1. Management of Hepatitis C: An Unprecedented Challenge for Corrections Brad Livingston Executive Director, Texas Department of Criminal Justice Lannette Linthicum, MD, CCHP-A, FACP Director, Health Services Division Texas Department of Criminal Justice ASCA/CCHA Meeting – September 11, 2014 – Phoenix, AZ

2. Overview Briefly describe the Texas Department of Criminal Justice, and its healthcare system – Brad Livingston Briefly describe the burden of Hepatitis C Virus (HCV) in the Texas Department of Criminal Justice – Dr. Lannette Linthicum Provide an overview of the challenges in managing HCV in a large prison system – Dr. Lannette Linthicum Describe strategies used to manage HCV – Dr. Lannette Linthicum Discuss the financial impact of HCV on TDCJ Correctional Managed Health Care Appropriations – Brad Livingston Review future options to consider for HCV management- Brad Livingston and Dr. Lannette Linthicum

3. Large Patient Population 1. Fiscal Year 2013 Statistical Report. Texas Department of Criminal Justice. TDCJ prison population in Fiscal Year (FY) 2013 –265,009 adults under community supervision –150,784 incarcerated –71,713 admissions –72,071 releases –87,000 under parole supervision

4. Texas Department of Criminal Justice Largest state prison system in US 109 facilities 150,784 incarcerated –92% male –8% female Average age 38 years –Range 16-91 years –19% ≥ 50 years Healthcare Expenditures $513,915,671

5. Prison Health Care Expenditures Spending increased in 41 states with median growth of 13 percent from 2007-2011 Spending totaled $7.7 billion in fiscal 2011 nationwide Number of older offenders, who typically require more expensive care, increased in all but two of the 42 states that submitted data State Prison Health Care Spending. An examination. Pew Charitable Trusts and MacArthur Foundation. July 2014. www.pewstates.org/healthcarespending

6. Prevalence rates: -General US population 1-1.5% -Prison populations 16-41% -TDCJ population 29% High Burden of Hepatitis in Texas Prisons 1.Correctional Facilities and Viral Hepatitis. CDC. http://www.cdc.gov/hepatitis/Settings/corrections.htm 2.Messina JP, et al. Global distribution and prevalence of hepatitis C virus genotypes. Hepatology. Article first published online: 28 JUL 2014. DOI: 10.1002/hep.27259.

7. High Burden of Hepatitis in US Prisons Binswanger A, et al. Prevalence of chronic medical conditions among jail and prison offenders in the USA compared with the general population. J Epidemiol Community Health 2009;63:912-919.

8. TDCJ Population with End Stage Liver Disease 8 End Stage Liver Disease is defined as patients with: ascites, hepatic encephalopathy, esophageal varices, significant cirrhosis or liver cancer.

9. Hepatitis is a Leading Cause of Death in State Prisons Mortality in local jails and state prisons, 2001-2011 – Statistical Tables. US Department of Justice. Office of Justice Programs. Bureau of Justice Statistics. August 2013, NCJ 242186.

10. Challenges Managing HCV ChallengesStrategies Large population & correctional system Centers of excellence Technology (e.g., EHR, telemedicine) Clinical guidelines Administrative practices (e.g., Medical Hold) High burden of chronic disease Health screenings Chronic care clinic Specialty clinics (e.g., HIV, HCV, ESLD) Changing and complex standards of care Collaboration with university providers & subject matter experts Special task force / workgroups Multi-disciplinary approach to care Rising drug costs and budget limitations Drug purchasing initiatives (e.g., 340B) Strict formulary controls Use of clinical guidelines Continuity of care and linkage to care Technology (e.g., EHR, telemedicine) TCOOMMI programs (e.g., case management, continuity of care and MRIS) Peer education programs Complex therapies completed during incarceration whenever possible

11. Major Pharmaceutical Cost Drivers Correctional Managed Care HIV Psychotropic agents Chronic hepatitis C Chronic care medications ‒ Dialysis agents ‒ Cardiovascular agents ‒ Antidiabetic agents ‒ Respiratory agents

12. HCV genotype 1 -PEG and RBV used prior to treatment advances -Currently PEG, RBV, and Boceprevir used -HCV treatment evolving rapidly & sofosbuvir recommended for most patients 2013 CMHCC guideline currently under review Significant increase in HCV drug costs expected Evolution of HCV Drug Therapy in Texas 12 SectorPeginterferon + Ribavirin PEG/RBV + Boceprevir PEG/RBV + Sofosbuvir UTMB$8,480$25,310$62,240 Texas Tech$8,620$77,420$80,730

13. Potential Impact HCV Drug Cost 13

14. Future Strategies Prioritize drug use Establish partnerships with 340B eligible entities so savings may be used to increase access to care Leverage technology –Use of EHRs and “Meaningful Use” requirements to improve linkage to care –Use telemedicine to reduce nonmedical expenses Close knowledge gaps Plan now for providing treatment with new agents and drugs in the pipeline

15. Future Strategies (Cont.) Develop and implement policies and strategies that provide for and address the unique needs of offenders with HCV –Corrections specific recommendations in national guidelines, reports, position statements, etc. –Expansion of Medicaid to include offenders and nondisabled adults without children to reduce the financial burden on state government and prison budgets –Less stringent criteria for meeting requirements for compassionate release from prison (e.g., medical or geriatric parole) Approach HCV from a societal perspective

16. Questions?