised by a treatise on the perils of this type of video.

When it comes to issues where someone clearly feels “wronged” by legal prescribing guidelines, I often take a logical approach. Prescribing guidelines for opioids aren’t written to punish “responsible” patients who adhere to the dosage instructions listed on the label for medically necessary prescriptions. But, the argument that was made, in this case, was that, “…like anabolic steroids,” the risks associated with these drugs has been blown way out of proportion, and videos like these instill in physicians a sense of fear that prevents them from prescribing medically necessary drugs.

For whatever reason, friends of mine who know I work in research related to HIV, HCV, and Harm Reduction frequently come to me with their gripes about opioid prescribing guidelines. In this example, my friend had undergone oral surgery, and his physician refused to prescribe a three-day prescription for an opioid pain reliever in the state of California. My friend said that he was “forced” to get his medications on the “black market,” because his physician was “afraid to prescribe” him the drugs. Mind you, this person is not, in fact, a physician; he is, however, a bodybuilder who openly admits to taking anabolic steroids to get bigger (as per his earlier reference).

What frustrates me about this type of argument is that it presupposes that whatever type or level of “pain” someone is in requires the use of prescribed opioid painkillers; that, regardless of the prescribing guidelines, or even best practices or medical advice, their pain makes an opioid prescription “medically necessary.” It is an unfortunate consequence of living in a society with a U.S. Food and Drug Administration and prescribing guidelines that what one person, who is not a physician, believes to be medically necessary may not, in fact, be.

In a similar vein, another friend of mine, knowing that a segment of my research has to do with opioid prescribing guidelines, asked me if I knew a physician who would prescribe them to her, against her current physician’s recommendations. She believes that the pain management alternative he suggests is not long enough lasting, and that, because she doesn’t have an “addictive personality,” she should be prescribed opioids on a continuing basis to deal with her chronic pain.

For the record: I am not a physician, nor am I in touch with physicians who would violate their respective states’ Doctor Shopping laws or Lock-In regulations. I do not know where to get opioids on the “black market,” nor do I have any connections who can “hook you up” with some illegal prescription drugs. For whatever reason, my well-meaning friends, who may or may not have “addictive personalities,” have it in their heads that they know better about what drugs they should be taking than the licensed professionals who spent several years and hundreds-of-thousands of dollars to obtain their advanced medical degrees.

These prescribing guidelines aren’t just made to make individuals’ lives more complicated; they are designed to address very serious addiction issues that are leading people to their literal graves. I get it: you think your pain is great enough that you deserve special treatment. Well, you don’t. At some point, it became an issue of grave importance that no one, ever, feel any sort of pain, and that all pain needed to be treated with drugs meant to be reserved for people who were in severely unbearable pain. That is simply not the case, regardless of what your black market drug dealer tells you. Suck it up, a bit, and you will live, just as humans have managed to survive with a modicum of pain for tens of thousands of years.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Regimen Adherence and Abandonment

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

One of the biggest concerns for healthcare providers when treating a patient for any disease is regimen adherence – whether or not a patient will properly adhere to a prescribed treatment or therapy. For example, one of the most common problems with the prescription of antibiotics to treat infections is patients who abandon the regimen once they begin to “feel” better, regardless of whether or not the entire prescribed amount has been taken. Early abandonment of drugs meant to treat conditions can lead to the bacterium or virus mutating to form a resistance to the drug, making resurgences more difficult to treat. When it comes to treating chronic diseases, such as HIV and Hepatitis C (HCV), these concerns are especially important, as treating resistant strains of these viruses can be incredibly frustrating, and may leave patients with few good options, drugs with more negative side effects, and costlier therapies than those used with patients whose strains have fewer drug resistances.

Pill Box with hand putting pills in Thursday's box

Photo Source: The Good Doctor, by Medica

The reality, however, is that there are some patients who simply are not likely to adhere to medication regimens; people for whom, for whatever reason, being compliant and doing things on a consistent basis is simply not in their skillset. My maternal grandparents exhibited this kind of reluctance to scheduled medication times. Regardless of how many day/night, week/month, or even time-released pill dispensers I gave them, they were simply unable to perform the appropriate task at the appropriate time, and often ended up taking double or triple doses of certain medications, until they were receiving truly dangerous levels of prescription medications. It took my mother and I essentially taking over my grandfather’s medications and wresting control from my grandmother to ensure that he was getting the right pills at the right time, when he was in his final months.

But, is there a better way to ensure regimen adherence without essentially doing it for a patient? Clinical specialty pharmacists and nurses at Johns Hopkins Medicine have demonstrated that there may be. They use a triage method to boost adherence rates, as well as the odds of successful outcomes, particularly for HCV, called the “stoplight protocol.” Before any costly specialty drug is ordered, patients presenting to the specialty clinic with newly diagnosed HCV infection are evaluated using a standardized screening tool and tagged with a stoplight color – green, yellow, or red – that indicates how well they understand the medication’s benefits and side effects, as well as how likely they are to stick to the regimen throughout the entirely of the treatment.

The patients’ designation also dictates the programmatic monitoring of HCV patients and how frequently the receiving nursing or pharmacist follow-up. Patients in the red zone for whom treatment is deemed appropriate may be monitored weekly, via either clinic visits or by telephone, while patients in the green zone are monitored far less frequently. This tight monitoring of patients’ regimen adherence has led to a therapy abandonment rate of just 4.2% for their HCV patient population, a rate comparable to the 1% – 4.5% discontinuation rate reported for patients in closely monitored HCV drug trials. In contrast, a 2014 “real-world analysis” conducted by the CVS Health Research Institute showed an overall abandonment rate of 8.1% for patients who were taking Sovaldi.

This type of approach looks to be a winning formula in a healthcare arena where specialty drugs to treat HCV run from $54k to $94k, before pricing agreements and rebates, and may be a key component in the treatment cascade that convinces state, federal, and private payers to lessen the often stringent pre-requisites for receiving treatment, especially if the favorable rates of abandonment reported by Johns Hopkins can be replicated at the state level. Perhaps the greatest struggle payers face is determining whether or not spending so much money on a potentially unreliable patient will be worth their investment, and as harsh as that sounds, when each prescription fill costs tens-of-thousands of dollars, it’s a determination that must be looked at for the continued solvency of pharmacy budgets.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

 

References

 

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