Establishing a Pharmacy Managed HCV Service LCDR Jessica L. Steinert, PharmD, MHA, BCGP LT Neelam Gazarian, PharmD

Prior to HCV Clinic With Insurance (Pvt./Federal) Without Insurance Referred to Medical Specialists $10,000-$15000/referral Distance Lost to follow-up Without Insurance Very Few Options Rationing Care Poor outcomes Lost to follow up/less documentation No tracking of patients

Inter-collaborative Approach Patient Primary Care Provider Pharmacist Laboratory Services Benefits Coordinator Behavioral Health Public Health Patient centered interprofessional collaboration to Policy making Education and awareness

Identifying Patients with Hepatitis C iCare 168 patients 25% screening rate VGEN 155 patients Getting a sense of how many patients with diagnosis of hcv. Jessica and David huge help Patients with visit in past year Screening rate with a denominator of patients born between 1945 and 1965 (baby boomers) From reports from vay, based on old labs. Often patients deceased, moved away

EHR Documentation Referral Initial Visit Treatment End of Treatment Consult from PCP Walk in Initial Visit PHQ-9 AUDIT-C Education Labs Immunizations Comprehensive visit Project ECHO Start Medication Authorization Treatment Counseling End of Treatment SVR Patient is cured! Counsel about re-infection and prevention Comprehensive visit usually done on the phone.

Consult Template

EHR Note Templates

Hepatitis C Labs Order Menu

Hepatitis C Labs Order Set

Managing Patients Snapshot of stage in treatment process drop down menus (these can be adjusted) Reminders for labs while in treatment, immunizations

Patient Panel

Individual Patient Data

Appointment Calendar Reminders for labs while in treatment, immunizations

Navigating Insurance/Prior Authorizations Comprehensive Visit Clinic Notes Project ECHO Recommended regimen Lab Values Chem 14, CBC, anemia panel, Vit D, AFT, HIV, Hep A & B, pregnancy Viral load and genotype Fibrosis Score: APRI, FIB4, Fibrotest Abstinence requirements Urine drug screens and/or clinical notes Compliance Differs by state

Patient Assistance Program Gilead’s Support Path Harvoni®, Epclusa® iAssist: https://www.assistrx.com/iassist/ AbbVie Patient Assistance Foundation Mavyret® Type 1: Epclusa ( sofosbuvir/velpatasvir, with ribavirin in cases of decompensated cirrhosis) , Harvoni (ledipasvir/sofosbuvir), viekira pak, zepatier Type 2: Epclusa, sovaldi (sofosbuvir) with ribavirin Type 3: Epclusa only given with ribavirin in cases of decompensated cirrhosis Type 4: Epclusa, Harvoni, zepatier Type 5: Epclusa, Harvoni Type 6: Epclusa, Harvoni Mavyret (glecaprevir/pibrentasvir): 1, 2, 3, 4, 5, 6 Mavyret still not on abbvie patient assistance program list, soon hopefully? ND Medicaid just added as preferred non-formulary

Patient Assistance Programs Tribal ID card Income documents Max income allowed differs by program Proof of no insurance American Indians/Alaska Natives (AI/AN): Indian Health Coverage Exemption “American Indians and Alaska Natives (AI/ANs) and other people eligible for services through the Indian Health Service, tribal programs, or urban Indian programs (like the spouse or child of an eligible Indian) don't have to pay the fee for not having health coverage. This is called having an Indian health coverage exemption.”

Time Investment and Workload (Minutes) 30 Initial Visit ECHO Prior Authorization 60 Treatment Counseling Almost 3 hours per patient

37 28 44 49 Current Status 24 22 2 4 9 7 5 22 Pending Project Echo ETR Medication Approval Pending 4 Treatment 9 ETR 7 SVR “cure” 5 Appointment with PCP, more labs pending (possible self clearers) ETR: end of treatment response 3 months 22 24 28 37 44 49

HCV Screening Rate

HCV Screening Rate

Cost Analysis: Cumulative $1,831,608 Flat rate reimbursement from ND Medicaid and expansion to IHS, outsource for cost avoidance

Questions

Thank you Contact Info: Jessica.Steinert@ihs.gov Neelam.Gazarian@ihs.gov