How to manage hepatitis C patients under MACRA

Screening patients for hepatitis C and discussing treatment options are both important from a clinical standpoint. These tasks can also help physicians score highly in the Medicare payment reform program known as the Medicare Access and CHIP Reauthorization Act of 2015  (MACRA).

In particular, MACRA’s Merit-based Incentive Payment System (MIPS) track provides physicians with either a bonus or penalty starting in 2019, depending on the quality data related to hepatitis C and other diagnoses that they submit. MIPS measures for hepatitis C are relatively easy to satisfy, with the help of technology and a willingness to communicate with sensitivity. 

They include:

• Annual hepatitis C virus screening for patients who are active injection drug users

• Discussion and shared decision-making surrounding treatment options

• Screening for hepatocellular carcinoma in patients with cirrhosis

• One-time screening for hepatitis C for patients at risk (i.e., those with a history of injection drug use, those who received a blood transfusion prior to 1992, those on maintenance hemodialysis, or those who were born between 1945 and 1965)

Through better documentation and collecting the right data -likely for things they are already doing-physicians can not only avoid a payment reduction from Medicare, but also possibly earn bonus payments.

Best practices strategies for screening

Three of the hepatitis C MIPS measures listed pertain to screening. The good news is that physicians can use their electronic health record (EHR) to help them screen perhaps the largest population of at-risk patients seen in a typical adult internal medicine practice: baby boomers. 

Internist Jacqueline Phillips, DO, who practices at Amistad Community Healthcare Center in Corpus Christi, Texas, says her EHR alerts her to screen all patients born between 1945 and 1965, for example.

However, hepatitis C spreads most frequently in the United States through sharing needles, syringes or other equipment injecting drugs. One challenge for physicians is that many patients don’t want to admit to their own risky behavior, says Phillips. Another challenge is that patients may not be aware of other risk factors associated with contracting the disease, which often presents without any symptoms. So unless physicians screen for the disease, patients may not know they have it. 

Ask open-ended questions to help to identify patients who might be at risk, says Phillips, who asks questions such as: Do you use drugs? If so, do you snort or inject? “I think it’s all in how you ask the question,” she says. “If you seem uncomfortable asking the question, the patient will feel uncomfortable answering it.” She also focuses on making her patients feel comfortable by making eye contact with them. 

Help patients understand that the purpose of these questions is to screen for hepatitis C, says Brian Boyce, BSHS, CPC-I, chief executive officer at ionHealthcare LLC, a company specializing in risk-adjustment coding, health management and education. “I think it’s important to say, ‘We’re just trying to screen everyone to keep them healthy, and I need to know what your risk factors are so I can take care of you in the best way possible,’” he adds.

It’s important that physicians don’t make assumptions because they could miss out on valuable clinical data, says Boyce. “That’s why you have to do a strong interview with patients to try and identify their exposure risks,” he says.

Shared decision-making about hepatitis C treatments

Physicians can also satisfy Medicare payment reform requirements by discussing hepatitis C treatment options with their patients. One challenge, however, is that many physicians don’t feel they have the specialized knowledge to treat these patients, says Norman Sussman, MD, a hepatologist at Baylor St. Luke’s Medical Center in Houston, Texas. 

“The biggest challenge is that physicians screen people and don’t know what to do with them,” he says.

Phillips agrees. “It’s very intimidating to treat these patients,” she says. “Personally, I was terrified to start prescribing medications because I didn’t want to do something that was going to hurt my patients.”

Rather than treating patients with hepatitis C at their practice, internists often refer patients to gastrointestinal (GI) or infectious disease (ID) specialists. However, finding these specialists can be difficult because not every GI or ID specialist has an interest in hepatology. If they do, they may be located hours away from the practice, says Sussman. Many patients simply don’t follow through with referrals because specialists are too far away, he adds.

That’s exactly what was happening at Amistad Community Health Center, where many patients have Medicaid coverage, says Phillips. There were only a handful of GI specialists in the area, and many of them didn’t accept Medicaid. Patients with hepatitis C were often referred to specialists several hours away and couldn’t afford to travel there, she adds.

Medicaid and other payers may have restrictions on who can prescribe, so physicians should check with their payers first.

Using telemedicine to connect with specialists 

Telemedicine may be one solution to help physicians treat these patients, says Sussman, who also serves as medical director of Project Extension for Community Healthcare Outcomes (ECHO), a telehealth program at Baylor St. Luke’s Medical Center in Houston, Texas. 

The program connects primary care providers in other states with specialists at Baylor St. Luke’s via videoconferencing to discuss each patient’s clinical condition and identify the appropriate course of treatment. Over time, primary care providers become more proficient in handling these cases on their own, says Sussman.

Telemedicine ultimately helps internists improve the quality of care they provide while also reducing costs-two important goals of Medicare payment reform, says Sussman. “As we move to quality metrics and cost-effective management, having access to experts will be very helpful,” he says. 

Since joining Project ECHO, Phillips says she’s become much more confident not only prescribing medications for treating patients with hepatitis C but also having conversations with patients about drug interactions, side effects and treatments. She says her patients are happier, too. 

Still, treating patients with hepatitis C requires time, effort and a willingness to learn about the disease, which is why it’s tempting sometimes simply to refer patients to specialists. However, this isn’t necessarily what patients want, Sussman says. “Patients go to their primary care physician first,” he adds, “and primary care physicians are more than capable of managing this problem.”