Tag Archives: healthcare

Hepatitis C Death Rate High Among Uninsured and Medicaid Recipients

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

Researchers presenting at Digestive Disease Week found that, between 2000-2010, adult who were infected with Hepatitis C (HCV) were more likely to die if they were either uninsured, or recipients of Medicaid benefits (Basen, 2018). Being HCV-Positive correlated with higher mortality rates (10.4% compared to 3.1% for HCV-Negative patients).

The limitations of these data are several – (a.) the data are nearly a decade old; (b.) these HCV mortality rates are from an era where the only curative treatments for the disease had a treatment abandonment rate of between 40-80%, because the Pegylated-Interferon treatments were almost impossible to tolerate; (c.) an artifact of those older treatments was that the Centers for Disease Control and Prevention (CDC) were not proactive about pushing HCV testing beyond the Birth Cohort (1945-1965).

While these data are nearing ten-years-old, they do reveal some interesting patterns that HEAL Blog has been contending for some time: (1.) Medicaid recipients were more likely to be infected with HCV than those with insurance; (2.) HCV infection rates were highest among the uninsured; (3.) HCV-Positive Medicaid recipients had higher rates of extra-hepatic (illnesses other than those affecting the liver) comorbid conditions, such as diabetes, congestive heart failure, and stroke.

Outpatient Medicaid Office

Photo Source: VinNews.com

Essentially, much like HIV, although neither disease discriminates against any class, color, or education level, those who are poorer, less educated, and minorities are disproportionately impacted by these fatal diseases. More to the point, there is no single rightway to deal with these issues; none of these issues exist in isolation:

  • less education correlates with and contributes to poverty, as well as leaving people less able to understand health risks and how to deal with any diseases they contract;
  • people who are impoverished tend to have less access to comprehensive (or even basic) healthcare services, and if they are poorly educated, they are less likely to utilize healthcare services, because they often don’t recognize symptoms of disease;
  • people who are have less access to healthcare services are likelier to develop chronic illnesses that prevent them from working, thereby increasing their likelihood of remaining in poverty.

Because these problems are interconnected, dealing with just one aspect is an ineffective approach – we cannot just address access to healthcare, because we’re not also addressing how people will pay for healthcare and treatment, nor are we considering the impact that accessing healthcare can have for people who have to miss hourly-wage jobs in order to access said care, and thus lose money, only to have to spend more money.

And, honestly, I don’t know what the answers in today’s America are. In a perfect world, we would have Universal Healthcare paid for by tax dollars that would low- to no-cost out-of-pocket, as well as expanded and affordable public transportation, higher wages, rent control, and free college and university paid for by taxes (like most of the rest of the modernized world). But, we don’t have those things, and it’s not likely we’re going to get those things any time soon.

In the meantime, looking at these data are a great way for us to craft policies to address these issues, particularly as new HCV infections are trending younger and younger, and younger people are less likely to be insured. Food for thought.

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 Kids Aren’t Alright

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

For nearly three years, healthcare officials and epidemiologists have been sounding the alarm: the face of the Hepatitis C (HCV) epidemic is changing – it’s getting younger by the minute. We, here at HEAL Blog, have been beating that drum alongside them, and yet, the U.S. Centers for Disease Control and Prevention (CDC) has yet to formally change the screening recommendations to reflect the new reality. As more evidence piles up that new Acute HCV infections are largely being driven by prescription opioid and heroin Injection Drug Use (IDU) among Americans aged 15-45.

A piece written by the Digestive Health Team out of the Cleveland Clinic – Why Is Hepatitis C on the Rise in 20- to 29-Year-Olds? – explicitly says as much. In addition, while African-Americans share a disproportionate burden in the epidemic (as a percentage of the population), these issues are particularly pronounced in white, non-urban (suburban and rural) populations living primarily in Appalachia, the Midwest, and New England.

So, what is it about these areas that drives people to abuse prescription opioids, heroin, and/or other illicit drugs? There isn’t just one answer. A lot of the areas where these outbreaks and epidemics are so pronounced share several similarities – struggling economic circumstances; higher-than-average unemployment; less access to and utilization of healthcare services; high rates of Social Security Disability Insurance utilization; economies driven by high-intensity labor industries (mining, for example). Any combination of these factors can lead people to develop substance addictions; that these areas are more remote with fewer outlets and opportunities for employment, entertainment, or social engagement essentially creates enclaves where people can all but disappear into a considerably isolated world of addiction.

Where the kids come in often has to do with the friends, relatives, and other adults whose legitimate opioid prescriptions get unknowingly diverted by experimenting teens who inadvertently become addicted to the highly addictive substances. As a young adult living in a small city in Tennessee in the 2000s, virtually all any of my friends and co-workers wanted to do was find “pills” (primarily OxyContin). Whereas I grew up in the cocaine-fueled 80s and ecstasy-addled 90s, parties in the 2000s were, for my generation, comparatively somber affairs, with everyone pilled out on opioids and barely able to function. Once the U.S. Food & Drug Administration (FDA) started to catch on and legislators began tightening prescribing guidelines, they turned to cheaper and more readily available heroin.

With IDU comes a whole host of risks that, for much of the 80s and 90s – particularly as it related to HIV/AIDS – were made explicitly known. Every health and D.A.R.E. (Drug Abuse Resistance Education) I was made to attend as a child, pre-teen, and teenager included a very graphic section on the dangers of injecting drugs. Almost every school in the 90s had a rumor going around about some random person who was dancing at a nearby club and got stabbed with a used needle and got AIDS. While a lot of hyperbole was involved in these stories, the sense of horror we were expected to evince – “WHAT?!?! A DIRTY NEEDLE?!?!” – led a lot of us to become more risk averse, particularly in our younger years.

Twenty years later? A lot of those fears have been forgotten. We no longer see horrific images of people dying from AIDS – the treatments are amazing, tolerable, and don’t kill you. We aren’t afraid of diseases like HIV or viral hepatitis, anymore, because…well, HIV isn’t a death sentence, and HCV is curable. Hepatitis B is still a huge problem, as it has no cure. But, the reality is that neither the fear of becoming addicted, nor the fear of becoming infected are presently palpable enough to prevent people from even starting. What starts out as a way to kick back with your friends and loosen up can quickly turn into a daily habit and morph into a physical dependency. Once you’re dependent and addicted, the risks become less frightening.

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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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Presidential Council Offers Uniquely American Take on Lowering Drug Prices

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

Within the office of the President exists the Council of Economic Advisors (CEA) – a group of three advisors who, due to their unique training and expertise, are deemed qualified to analyze and interpret economic developments and advise the President of matters within that scope. The council consists of a chairman and two additional members, only the first of which must be confirmed by the Senate. The CEA, this month, released a White Paper (a government or authoritative report giving information or proposals on an issue) related to the topic of reducing prescription drug prices, and I have to say, as a patient advocate and someone who is pretty knowledgeable about prescription drugs and pricing, their response is entirely American in its analysis.

When it comes to pharmaceutical and biopharmaceutical drugs, Americans pay the highest prices in the world. The CEA report says that’s because the U.S. is paying the “market price” for drugs. Other developed countries who have the dreaded “single-payer” healthcare disease of which Republicans and Libertarians are so derisive institute government controls on pricing, forcing the poor, defenseless pharmaceutical giants (whose profits are measured in the billions) to comply with those controls in order to gain access to the market. The solution, the paper concludes, is to reduce “free-riding” abroad.

Did you get that? The key to reducing drug prices for Americans is to force other countries’ citizens to pay more for their drugs. Yes – rather than look at the American model of healthcare delivery and pricing (which virtually any person who’s ever looked at an itemized bill can attest is completely jacked), the CEA instead all but openly states, “Well, those other countries are just doing it wrong! Those silly Socialists and their insistence that healthcare be affordable just don’t know what they’re missing!”

The paper, which can be found here, contains lots of uniquely American concepts: the “Free Market” should dictate drug prices; because the rest of the world doesn’t have a Free Market, drug prices are artificially high; Medicaid and Medicare should stop requiring “best prices” and rebate minimums; we need more Pharmacy Benefit Mangers (PBMs) to enhance competition; make innovation more attractive through incentives.

Report Cover for the "Reforming Biopharmaceutical Pricing at Home and Abroad"

Photo Source: The Council of Economic Advisors

These “solutions,” while certainly things that could reduce the cost of pharmaceutical products, rely almost entirely upon the cooperation of private companies whose main incentives are profits – profits that are already obscene. Moreover, Americans pay for 70% of patented biopharmaceutical profits, despite being only 34% of the Organization for Economic Co-Operations and Development (OECD) market. So, rather than look at our own system and say, “Jesus – we’ve got to follow the leads of these other, healthier countries,” the solutions provided by the CEA instead insist that we not only double-down on our Free Market Madness, but that we attempt to force smarter countries to comply with our lunacy.

Obviously, this is my take on the issue, which is informed by my experience as a healthcare consumer for life (thanks, AIDS) and as someone who has closely tracked pharmaceutical development and pricing for the past five years. While virtually every other developed nation in the world, and even developing nations, pay reasonable prices for pharmaceutical products, Americans get screwed, all in the name of the “Free Market.”

How is it that America went from the government developing some of the most effective vaccines and medicines in the entire world from the 1950s through the 1970s, and then, we just handed over the reins to private companies, while funding at least half of their R&D costs, only to have the drugs sold back to us at exponentially higher prices?

The answer isn’t that other countries are doing it wrong; it’s that we are idiots, when it comes to healthcare, and before long, we’re either going to be completely priced out of the market, or intelligent people will ditch our hackneyed healthcare system, and join the rest of the Modern World and go with Universal Healthcare.

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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“Cruel and Unusual” Neglect in Prisons

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

HEAL Blog has long been banging the drum of patient healthcare access in incarcerated populations. Under Estelle v. Gamble (1976), the U.S. Supreme Court found that denying medical treatment is unconstitutional under the 8th Amendment’s “cruel and unusual punishment” clause, and established the criteria under which prisoners must file suit – “deliberate indifferent.” This essentially means that, if a patient needs medical attention, this cannot be denied, and that, if medical staff deems treatment necessary and orders it, that order must be honored, and that treatment order cannot be countermanded. Additionally, neither security staff, nor internal bureaucracies can hinder said treatment order in any way, and treatment decisions must be made based on medical need, rather than on convenience or the needs for security (Schoenly, n.d.). Estelle v. Gamble basically made inmates the only Americans for whom healthcare is a Constitutional right.

Gavel next to stethoscope

Photo Source: CorrectionalNurse.net

This argument has been successfully made as it relates to HIV, and more recently Hepatitis C (HCV), as numerous courts have ruled in favor of plaintiffs for whom HCV treatment has been denied. Courts have repeatedly rule that, regardless of the costs associated with treatment, prisons are required by the Constitution to provide Direct-Acting Antiviral (DAA) HCV drugs to inmates. Unfortunately for the states, this has the potential to explode correctional pharmacy budgets – a valid concern that, nonetheless, runs counter to case law. In order to avoid having to pay for treatment, many prisons actively avoid the Federally mandated HIV/HCV screenings required in Federal prisons by making state-level inmate screening “on request.”

When conducting research on state screening requirements, an official from the Kentucky Department of Corrections (KDOC) informed me that the state does NOT require inmates to be screened for either HIV or HCV during the intake process or on a regular basis. This is troubling, as Kentucky has the 3rd highest rate of HCV in the U.S. – 2.7 per 100,000 (Centers for Disease Control and Prevention, 2017). Kentucky also has the 10th highest rate of Opioid Overdose Deaths, having seen a 12% increase to a rate of 23.6 per 100,000 in 2016 (Kaiser Family Foundation, 2017).

Many, if not most, of those opioid drug-related death are a result of Injection Drug Use (IDU), the leading cause of new HCV infections in the U.S. With the high rate of arrest for illicit prescription opioid and heroin IDU comes a marked increase in the number of inmates living with HIV and HCV acquired via IDU. Incarceration settings are, perhaps, the best location for the U.S. to begin actively eradicating the HCV epidemic, but cost concerns make that an unlikely occurrence. Further complicating the issue is that prisons, jails, and youth correctional facilities do not have the same price bargaining powers enjoyed by Medicaid, Ryan White (AIDS Drug Assistance Programs – ADAP), and private insurers, meaning that prisons often pay the highest prices for HCV DAAs and other prescription drugs. This must change, if the U.S. hopes to adequately approach eradicating HCV.

Next week, HEAL Blog will take a look at some recent HCV-related issues in the U.S. correctional system.

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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HIPAA: Healthcare mailers violate privacy rights of people living with HIV

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

It came to light, last week, that Aetna – one of the largest health insurers in the U.S. – inadvertently revealed the HIV status of up to 12,000 clients by way of a mailer sent on July 28th, 2017 containing information about their options when they filled prescriptions for HIV medications. The notice was sent in the traditional envelopes sent by businesses, with the clear plastic window through which the letters “HIV” were clearly visible. The letters went out to people who are currently taking medications to treat HIV, as well as those taking Pre-Exposure Prophylaxis (PrEP), a regimen used to prevent the transmission of HIV (Kennedy, 2017).

Aetna mailer showing privacy violations.

In a similar incident, Ohio’s AIDS Drug Assistance Program (OhDAP), along with CVS/Caremark, sent out a similar mailer to roughly 4,000 clients containing their new “Insurance” cards, along with the full names, addresses, and the letters HIV above their names. In addition to that, the card provided inside the mailer contained ID numbers that included the clients’ date of birth, which creates the potential for identity theft (Hamilton, 2017).

Eddie Hamilton, who leads the ADAP Educational Initiative, was one of the victims of the privacy violations executed by OhDAP and CVS/Caremark. He provided a copy of the mailer to the HEAL Blog.

CVS/Caremark mailer showing privacy violations.

Both of these instances are a violation of Health Insurance Portability and Accountability Act (HIPAA), specifically Title II’s Privacy Rule, which regulates the use and disclosure of Protected Health Information (PHI), which prevents any information related to health status, provision of health care, or payment of healthcare that can be linked to an individual from being disclosed without the patient’s direct consent. These provisions were put in place in no small part because sensitive information, such as one’s HIV status, is something that can be used against individuals to deny access to certain benefits and jobs (which is also illegal under the Americans with Disabilities Act, or ADA), and/or have this information get into the hands of those who will use the patient’s HIV status against them in either a private or public manner.

What is most galling about these disclosures is that they were easily avoidable. While it is common business practice to use envelopes with clear windows in an effort to save a few cents per piece of mail, the relative savings compared to printing the address on a sticker and applying it to the outside of the envelope pale in comparison to the potentially high dollar amount in fines for each HIPAA violation, which can range from $100 to $50,000 per violation. And all to save a few centers per mailer.

Aetna, in response to their error, sent out a second letter informing customers of the privacy breach, and in a statement blamed an unnamed vendor for their failure to protect patients’ private health information. The letter was sent to customers in Arizona, California, Georgia, Illinois, New Jersey, New York, Ohio, Pennsylvania, and Washington, D.C. (O’Donnell, 2017). Attorneys for the Legal Action Center and the AIDS Law Project of Pennsylvania sent Aetna a demand letter that included a cease and desist order, as well as calling on Aetna to develop a plan of action to ensure that these types of incidents do not occur in the future (Legal Action Center, 2017).

Neither OhDAP, nor CVS/Caremark have made public statements regarding the disclosure of 4,000 clients’ HIV status. Additionally, the clients in question are those who rely solely upon ADAP funds to procure their medications, a program designed to help those who fall within a certain percentage of the Federal Poverty Limit (FPL) afford medications they might not otherwise be able to access. This means that these clients are less likely to have access to legal aid to help them redress the breach of their confidential PHI, and are less likely to know the appropriate steps to take in order to file HIPAA violation complaints with the Department of Health and Human Services (DHHS) Office for Civil Rights (OCR) or other state authorities.

One of the reasons why HIPAA is so vital for patients living with HIV is that it is their decision to disclose their HIV status, rather than that of healthcare workers, insurers, or any related businesses and partners. While certain areas of the U.S. tend to be more openly accepting about HIV status, other areas may be less than accommodating. Having one’s status revealed to family members, roommates, or friends without permission can have social repercussions, particularly in more religious areas of the country. It is difficult to overstate the severity of these breaches of confidentiality and privacy.

Beyond that, it is unclear whether the current administration’s OCR is going to take any actions against any of the offending parties, in which case patients and clients will have to resort to private or class-action suits against these organizations in order to properly address the situation. Normally, the OCR accepts settlements from offending parties, involving a lump sum payment and no admission of guilt (which is already assumed with the companies reveal that they’ve disclosed this information). HEAL Blog will continue to monitor these issues to see if any resolutions are met.

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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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.

 

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