HIV: Managing a Complex, Chronic Condition

BRIEFING
November 1, 2017
Executive Vice President, Chief Medical Officer, CVS Health

High drug costs, social stigma, complications, comorbidities, and complexity of the prescribed regimen, make human immunodeficiency virus (HIV) a challenging disease for patients, providers, and payors, and may prevent some patients from getting effective care.

Medication side effects can be particularly daunting. Short-term side effects of HIV medications include fever, nausea, and fatigue, while long-term side effects can include diabetes, liver damage, heart disease, depression (including suicidal thoughts), kidney problems, and even kidney failure.

A whole-patient management approach is vital. The CVS Specialty HIV Care Management program offers dedicated support through Accordant rare-disease care management nurses specially trained in HIV care.* This differentiated model proactively engages plan members to help close gaps that can exist within the traditional specialty pharmacy model. Providing members with comprehensive, continuous care helps promote adherence, improve outcomes, and reduce overall health costs. The Care Management program recently received NCQA Patient and Practitioner Oriented Disease Management (DM) accreditation for a range of conditions including HIV. The accreditation is an indication that a DM program is dedicated to giving patients and/or practitioners the support, education, and other help necessary to facilitate good outcomes and good care.

Using this Care Management model, CVS Health has seen up to 13 times greater engagement from members, including following prescribed steps to improve lifestyle or effectively address health issues.**

Complex Disease, Comprehensive Care

Less than 1.1 million Americans live with HIV. Regular care and therapy adherence key to good outcomes.

Antiretroviral therapy (ART), which began in the 1990s, transformed HIV from a fatal infection to a chronic condition that must be managed for a lifetime. Although more single-tablet regimens (STRs) have been introduced in recent years, which can reduce the number of pills to manage, treatment is becoming more expensive and there are still many hurdles that too often go unaddressed. Only about 55 percent of patients prescribed ART are adherent, and non-adherence can lead to drug resistance.

Less than 1.1 million Americans live with HIV. Regular care and therapy adherence key to good outcomes.

About 63 percent of patients experience at least one gap in care, which can be dangerous. Gaps in care are associated with poorer outcomes, such as increased hospitalizations and a higher mortality rate.

Another significant factor in patients delaying or stopping treatment is the high prevalence of comorbidities. About 25 percent of those with HIV have hepatitis C as well, 30 percent may have kidney disease, and people with HIV are at much higher risk for some cancers.

Although there is no simple HIV case, the degree of complexity depends on several factors, such as gender, age, financial situation, geographical location, and whether the patient belongs to a particular high-risk group. Effectively managing these challenges can help improve health outcomes and lower costs, for patients and payors.

From Deadly to Chronic Accordian

Importance of Care Management
The more complex a disease and its treatment are to manage, the greater the need for patient support to improve self-care, symptom management, and, ultimately, adherence.

The more complex a disease and its treatment are to manage, the greater the need for patient support to improve self-care, symptom management, and, ultimately, adherence. Under the traditional specialty pharmacy model, patients receive some drug education, side effect management, and other adherence support. CVS Health’s HIV Care Management builds significantly on that model by adding more frequent, proactive, and personalized interactions to help improve member engagement. By looking at the whole patient, our care management nurses, in consultation with pharmacists when needed, address a wide range of issues including:

  • Medication optimization, which addresses adherence challenges, such as side effects, across all prescriptions, as well as safety monitoring, including potential drug interactions. Nurses review a patient’s risk factors to help ensure the patient is on the optimal treatments according to national guidelines.
  • Care optimization, including advice on cost issues and transportation concerns. Nurses can engage resource specialists and social workers for assistance, when needed.
  • Management of symptoms, which can include weight loss, diarrhea, skin conditions, and medication side effects.
  • Self-care education regarding risk behaviors, transmission, appropriate screenings, lab monitoring and results, vaccinations, nutrition, and smoking cessation.
  • Comorbidity management, including screening for other sexually transmitted diseases, cancer, osteoporosis, diabetes, viral hepatitis, as well as depression and anxiety, which can hinder care.
  • Continuity of care, which means the nurse collaborates with other providers and supports consistent, healthy patient-provider relationships.
  • Emotional and social support, which includes helping patients navigate concerns about social stigma, which can be a deterrent to adherence.

Specially trained Accordant rare-disease care management nurses conduct a total health assessment of patients and regularly engage with patients throughout the course of treatment. Patient support is available 365 days a year. We are also utilizing technology tools including a cell phone app, website, and email to make it easier for patients to engage with us through a channel of their choosing.

In our effort to continually expand the plan designs we can support, we’ve modified the Exclusive Specialty Network to offer members greater access and flexibility when filling their HIV prescriptions. A plan with Exclusive Specialty can choose to provide members with HIV the ability to fill their prescriptions at any retail pharmacy that participates in their plan’s network.

Improved Adherence, Outcomes

Holistic Care Management helps improve outcomes and the overall patient experience. By collaborating with a patient’s other providers, assessing all of their needs, and giving them the tools to stay healthy, CVS Health offers a tailored, holistic approach to a complex disease. And it works.

Patients with access to our care management program saw a 5 percentage point improvement in medication possession ratio and reduced gaps between fills by five days, compared to retail patients.*** Care management also led to an 11 percent reduction in total health care costs for managed conditions, based on a 7 percent drop in emergency room visits and a 23 percent reduction in hospital admissions.****

By focusing on building and reinforcing patients’ understanding of their disease, helping them generate their own motivation, and supporting the creation of positive health behaviors, we can help achieve better outpatient care and disease management, and fewer complications and costs, benefits members, their providers, and payors.

Want to learn more about how holistic care management can improve outcomes for patients with HIV? Ask Us
BRIEFING
November 1, 2017
Executive Vice President, Chief Medical Officer, CVS Health

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*Nurse support is available to members whose plans including Accordant Care Management (including CareTeam Choice or CareTeam Advanced).

**13x greater engagement rate driven by those programs utilizing our embedded nursing model, Internal Analysis; Accordant Comprehensive Data Warehouse, 2016.

***CVS Health Enterprise Evaluation and Population Health Analytics, January, 2015 – February, 2016.

****Up to 11.1% reduction in overall spend. Accordant Comprehensive Data Warehouse; SQL Server 2008. Greensboro, NC: care management Health Services, a CVS Health Company, 2013. Source of reduction rates: Accordant internal analysis of Book of Business data, 2013. Projections based on Caremark data. Individual results will vary based on plan design, formulary status, demographic characteristics and other factors. Client-specific modeling available upon request.

1. Centers for Disease Control and Prevention: HIV/AIDS Basic Statistics: https://www.cdc.gov/hiv/basics/statistics.html.

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