By: Marcus J. Hopkins, Policy Consultant
More than once, we, here at HEAL Blog, have called for the easing of restrictions not only on who can have access to curative Hepatitis C (HCV) Direct-Acting Agents (DAAs), but also on who can treat patients for HCV. Restricting the treatment of HCV to only hepatologists (liver, pancreas, gallbladder, and biliary tree specialists) and/or infectious disease specialists severely limits the number of physicians who are legally allowed to treat patients living with the disease. Obviously, this decreases access to care in rural, more isolated parts of the U.S. When we expand that thinking out to correctional institutions – that incarcerated individuals may only be diagnosed and treated by specialists – already limited access to treatment is further complicated.
One of the growing arguments in the world of American healthcare provision involves the roles nurses play in the treatment delivery model. Most nurses are trained to provide far more medical services than they are currently permitted to do (in most states), which increases the wait times for all patients to be seen, diagnosed, and administered treatment. Requiring treatments to be administered and overseen only by specialists wastes time and resources. In correctional settings, inmates may often see only nurses for long stretches of time, as doctors may make only occasional trips to correctional facilities.
New findings out of Australia indicate that a nurse-led, decentralized treatment model for inmates was highly successful, resulting in a 95% rate of Sustained Virologic Response (SVR – “cure”) in all genotypes across 562 eligible patients (Papaluca, et al., 2019). Most patients were considered “low risk” and suitable for treatment based on nurse-led evaluation only and did not require a formal hepatologist assessment (82% of patients), while “higher risk” patients required a face-to-face consultation, telemedicine consultation, or both (Papaluca).
The model was implemented across multiple correctional facilities, utilizing a nurse-led treatment delivery model on the local level (at each location), the use of information technology (telemedicine and a central electronic medical record), and a centralized pharmacy distribution with real-time prisoner tracking (Papaluca). All of these were made possible by federal-level support for policies ensuring prisoners access to DAA therapies – something that would be hard to replicate in the U.S.
As HEAL Blog has highlighted several times over the past two years, Australia has made significate strides in their efforts to eliminate HCV by 2030 – a goal that is likely unachievable in the U.S. So, what makes Australia different from the U.S. that allows them such success while we continue to see growing rates of HCV? Well, a few things:
Healthcare: Healthcare in Australia is a mix between a public Universal Healthcare model and private providers (insurance), whereas the U.S. continues to rely upon an outdated, unwieldy, and high cost-ineffective for-profit private insurance model. The majority of healthcare provision in Australia occurs at public hospitals and primary care physicians, while the remaining portion is performed in private hospitals and allied healthcare providers (e.g. – dentists).
The U.S., conversely, has a system where health insurers essentially dictate where patients can and cannot go, and even when they go, the out-of-pocket costs can be astronomical. Ironically, 1 in 5 Americans are covered by what was supposed to be our own Universal Healthcare model – Medicaid. Despite this, the program is structed as a Federally-funded, state-administered program, meaning that what is covered varies from state to state, who can receive Medicaid benefits varies widely from state to state, and whether or not recipients have co-pays/premiums varies from state to state. This model – a uniquely American and highly inefficient model – creates numerous barriers to care and treatment.
Prison Stewardship: The Australian prison system is set up differently from the U.S., in that there is no separate Federal prison infrastructure – there are only state prisons. That said, the rules for how those prisons must operate (and who they must treat) are set at the Federal level. The U.S., however, has a setup that includes Federal prisons, state prisons, city and county jails, juvenile detention centers, and private prisons, all of which operate on different sets of rules, governance, and structures. The provision of services, what diseases prisons test inmates for, and medication dispensing policies for non-Federal prisons are all set at the state and local levels, meaning that one set of prisoners (let’s say those in Rhode Island) receive considerably better standards of care and case management than those in, let’s say, Arizona or Iowa.
This model creates a patchwork of disparate programs across the country where inmates may or may not be receiving the treatment they need. So poor is the treatment provision in state-run facilities that most states have had to be forced to provide treatment for HCV by way of individual or Class-Action lawsuits.
The nurse-led model of treatment, however, can be expanded outside of prisons, here in the U.S., and used in rural Appalachia and other isolated parts of the country to reach HCV patients for whom travel is a barrier to treatment. We would do well to examine this approach and apply it to our own country.
Papaluca, T., McDonald, L., Craigie, A., Gibson, A., Desmond, P., Wong, D., Winter, R., Scott, N., et. al. (2019, January 14). Outcomes of treatment for hepatitis C in prisoners using a nurse-led, state-wide model of care. Journal of Hepatology. DOI: https://doi.org/10.1016/j.jhep.2019.01.012
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.