Abstract
Background
Curative treatment for hepatitis C virus (HCV) exists, making elimination of HCV possible. However, most people with HCV have not received treatment. One barrier is limited access to treatment providers. HCV treatment can be effectively provided by primary care providers and, since 2017, Wisconsin Medicaid allows non-specialists to prescribe treatment. We surveyed family medicine physicians in Wisconsin to evaluate capacity for the provision of HCV treatment.
Methods
We mailed a survey to family medicine physicians in Wisconsin during June-September 2018. Physicians were asked whether they prescribe HCV treatment and about their knowledge regarding HCV treatment and relevant statewide Medicaid policy. Using multivariable logistic regression, we evaluated physician characteristics associated with prescribing HCV treatment.
Results
Of 1,333 physicians surveyed, 600 (45%) responded. Few respondents reported prescribing HCV treatment independently (1%; n=4) or in consultation with a specialist (6%; n=35). Only 6% (n=36) reported having a “great deal” of knowledge about HCV treatment. Most (86%; n=515) were not aware that family medicine physicians can now prescribe HCV treatment covered by Medicaid. Physicians who practiced in offices affiliated with health systems were less likely to prescribe HCV treatment than physicians who practiced in an independent office or a Rural Health Clinic.
Conclusions
Among family medicine physicians in Wisconsin, experience with and knowledge of HCV treatment was limited. Developing knowledge and skills among primary care providers is needed to expand treatment access and make progress toward HCV elimination. Studies are needed to evaluate treatment access in primary care offices affiliated with health systems.
Introduction
Hepatitis C virus (HCV) infection is the most commonly reported bloodborne infection in the United States,1 and more than half of infected persons develop chronic infection.2 Chronic HCV progresses slowly, often without symptoms, but is a leading cause of hepatocellular carcinoma, a leading reason for liver transplantation, and a leading infectious cause of death.3,4 Before 1992, when universal screening of the blood supply began, transmission commonly occurred through receipt of contaminated blood products and organs. Today, the most common method of HCV transmission is injection drug use. Historically, the majority of persons living with HCV were born during 1945–1965 (i.e., the baby boomer generation).5 In recent years, however, increasing numbers of younger adults, particularly in rural areas, have become infected with HCV as a result of increased injection drug use driven by the opioid crisis.6–8
Until 2013, treatment for chronic HCV was complex, had sub-optimal cure rates, and caused many side effects, requiring management by a specialist. In contrast, the currently available HCV treatments, which consist of an 8–12 week course of all-oral direct-acting antiviral (DAA) medication, have >95% cure rates, far fewer side effects, and can be safely administered to persons with most other chronic health conditions.9 Furthermore, multiple studies have demonstrated that DAAs can be safely and effectively administered by primary care providers.10–12
Despite these advances in the treatment of HCV, a recent literature review found that only 39% of people who attended a follow-up visit after diagnosis with HCV received treatment.13 There are multiple barriers to receiving HCV treatment, including medical insurance policies. For example, despite clear guidance that limitations to HCV treatment through state Medicaid programs violate federal law,14 the high cost of DAAs has motivated many state Medicaid programs to limit access by requiring treatment to be prescribed by a specialist and by limiting treatment to patients who meet certain clinical and sobriety criteria.15 However, the current specialist workforce is insufficient, particularly in rural areas, to treat the increasing numbers of people diagnosed with HCV.16–18 To improve access to HCV treatment and make progress toward HCV elimination, the U.S. Department of Health and Human Services and the Centers for Disease Control and Prevention have called for expanding the HCV treatment workforce to include non-specialists such as primary care providers.16,19,20
In Wisconsin, as many as 70,000 people are estimated to be living with chronic HCV and new HCV infections have increased as a result of increased injection drug use.6,8 Rates of new infections are highest in rural areas where there are few HCV treatment providers.8,17,18 In recent years, Wisconsin Medicaid has removed all barriers to prescribing and receiving HCV treatment, including removing prior authorization (effective July 2020), sobriety restrictions (effective July 2019), and disease severity restrictions (effective July 2017). Also in July 2017, Wisconsin Medicaid removed the requirement that HCV treatment be prescribed by a specialist, allowing all primary care providers to prescribe HCV treatment paid for by Medicaid. To evaluate the capacity of primary care providers in Wisconsin to provide HCV treatment, we surveyed family medicine physicians in Wisconsin one year after this change to assess their experience with and knowledge of HCV treatment. Because HCV has increased in rural areas of Wisconsin, we investigated differences in experience and knowledge by whether the provider practiced in a rural or urban area. In addition, we investigated the characteristics of family medicine physicians who reported already prescribing HCV treatment to gain insight into possible facilitators of or barriers to providing HCV treatment.
Methods
We conducted a cross-sectional survey of family medicine physicians in Wisconsin. The purpose of the survey was to understand their knowledge and practices regarding prevention and treatment of opioid use disorder and HCV. This manuscript focuses only on the findings specific to HCV. The survey was administered and data were collected by the University of Wisconsin Survey Center from June 25, 2018 through September 7, 2018. Physicians were selected from a list of all family medicine physicians in Wisconsin procured from the data science company IQVIA (Plymouth Meeting, PA). One thousand five hundred physicians were selected from 3,052 physicians on the list. The selected sample included all physicians who were known to have a federal waiver to provide buprenorphine (a medication for opioid use disorder).21 In addition, we oversampled physicians in rural areas to better understand knowledge and practice among rural physicians. The survey design consisted of three mailings via the U.S. Postal Service: a full mailing with cover letter to all 1,500 selected physicians (including a cover letter, questionnaire, a business reply envelope, and $5 bill), a postcard reminder, and two additional full mailings to those who had not responded to previous mailings. Physicians were excluded if they returned the survey and indicated they were no longer practicing medicine or if the survey was returned by the U.S. Postal Service with no forwarding address.
The survey instrument is included as a supplement. The survey collected information on physician demographic and clinical practice characteristics in addition to five different domains related to their: (1) experience providing HCV treatment, (2) knowledge of HCV treatment, (3) knowledge of relevant statewide policy regarding HCV treatment, (4) treatment considerations for persons who inject drugs, and (5) self-identified knowledge gaps related to HCV. Physicians were also asked “Compared to the epidemic of opioid misuse and opioid overdose across Wisconsin, how serious of a problem is opioid misuse in the community where you practice?”.
We categorized physician practice locations as rural or urban using the reported practice zip code and the designation by the Federal Office of Rural Health Policy.22 Using chi-square and Fisher’s exact tests, physicians’ knowledge and experience were compared by whether the physician was located in a rural or urban area.
To better understand the characteristics of family medicine physicians who have already started providing HCV treatment, we compared characteristics of two groups of physicians: (a) physicians who reported prescribing HCV treatment independently or in consultation with a specialist and (b) physicians who reported not prescribing HCV treatment, including physicians who reported they do not prescribe HCV treatment but would if they could. We calculated percentages of physicians, by characteristic, who reported prescribing treatment. For each characteristic, we calculated bivariate odds ratios for prescribing HCV treatment. Characteristics significantly (P<0.05) associated with prescribing HCV treatment were included into a multivariable logistic regression model to understand which characteristics were independently associated with prescribing HCV treatment.
All data were analyzed using SAS version 9.4. This study was approved by the University of Wisconsin-Madison institutional review board.
Results
Of the 1,500 family medicine physicians who were sent a survey, 11 reported being ineligible to participate (no longer practicing medicine) and 156 had surveys returned indicating the address was invalid. Of the remaining 1,333 physicians sent the survey, 600 (45%) responded. Respondents and non-respondents were not significantly different in terms of gender, whether their practice site was primary care only or multi-specialty, whether they practiced in a hospital, or rural location based on zip code. Among respondents, median physician age was 50 years, 57% were male, 83% were white or Caucasian, and 46% had practiced medicine for >20 years (Table 1). The majority (58%) reported practicing in an office-based practice affiliated with a hospital or health system, 16% reported practicing in an independent practice, and 5% reported practicing in a Rural Health Clinic. Respondents were from 69 of Wisconsin’s 72 counties, and 40% were categorized as practicing in a rural area. The estimated percentage of patients with Medicaid reported by this group of providers ranged from 0 to 90% (median: 25%). Most respondents (88%) reported that opioid misuse in the community where they practice is as much or more of a problem than it is statewide.
Table 1.
Characteristics of family medicine physicians who responded to the survey, Wisconsin, 2018
| Provider Characteristic | No. | (%) |
|---|---|---|
| Total | 600 | (100) |
| Age | ||
| 30 to 39 | 131 | (22) |
| 40 to 49 | 136 | (23) |
| 50 to 59 | 149 | (25) |
| 60+ | 163 | (27) |
| Unknown | 21 | (4) |
| Gender | ||
| Male | 343 | (57) |
| Female | 239 | (40) |
| Unknown | 18 | (3) |
| Race/ethnicity | ||
| White or Caucasian | 499 | (83) |
| Asian or Pacific Islander | 38 | (6) |
| Latino or Hispanic | 16 | (3) |
| Black or African American | 7 | (1) |
| Native American | 3 | (1) |
| Other | 13 | (2) |
| Unknown | 24 | (4) |
| Number of years in practice after residency | ||
| 0–5 years | 92 | (15) |
| 6–10 years | 64 | (11) |
| 11–15 years | 59 | (10) |
| 16–20 years | 94 | (16) |
| More than 20 years | 274 | (46) |
| Unknown | 17 | (3) |
| Practice type | ||
| Hospital or health system affiliated office-based practice | 349 | (58) |
| Independent office-based practice | 96 | (16) |
| Urgent care center | 34 | (6) |
| Rural health clinic | 27 | (5) |
| Federally Qualified Health Center/Community Health Center | 26 | (4) |
| Emergency department | 17 | (3) |
| Hospital inpatient | 11 | (2) |
| Other | 27 | (5) |
| Unknown | 13 | (2) |
| Practice location, by zip code | ||
| Rural | 241 | (40) |
| Urban | 327 | (55) |
| Unknown | 32 | (5) |
| Number of adolescent and adult patients cared for in past year | ||
| <1000 | 133 | (22) |
| 1000 to 1999 | 172 | (29) |
| 2000 to 2999 | 122 | (20) |
| >=3000 | 115 | (19) |
| Unknown | 58 | (10) |
| Percent of patients covered through Medicaid | ||
| <10% | 58 | (10) |
| 10 to 19% | 134 | (22) |
| 20 to 29% | 117 | (20) |
| 30 to 39% | 99 | (17) |
| 40 to 49% | 47 | (8) |
| >50% | 93 | (16) |
| Unknown | 52 | (9) |
| Compared to all of Wisconsin, how serious is opioid misuse in the community where you practice? | ||
| Not a problem at all in my community | 1 | (0) |
| Less of a problem | 68 | (11) |
| As much of a problem | 432 | (72) |
| More of a problem | 95 | (16) |
| Unknown | 4 | (1) |
Unknown responses are those where the respondent did not provide a response to the question.
As a result of rounding, percentages may not sum to exactly 100%.
Experience providing HCV treatment
Few physicians reported prescribing HCV treatment independently (1%; n=4) or in consultation with a specialist (6%; n=35) (Table 2). In total, 546 (91%) physicians reported they did not prescribe HCV treatment. Among these 546 physicians, 105 reported they did not prescribe HCV treatment but they would if they could (Table 2). Fifteen (2%) physicians did not provide a response to the question.
Table 2.
Physician knowledge and experience related to hepatitis C treatment
| Total | |
|---|---|
| No. (%) | |
| Total | 600 (100) |
| Hepatitis C Treatment: Experience and Knowledge | |
| Do you prescribe treatment for hepatitis C? | |
| Yes | 4 (1) |
| Yes, but only in consultation with a specialist | 35 (6) |
| No, but I would prescribe if I could | 105 (17) |
| No | 441 (74) |
| Unknown | 15 (2) |
| How much do you feel you know about current treatment guidelines for hepatitis C? | |
| A great deal | 36 (6) |
| A moderate amount | 247 (41) |
| A little bit | 254 (42) |
| Nothing | 41 (7) |
| Not applicable | 5 (1) |
| Unknown | 17 (3) |
| Consideration of hepatitis C among patients who inject drugs | |
| If you have a patient who injects drugs with hepatitis C, would you …? (select all that apply * ) † | |
| Encourage the patient to get treated | 341 (59) |
| Treat the patient yourself | 15 (3) |
| Make a referral to another provider for treatment | 532 (92) |
| Tell the patient to return for treatment when he/she is no longer using/injecting drugs | 19 (3) |
| Knowledge gaps | |
| Which of the following training topics would help you improve your knowledge of hepatitis C? (select all that apply * ) | |
| Treatment of hepatitis C | 436 (73) |
| Prevention of hepatitis C | 204 (34) |
| Risk factors for contracting and transmitting hepatitis C | 200 (33) |
| Liver disease, cirrhosis, and liver transplantation | 189 (32) |
| I already know a lot about hepatitis C and do not need any more training | 69 (12) |
| Knowing about hepatitis C is not very important to my job and I do not need training | 18 (3) |
For questions where respondents were asked to “select all that apply”, for each response, the percentage that chose this response was calculated using the total number of respondents as the denominator.
Among 579 physicians who reported having patients who inject drugs
Unknown responses are those where the respondent did not provide a response to the question.
Knowledge of HCV treatment
When asked about knowledge of HCV treatment guidelines, 6% reported “a great deal”, 41% reported “a moderate amount”, 42% reported “a little bit” and 7% reported no knowledge of current HCV treatment guidelines (Table 2).
Knowledge of relevant statewide policy regarding HCV treatment
Only 14% (n=85) of physicians correctly responded that Wisconsin Medicaid does not require HCV treatment to be prescribed by a specialist. The majority of physicians reported they did not know whether Wisconsin Medicaid restricted HCV treatment based on patient sobriety, disease severity, or previous treatment (Figure 1).
Figure 1. Physician knowledge of whether Wisconsin Medicaid has restrictions to prescribing and receiving HCV treatment, by type of restriction.
A * indicates the correct answer at the time of the survey (June 25, 2018 through September 7, 2018). Starting in July 2019, Wisconsin Medicaid does not have sobriety restrictions or retreatment restrictions.
Percentages are of the 600 physicians surveyed.
The missing category includes respondents who did not respond to the question.
Physicians were asked if Wisconsin Medicaid had provider specialty restrictions (so that only gastroenterologists or infectious disease specialists can prescribe treatment), sobriety restrictions (so that patients must be abstinent from drugs or alcohol for at least 6 months), liver disease severity restrictions (so that only patients with documented fibrosis or cirrhosis are eligible), and retreatment restrictions (so Medicaid will only cover one treatment course per patient).
Consideration of persons who inject drugs
Among the 579 (97%) physicians who reported seeing patients who inject drugs in their practice, 59% (n=341) reported they would encourage patients who inject drugs and have HCV to receive HCV treatment. However, only 3% (n=15) reported they would treat the patient themselves and most (92%, n=532) reported they would refer the patient for treatment. Few (3%; n=19) reported they would tell the patient to return for treatment when the patient is no longer using drugs (Table 2).
Knowledge gaps
Physicians were asked which training topics would help improve their knowledge of HCV. Most physicians (73%) reported that training regarding HCV treatment would help improve their knowledge (Table 2). Approximately one-third of physicians reported interest in each of the following training topics: HCV prevention, risk factors, and disease progression. Only 12% (n=69) reported that they “already know a lot” about HCV and do not need additional training (Table 2).
Comparison of rural and urban physicians
Experience with HCV treatment was minimal among physicians practicing in both rural and urban areas of Wisconsin, but physicians practicing in rural areas were more likely to report prescribing treatment (independently or in consultation with a specialist) than physicians practicing in urban areas (rural: 9%, urban: 5%, P<0.05) (Table 3). Only 7% of physicians practicing in rural areas and 6% of physicians practicing in urban areas reported having “a great deal” of knowledge about HCV treatment (Table 3). Similarly low percentages of physicians in rural (14%) and urban (16%) areas were aware that non-specialists could now prescribe HCV treatment paid for by Medicaid. Physicians practicing in rural areas less often reported that they would tell a patient to return for HCV treatment when they are no longer using drugs (rural: 1% vs. urban: 5% vs., P<0.05) (Table 3). Physicians practicing in rural areas more often reported that training in HCV treatment (rural: 80% vs. urban: 71%, P=0.01) and prevention (rural: 40% vs. urban: 31%, P<0.05) would help improve their knowledge of HCV (Table 3).
Table 3.
Comparison of physician knowledge and experience by whether the physician reported practicing in a rural or urban area
| Rural | Urban | |
|---|---|---|
| No. (%) | No. (%) | |
| Total | 241 (100) | 327 (100) |
| Hepatitis C Treatment: Experience and Knowledge | ||
| Do you prescribe treatment for hepatitis C? | ||
| Yes or Yes, but only in consultation with a specialist* | 22 (9) | 16 (5) |
| How much do you feel you know about current treatment guidelines for hepatitis C? | ||
| A great deal | 16 (7) | 20 (6) |
| Consideration of hepatitis C among patients who inject drugs | ||
| If you have a patient who injects drugs with hepatitis C, would you …? (select all that apply † ) ‡ | ||
| Encourage the patient to get treated | 147 (64) | 186 (59) |
| Treat the patient yourself | 8 (3) | 6 (2) |
| Make a referral to another provider for treatment | 218 (94) | 295 (93) |
| Tell the patient to return for treatment when he/she is no longer using/injecting drugs* | 3 (1) | 15 (5) |
| Knowledge gaps | ||
| Which of the following training topics would help you improve your knowledge of hepatitis C? (select all that apply † ) | ||
| Treatment of hepatitis C* | 193 (80) | 231 (71) |
| Prevention of hepatitis C* | 96 (40) | 102 (31) |
| Risk factors for contracting and transmitting hepatitis C | 90 (37) | 104 (32) |
| Liver disease, cirrhosis, and liver transplantation | 81 (34) | 104 (32) |
| I already know a lot about hepatitis C and do not need any more training | 23 (10) | 43 (13) |
| Knowing about hepatitis C is not very important to my job and I do not need training | 6 (2) | 12 (4) |
P < 0.05
For questions where respondents were asked to “select all that apply”, for each response, the percentage that chose this response was calculated using the total number of respondents as the denominator.
Among 231 rural and 316 urban physicians who reported having patients who inject drugs.
Characteristics of physicians already prescribing HCV treatment
Overall, 39 physicians reported prescribing HCV treatment independently or in consultation with a specialist and 546 physicians reported not prescribing HCV treatment. In bivariate analyses, physician characteristics significantly associated with providing HCV treatment included practicing in an independent practice or Rural Health Clinic (compared to practicing in an office-based practice affiliated with a hospital or health system); practicing in a rural zip code (compared to an urban zip code); and having a higher percentage of Medicaid-insured patients (Table 4). In addition, compared to physicians aged 60 years and older, younger physicians reported prescribing HCV treatment less often (Table 4).
Table 4.
Physician and practice characteristics associated with providing HCV treatment
| Physician reported prescribing HCV treatment independently or in consultation with a specialist | |||||
|---|---|---|---|---|---|
| No (n=546) | Yes (n=39) | Percentage Yes | Odd ratio and 95% confidence interval of prescribing HCV treatment | ||
| Characteristics | No. (%) | No. (%) | % (n/N) | Unadjusted | Adjusted |
| Age | |||||
| 30 to 39 | 126 (23) | 5 (14) | 4% (5/131) | 0.34 (0.12–0.94) | 0.24 (0.07–0.83) |
| 40 to 49 | 124 (23) | 11 (30) | 8% (11/135) | 0.75 (0.34–1.67) | 0.57 (0.21–1.56) |
| 50 to 59 | 145 (27) | 4 (11) | 3% (4/149) | 0.23 (0.08–0.71) | 0.33 (0.10–1.08) |
| 60+ | 144 (27) | 17 (46) | 11% (17/161) | reference | reference |
| Gender | |||||
| Male | 318 (59) | 23 (59) | 7% (23/341) | reference | |
| Female | 222 (41) | 16 (41) | 7% (16/238) | 1.00 (0.52–1.93) | |
| Race/ethnicity | |||||
| White or Caucasian | 464 (87) | 32 (84) | 6% (32/496) | reference | |
| Asian or Pacific Islander | 36 (7) | 2 (5) | 5% (2/38) | 0.81 (0.19–3.50) | |
| Latino or Hispanic | 15 (3) | 1 (3) | 6% (1/16) | 0.97 (0.12–7.55) | |
| Black or African American | 6 (1) | 1 (3) | 14% (1/7) | 2.42 (0.28–20.69) | |
| Native American | 2 (0) | 1 (3) | 33% (1/3) | 7.25 (0.64–82.11) | |
| Other | 12 (2) | 1 (3) | 8% (1/13) | 1.21 (0.15–9.59) | |
| Number of years in practice after residence | |||||
| 0–5 years | 86 (16) | 6 (16) | 7% (6/92) | 0.86 (0.34–2.22) | |
| 6–10 years | 62 (12) | 1 (3) | 2% (1/63) | 0.20 (0.03–1.51) | |
| 11–15 years | 53 (10) | 5 (14) | 9% (5/58) | 1.17 (0.42–3.24) | |
| 16–20 years | 87 (16) | 5 (14) | 5% (5/92) | 0.71 (0.26–1.95) | |
| More than 20 years | 247 (46) | 20 (54) | 7% (20/267) | reference | |
| Practice type | |||||
| Hospital or health system affiliated office-based practice | 328 (63) | 16 (50) | 5% (16/344) | reference | reference |
| Independent office-based practice | 83 (16) | 10 (31) | 11% (10/93) | 2.47 (1.08–5.64) | 2.55 (1.01–6.42) |
| Rural Health Clinic | 22 (4) | 5 (16) | 19% (5/27) | 4.66 (1.56–13.9) | 5.37 (1.53–18.87) |
| Urgent care center | 32 (6) | 1 (3) | 3% (1/33) | 0.64 (0.08–4.99) | 0.6 (0.07–4.98) |
| Federally Qualified Health Center/Community Health Center | 25 (5) | 0 (0) | 0% (0/25) | ||
| Emergency department | 17 (3) | 0 (0) | 0% (0/17) | ||
| Hospital inpatient | 11 (2) | 0 (0) | 0% (0/11) | ||
| Practice location, by zip code | |||||
| Rural | 218 (41) | 22 (58) | 9% (22/240) | 1.95 (1.00–3.80) | 1.23 (0.51–2.98) |
| Urban | 309 (59) | 16 (42) | 5% (16/325) | reference | reference |
| Number of adolescent and adult patients cared for in past year | |||||
| <1000 | 123 (25) | 8 (24) | 6% (8/131) | 0.61 (0.24–1.57) | |
| 1000 to 1999 | 158 (32) | 9 (26) | 5% (9/167) | 0.53 (0.21–1.33) | |
| 2000 to 2999 | 113 (23) | 6 (18) | 5% (6/119) | 0.50 (0.18–1.39) | |
| >=3000 | 103 (21) | 11 (32) | 10% (11/114) | reference | |
| Percent of patients covered through Medicaid | |||||
| <30% | 292 (58) | 11 (34) | 4% (11/303) | reference | reference |
| >=30% | 213 (42) | 21 (66) | 9% (21/234) | 2.62 (1.24–5.54) | 3.23 (1.38–7.56) |
| Compared to the epidemic of opioid misuse and opioid overdose across Wisconsin, how serious of a problem is opioid misuse in the community where you practice? | |||||
| As much or more of a problem | 480 (88) | 37 (95) | 7% (37/517) | 2.43 (0.57–10.32) | |
| Not a problem at all in my community/Less or a problem | 63 (12) | 2 (5) | 3% (2/65) | reference | |
Data for physicians with unknown or missing responses are not included in Table 4. In the first two columns, percentages were calculated excluding physicians with unknown or missing responses and, as a result of rounding, percentages may not sum to exactly 100%.
In multivariable analysis, compared to practicing in a hospital or health system affiliated practice, practicing in a Rural Health Clinic (odds ratio (OR): 5.37 (95% confidence interval (CI): 1.53–18.87)) or an independent practice (OR: 2.55 (1.01–6.42)) was significantly associated with prescribing HCV treatment. Compared to the physicians age 60 years and older, physicians age 30–39 less often reported prescribing HCV treatment (OR: 0.24 (0.07–0.83)). Compared to physicians with <30% of patients insured by Medicaid, having ≥30% of patients covered by Medicaid was significantly associated with prescribing HCV treatment (OR: 3.23 (1.38–7.56)) (Table 4).
Discussion
The results of this survey highlight the significant knowledge gap among family medicine physicians in Wisconsin regarding HCV treatment and Wisconsin Medicaid policy allowing for the delivery of HCV treatment in primary care settings. Only 7% of the respondents reported they had prescribed HCV treatment either independently or in consultation with a specialist, and most (86%) were not aware that family medicine physicians can now prescribe HCV treatment covered by Wisconsin Medicaid. This lack of experience with and knowledge of HCV treatment was similar among physicians in both rural and urban areas of Wisconsin. These findings suggest the need for additional training, clinical support, and incentivization of primary care providers to deliver HCV treatment. Engagement of family medicine physicians and other primary care providers, particularly in rural areas where there are few specialists,17–18 will be critical to achieving HCV elimination throughout Wisconsin.
Coordinated efforts are needed to train primary care providers to treat HCV. In this survey, younger physicians less often reported prescribing HCV treatment. In addition, almost three-quarters of all physicians (and 80% of physicians practicing in rural areas) reported they would benefit from training about HCV treatment. Incorporating HCV treatment training into family medicine and other primary care training programs could equip new physicians with the knowledge and experience to treat HCV. For primary care providers already in practice, telementoring (e.g. Project ECHO) is a demonstrated method for improving HCV treatment knowledge and practice among primary care providers, and for increasing treatment access in rural areas.10–12 Other specific knowledge gaps identified through this survey, including lack of knowledge about state Medicaid policy related to HCV treatment, could also be addressed through utilization of telementoring.
In addition to identifying important knowledge gaps among family medicine physicians in Wisconsin, the findings of this survey also suggest there may be institutional barriers limiting family medicine physicians from providing HCV treatment. For example, in this survey, physicians practicing in offices affiliated with a hospital or health system were less likely to report prescribing HCV treatment than physicians practicing in an independent practice or Rural Health Clinic. Little has been documented in the peer-reviewed literature about the barriers to accessing HCV treatment within health systems. It is possible some health systems have restrictions, including that treatment be provided by a specialist. Alternatively, it is possible that physicians working in health systems have easier access to specialists or are more familiar with the specialists in their system, and therefore are more likely to refer than to prescribe treatment themselves. Additional research is needed to understand what barriers -- institutional or otherwise -- might be contributing to family medicine physicians in health systems not prescribing HCV treatment.
Barriers to prescribing and receiving HCV treatment covered by state Medicaid programs are well-documented and many states, including Wisconsin, have removed restrictions in recent years.15 At the time of this survey, Wisconsin Medicaid allowed non-specialists to prescribe HCV treatment, but still restricted access based on patient sobriety. In this survey, physicians who reported higher percentages of patients covered by Medicaid were more likely to report prescribing HCV treatment. This could be because physicians in these settings have more patients with HCV (national results indicate Medicaid-insured patients have a higher prevalence of HCV than commercially-insured patients23) and have recognized a need among their patient population. Alternatively, having higher percentages of patients with commercial insurance might be a barrier to prescribing treatment. Little is documented in the peer-reviewed literature about barriers to accessing HCV treatment through commercial insurance. However, one study of HCV treatment prescriptions submitted to a national pharmacy found that more than half of persons insured by commercial plans had their HCV treatment medication claims denied.24 In addition to removing all barriers to receiving HCV treatment within Medicaid programs, as Wisconsin Medicaid has now done, efforts must be undertaken to identify and remove barriers to HCV treatment among commercial insurance plans.
This study has several limitations. Because the survey focused on HCV and opioid use disorder, physicians who chose to respond might have more interest, knowledge, or experience with HCV treatment than non-respondents. Nevertheless, few respondents reported HCV treatment knowledge or experience. This study included only family medicine physicians. Future studies should explore whether similar trends are found among primary care providers of different specialties (e.g., internal medicine) and disciplines (advance practice nurses and physician assistants). We did not assess barriers to providing HCV treatment that may be specific to employer type (health system vs. independent practice) or commercial insurance plans. We also did not explore facilitators or incentives that may support or encourage physicians who already prescribe HCV treatment. Future studies should evaluate the extent to which employers and insurers can encourage primary care providers to prescribe HCV treatment, including but not limited to: educational opportunities, clinical staff support in treatment delivery, mentorship programs, alleviation of insurance administrative barriers such as prior authorizations, and financial incentive programs.
Our study highlights the need to engage more Wisconsin family medicine physicians in efforts to eliminate HCV. Primary care providers should be encouraged and supported in providing HCV treatment, and coordinated efforts are needed to train and mentor these providers to prescribe HCV treatment. Further research is needed to better understand both the barriers and facilitators to delivering HCV treatment in primary care settings. Health insurers and health systems have important roles to play in examining existing policies that may promote or limit access to HCV treatment. Given the increasing rates of HCV infection and the highly effective, simplified HCV treatment regimens, now is an opportune time to expand access to HCV treatment through primary care.
Supplementary Material
Acknowledgements
Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number P30CA014520 and the National Institute on Drug Abuse of the National Institutes of Health under Award Number UG3DA044826. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We also thank the Wisconsin Department of Health Services, Division of Care and Treatment Services, for providing additional funding for survey distribution. We gratefully acknowledge the University of Wisconsin Survey Center for conducting the survey.
References
- 1.Centers for Disease Control and Prevention. Viral hepatitis surveillance—United States, 2017. Accessed January 15, 2020. https://www.cdc.gov/hepatitis/statistics/2017surveillance/pdfs/2017HepSurveillanceRpt.pdf
- 2.Seo S, Silverberg MJ, Hurley LB, et al. Prevalence of Spontaneous Clearance of Hepatitis C Virus Infection Doubled From 1998 to 2017. Clin Gastroenterol Hepatol. 2020;18(2):511–513. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC Recommendations for Hepatitis C Screening Among Adults - United States, 2020. MMWR Recomm Rep. 2020;69(2):1–17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Ly KN, Hughes EM, Jiles RB, Holmberg SD. Rising Mortality Associated With Hepatitis C Virus in the United States, 2003–2013. Clin Infect Dis. 2016;62(10):1287–1288. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Smith BD, Morgan RL, Beckett GA, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965. MMWR Recomm Rep. 2012;61(RR-4):1–32. [PubMed] [Google Scholar]
- 6.Zibbell JE, Asher AK, Patel RC, et al. Increases in Acute Hepatitis C Virus Infection Related to a Growing Opioid Epidemic and Associated Injection Drug Use, United States, 2004 to 2014. Am J Public Health. 2018;108(2):175–181. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Zibbell JE, Iqbal K, Patel RC, et al. Increases in hepatitis C virus infection related to injection drug use among persons aged <=30 years - Kentucky, Tennessee, Virginia, and West Virginia, 2006–2012. MMWR Morb Mortal Wkly Rep. 2015;64(17):453–458. [PMC free article] [PubMed] [Google Scholar]
- 8.Wisconsin Department of Health Services, Division of Public Health. Hepatitis C in Wisconsin, Wisconsin Hepatitis C Virus Surveillance Annual Review, 2019. Accessed November 30, 2020. https://www.dhs.wisconsin.gov/publications/p00440-2019.pdf
- 9.American Association for the Study of Liver Diseases (AASLD), Infectious Diseases Society of America (IDSA). HCV guidance: recommendations for testing, managing, and treating hepatitis C. Accessed January 15, 2020. https://www.hcvguidelines.org
- 10.Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011;364(23):2199–2207. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kattakuzhy S, Gross C, Emmanuel B, et al. Expansion of Treatment for Hepatitis C Virus Infection by Task Shifting to Community-Based Nonspecialist Providers: A Nonrandomized Clinical Trial. Ann Intern Med. 2017;167(5):311–318. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Syed TA, Bashir MH, Farooqui SM, et al. Treatment Outcomes of Hepatitis C-Infected Patients in Specialty Clinic vs. Primary Care Physician Clinic: A Comparative Analysis. Gastroenterol Res Pract. 2019;2019:8434602. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Owens DK, Davidson KW, Fu R, et al. Screening for Hepatitis C Virus Infection in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2020. Mar 2. pii: 2762186. doi: 10.1001/jama.2020.1123 [DOI] [PubMed] [Google Scholar]
- 14.Centers for Medicare & Medicaid. Assuring Medicaid Beneficiaries Access to Hepatitis C (HCV) Drugs. 2015. Accessed January 15, 2020. https://www.medicaid.gov/medicaid-chip-program-information/by-topics/prescription-drugs/downloads/rx-releases/state-releases/state-rel-172.pdf
- 15.National Virus Hepatitis Round Table & Harvard Law School Center for Health Law and Policy Innovation. Hepatitis C: The state of Medicaid access. August 1, 2020.. Accessed December 1, 2020. http://stateofhepc.org/wp-content/uploads/2020/11/HCV_State-of-Medicaid-Access_August-2020-update.pdf
- 16.U.S. Department of Health and Human Services. When it Comes to Curing Hepatitis C, Your Health Care Provider May Not Need to Be A Specialist. September 2017. Accessed September 17, 2019. https://www.hhs.gov/hepatitis/blog/2017/09/20/study-calls-for-expansion-of-hepatitis-c-treatment.html
- 17.Westergaard RP, Stockman LJ, Hyland HA, Guilfoyle SM, Fangman JJ, Vergeront JM. Provider Workforce Assessment in a Rural Hepatitis C Epidemic: Implications for Scale-up of Antiviral Therapy. J Prim Care Community Health. 2015;6(3):215–217. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Wisconsin Department of Health Services, Divison of Public Health. Preventing and treating harms of the opioid crisis: An assessment to identify geographic gaps in services, and a plan to address these gaps. Published February 2020. Accessed July 1, 2020. https://www.dhs.wisconsin.gov/publications/p02605.pdf
- 19.U.S. Department of Health and Human Services. National Viral Hepatitis Action Plan, 2017–2020. Published January 2017. Accessed July 1, 2020. https://www.hhs.gov/sites/default/files/National%20Viral%20Hepatitis%20Action%20Plan%202017-2020.pdf
- 20.Centers for Disease Control and Prevention. Division of Viral Hepatitis 2025 Strategic Plan. Published August 2020. Accessed August 26, 2020. https://www.cdc.gov/hepatitis/pdfs/DVH-StrategicPlan2020-2025.pdf
- 21.Substance Abuse and Mental Health Services Administration. Buprenorphine Practitioner Locator. 2019. Accessed May, 2018. https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator
- 22.U.S. Department of Health and Human Services, Health Resources and Services Administration. Federal Office of Rural Health Policy (FORHP) Data Files. 2019. Accessed October 2019. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html
- 23.Bush H, Paik J, Golabi P, de Avila L, Escheik C, Younossi ZM. Impact of hepatitis C virus and insurance coverage on mortality. Am J Manag Care. Feb 2019;25(2):61–67. [PubMed] [Google Scholar]
- 24.Gowda C, Lott S, Grigorian M, et al. Absolute Insurer Denial of Direct-Acting Antiviral Therapy for Hepatitis C: A National Specialty Pharmacy Cohort Study. Open Forum Infect Dis. Jun 2018;5(6):ofy076. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.