The Department of Veterans Affairs is moving to outsource care nationwide for up to 180,000 veterans who have hepatitis C, a serious blood and liver condition treated with expensive new drugs that are costing the government billions of dollars. Hepatitis C is a type that can result in chronic disease of the liver and cause long-term damage, including cirrhosis. It is most commonly spread when an infected person’s blood is transmitted to someone who is not infected.
Many veterans contracted it from blood transfusions and organ transplants before the start of routine blood screenings in 1992. The VA has spent weeks developing a dramatic and controversial transition as patient loads have surged and funding has run out. Instructions on how to carry out the program show that the sickest veterans generally will get top priority for treatment.
However, patients who have less than a year to live or who suffer “severe irreversible cognitive impairment” will not be eligible for treatment.
That provision, and the mass shifting of patients, drew immediate criticism from veterans advocates. Tom Berger, executive director of a health council established by Vietnam Veterans of America, ripped the VA for launching a “faulty plan” and blasted the idea of medical teams deciding which patients will be denied antiviral remedies.
The transition plan for so-called HCV patients was developed in a working group chaired by Kenneth Berkowitz, acting executive director of VHA’s National Center for Ethics in Health Care. In an April e-mail, he told colleagues they needed to develop an “ethical framework” in anticipation of a complete depletion of funds for drugs.
VHA administrators concede they implemented the plan without a cost-benefit analysis or studies on provider availability and patient impacts. Records indicate only eight HCV veterans received antiviral therapy through the Choice Program from August 2014 through May 31, while more than 16,000 were getting treatment in VA medical centers.
The VA had set aside nearly $700 million this year for HCV antiviral drugs. In documents and a written statement, department officials confirmed soaring patient loads and medication expenses have nearly wiped out that budget with several months to go in the federal fiscal year that ends Sept. 30. That’s an estimated $400 million shortfall with more dramatic costs expected, beginning in October.
During a hearing last month of the Senate Committee on Veterans’ Affairs, Deputy VA Secretary Sloan Gibson pleaded with lawmakers for “additional flexibility” to use Choice Program funds to pay for the hepatitis remedy. There was no official action by Congress. But, a week later, on May 21, Undersecretary for Health James Tuchschmidt issued national orders to begin shifting HCV patients out of VA care “effective immediately.” Instructions accompanying that internal directive stressed the process should be “ongoing and transparent,” but it was not publicized outside the agency. Instructions reportedly specify:
• Patients already receiving the antiviral therapy in veterans’ facilities will continue. The remainder will be contacted by their VA doctors, told of the Choice Program and evaluated to determine whether they meet eligibility for treatment.
• Decisions on who will be first in line for treatment, and who will be denied the cure, are to be made by teams at Veterans Integrated Service Networks, regional offices also known as VISNs. An appeals process also is being devised for veterans who are denied the medication.
Crackdown raises new issue
The number of veterans prescribed opiates and other pain medications through Veterans Affairs has declined under a drug safety initiative, but the aggressive monitoring program may have deadly consequences for some who turn to street drugs or suicide to stop their pain.
Congressional representatives and veterans advocates raised concerns that VA physicians often over-prescribe addictive opiate painkillers but also may now be under prescribing them as VA hospitals and clinics move to crack down on their use for chronic pain and mental health conditions. Both approaches can be harmful.
According to VA, the number of veterans prescribed opioids since the VA-wide implementation of its Opioid Safety Initiative in 2013 has dropped by nearly 110,000, and the number receiving opioids and benzodiazepines together — a mix that can cause respiratory distress and accidental death — declined by nearly 34,000.
No statistics are available regarding the number of veterans in chronic pain who take to buying opiate-based prescription painkillers or heroin on the illegal market.
This year, the VA is undertaking new initiatives to further reduce veterans’ dependence on opiates and other pain medications, according to Dr. Carolyn Clancy, interim VA undersecretary for health. New educational initiatives and an increased emphasis on counseling, cognitive therapy and alternative treatments should help further reduce those numbers, Clancy said.
But committee members expressed concern that many VA doctors do not follow recommendations and clinical practice guidelines for these therapies and instead medicate patients immediately with little follow through. According to GAO, of 30 cases reviewed of veterans diagnosed with major depressive disorder, 86 percent of patients were not reassessed within the recommended four to six weeks after first being prescribed an antidepressant.
During the hearing, representatives and advocates weren’t the only ones agitated by what they believe is a lackluster response, from both VA and Congress on the issues of mental health treatment for veterans and suicide.