Hepatitis C treatment, why isn't family medicine doing more of it?

[MedicineZ0Z]

I know some do it all the time as part of their practice but the general tendency is to refer out. Why? Treatment is not overly complex, you don't have lots of different drug choices like with HIV, side effects are minimal with the new meds and treatment is short term. So why not do it?

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[AMEHigh]

I really think it depends on where you work/train. Where I work now we treat all Hep C and HIV. We do have a specialist we can curbside consult in our office a couple of times per week for more complex cases. But where I work is a largely un and underinsured population so if we don’t provide care then no one else will in many cases.

Where I train a lot of people just had the expectation to go to a specialist so that’s what we did. Most people had insurance so it wasn’t a problem.

Like most things in family med you can pick and choose what you feel comfortable with working up and treating extensively and that’s ok.

 

[MedicineZ0Z]

I really think it depends on where you work/train. Where I work now we treat all Hep C and HIV. We do have a specialist we can curbside consult in our office a couple of times per week for more complex cases. But where I work is a largely un and underinsured population so if we don’t provide care then no one else will in many cases.

Where I train a lot of people just had the expectation to go to a specialist so that’s what we did. Most people had insurance so it wasn’t a problem.

Like most things in family med you can pick and choose what you feel comfortable with working up and treating extensively and that’s ok.

That's fair but I just mean that like many other things we treat, it's sort of like why can't we just all do it anyway? We do insulin for diabetes and that can be more complicated than hepC. We do CHF and that's more grave that treating hepC in 2019.

I can say the same about things like PCSK9 inhibitors also. Totally within the realm of family med.

 

[MedicineZ0Z]

I guess my main point is that 4 years of med school and 3 years of residency should be preparing you to manage all sorts of things. Yet stuff that can and should be managed by PCPs ends up in specialists' offices. This leads to excessive wait times in places without many specialists and obviously to a waste of healthcare money.

You really don't need 3 years of residency to treat HTN and lipids. Or even to treat community PNA etc inpatient.

 

[AMEHigh]

That's fair but I just mean that like many other things we treat, it's sort of like why can't we just all do it anyway? We do insulin for diabetes and that can be more complicated than hepC. We do CHF and that's more grave that treating hepC in 2019.

I can say the same about things like PCSK9 inhibitors also. Totally within the realm of family med.

Yep as I said above I think people just pick and choose things to treat if they don’t have to and have the luxury of specialists. This is obviously a concern when talking about the cost of healthcare as specialist visits cost more to the system in general.

FM could do a lot of reproductive health care like IUDs, nexplanon, endometrial biopsies, colposcopy, abortion care, miscarriage management, etc. None of that needs to be referred to gyn but often is because people choose not to do it. These are all things I do on a weekly basis, but I know not all FMs do.

So I agree with you that FM could absolutely manage Hep C, but if people have the luxury of not wanting to do so then they might not opt to do so.

 

[septoplasty]

I guess my main point is that 4 years of med school and 3 years of residency should be preparing you to manage all sorts of things. Yet stuff that can and should be managed by PCPs ends up in specialists' offices. This leads to excessive wait times in places without many specialists and obviously to a waste of healthcare money.

You really don't need 3 years of residency to treat HTN and lipids. Or even to treat community PNA etc inpatient.

You're right. That's easy to do, the 3 years are spent on learning about ddx, complications and how to manage these complications. Midlevels can read the IDSA guideline on CAP and do it too..

Hep C is relatively easy to manage.. AASLD/IDSA has great online education in this regards as well. Same with PCSK9/ACC.

 

[Gastrapathy]

It’s history. It used to be miserable to treat HCV. Now it’s easy. Just don’t miss the cirrhotics.

 

[deleted87716]

I have no doubt that other patient populations are different than mine, but I could count the number of hep. C and HIV patients I've run across in the past 20 years on my fingers. It's just not worth it. Referral is far easier.

 

[VA Hopeful Dr]

Because at present it's a pain in the ass to get the Hep C meds covered by insurance.

Same reason I don't write for Repatha or Praluent. I easily could, but I don't want to spend time trying to get those meds covered.

 

[septoplasty]

But the former is super easy, you follow AASLD guideline, which insurance companies use.
Praluent is preferred PCSK9 almost always, and again, easy to do.

Interesting, though, alot of the colleagues i've worked with with the above regards, they cite the same issue.. but its easy.

 

[VA Hopeful Dr]

But the former is super easy, you follow AASLD guideline, which insurance companies use.
Praluent is preferred PCSK9 almost always, and again, easy to do.

Interesting, though, alot of the colleagues i've worked with with the above regards, they cite the same issue.. but its easy.

That has not been my experience

 

[Bacchus]

Because at present it's a pain in the ass to get the Hep C meds covered by insurance.

Same reason I don't write for Repatha or Praluent. I easily could, but I don't want to spend time trying to get those meds covered.

Agree. Send to the Hep Center or Lipid Clinic.

 

[Gastrapathy]

I have no doubt that other patient populations are different than mine, but I could count the number of hep. C and HIV patients I've run across in the past 20 years on my fingers. It's just not worth it. Referral is far easier.

Are you screening all your baby boomers? It’s 1% of the adult population so even if your patient population was relatively low risk, they are out there if you look.

 

[deleted87716]

Are you screening all your baby boomers? It’s 1% of the adult population so even if your patient population was relatively low risk, they are out there if you look.

For hep C, yes ('cause quality measures - still, virtually all of my screenings are negative). For HIV, no ('cause, not quality measures). Frankly, I doubt I'm missing (m)any. Even when I go looking ('cause, risk factors), I come up empty.

Frankly, I think we over-screen for damn near everything.

 

[smq123]

Are you screening all your baby boomers? It’s 1% of the adult population so even if your patient population was relatively low risk, they are out there if you look.

In Miami Beach, yes, we screen everyone. Not just Hepatitis C and HIV (for obvious reasons) but also Hepatitis B - I have had a number of recently immigrated patients who had active Hepatitis B and did not know it.

We also treat Hepatitis C and HIV - because if we waited to get these patients in with GI or ID, it would take forever. Getting Hepatitis C meds approved has been surprisingly "easy," if you have someone to do it for you. We have a few people in our in-house pharmacy who do this; they generate a checklist in the patient's chart, with the things that you need to order for the patient highlighted. Pretty easy.

 

[smq123]

For hep C, yes ('cause quality measures - still, virtually all of my screenings are negative). For HIV, no ('cause, not quality measures). Frankly, I doubt I'm missing (m)any. Even when I go looking ('cause, risk factors), I come up empty.

Frankly, I think we over-screen for damn near everything.

While I generally agree with you that we over-screen, I don't think it's fair to lump Hep C and HIV (and Hepatitis B, for that matter) with things like PSAs or CA 19-9s. Unlike tumor markers, it's pretty black and white - either you have active hepatitis or HIV, or you don't. Screening for hepatitis or HIV doesn't lead to the same "work up quagmire" that a PSA or a CA-125 might. And yeah, while you might come up empty a lot of times, because they are contagious, I think it's worth making sure that your patient truly doesn't have it.

Even screening for risk factors isn't always enough. I had one unfortunate young lady who told me that checking her for HIV was a waste of time because "I'm married; we're monogamous and I was negative before we started dating," but she let me order it anyway. Good thing, because that's how we found out that her husband had been hiding his HIV positive status from her.

 

[deleted87716]

Even screening for risk factors isn't always enough. I had one unfortunate young lady who told me that checking her for HIV was a waste of time because "I'm married; we're monogamous and I was negative before we started dating," but she let me order it anyway. Good thing, because that's how we found out that her husband had been hiding his HIV positive status from her.

I don't disagree. However, I think it should involve a conversation prior to ordering the test in order to avoid pissing patients off, especially since we don't give HIV results over the phone. *

* Communicating HIV Test Results: Who? What? How?