Primary care program cost-effectively reaches underserved with HCV infection

Last Updated: 2017-11-03

By Marilynn Larkin

NEW YORK (Reuters Health) - The Extension for Community Healthcare Outcomes (Project ECHO) is a cost-effective way to find and treat underserved people with HCV infection using primary care providers, but incremental rollout is needed to mitigate high upfront costs, researchers say.

In 2016, the U.S. Congress passed the ECHO Act, requiring the Department of Health and Human Services to investigate the model, which enables care delivery for complex conditions to the underserved, according to Thilo Rattay of the University of Michigan in Ann Arbor and colleagues.

Project ECHO has already been shown to increase treatment rates for HCV infection in the U.S. state of New Mexico. In this study, the team analyzed Project ECHO's cost-effectiveness for HCV infection diagnosis and treatment using a simulated primary care patient panel with or without the model, based on a nationally representative sample. In the comparison group - "status quo" without Project ECHO - patients were referred to specialists after a primary care diagnosis.

"ECHO is likely to be a cost-effective health care delivery design to find and treat patients with chronic HCV infection at scale in the United States," Rattay told Reuters Health. "Cost-effective, however, does not mean cheap or cost-saving."

"ECHO's administrative overhead is negligible when compared to the investment for HCV drugs that is necessary to treat more patients than is currently the norm," he said by email.

"To work towards the elimination of HCV - a World Health Organization goal - treatment rates must rise sharply," he observed. "The necessary drugs are still very expensive. They, too, were shown to be cost-effective, but some only barely so."

New drugs, such as the recently FDA-approved glecaprevir and pibrentasvir, marketed as Mavyret, "may bring down costs enough for HCV care to be affordable at a much larger scale," he suggested.

As reported in Gastroenterology, online October 23, Project ECHO increased both costs and quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio of ECHO was $10,351 per QALY compared with the status quo - well below the willingness-to-pay threshold of $100,000 per QALY.

The simulation could not confirm whether the increased treatment rates associated with Project ECHO were due to greater or more-targeted screening, higher adherence, or better access to treatment. However, sensitivity analyses showed that the results largely persisted regardless of the cause.

The budget-impact analysis showed that payers would have to invest an additional $339.54 million over a five-year period to increase treatment by 4,446 patients per one million covered lives.

"ECHO operations rely on experts and administrative staff at a major clinic who are not immediately involved in treating individual patients," Rattay explained. "Currently, there is little to no reimbursement for such operations outside of closed-systems such as the Veterans Administration or the prison systems."

"To allow for self-sustaining, continued practice, the legislature and payers would have to design a model that rewards such operations financially," he added. "My understanding is that this has been done in New Mexico."

"The U.S. healthcare system is on the move towards value-based payments. Certainly, a model that is effective both clinically and financially could represent enough value to be viable for financial reimbursement of some sort," Rattay concluded.

Dr. Douglas Dieterich, professor of medicine, liver diseases and director of continuing medical education at the Icahn School of Medicine at Mount Sinai in New York City, told Reuters Health by email, "I'm familiar with Project ECHO, which is a well-known system for using outreach to teach primary care providers how to treat hepatitis C, often in very rural areas."

"It has been very successful in the past in terms of the cure rate of treatment," he said, "equaling that of patients who come all the way to major medical centers, so it is not surprising that it is effective in this study, as well."

SOURCE: http://bit.ly/2xMgxNV

Gastroenterology 2017.