New Therapy Approved to Combat Growing Hepatitis C Problem

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Leading IRO, AllMed, helps health plans learn about new standard of treatment for chronic HCV, importance of consulting with independent review organizations, and clinical criteria applied to managing care

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Expanded HCV testing may prevent more than 120,000 deaths from HCV, but is likely to surface more than 800,000 infections that payers and providers will have to manage - Kimberly Beavers, MD

The Hepatitis C virus (HCV) is a growing problem in the United States. It currently affects 3.2 million people, a number that is expected to jump as the baby boom generation comes of age – older adults are more susceptible to the virus – and swells the healthcare ranks.

Two new medicines, now available for treatment of HCV, are part of an FDA-approved therapeutic regimen that promises to combat the disease very effectively. However, the regimen poses challenges for physicians with HCV patients and for insurance companies which are faced with covering treatment costs, according to the independent review organization, AllMed Healthcare Management.

These challenges were discussed in a recent webinar – hosted by AllMed – that brought together medical management and claims professionals from across the country. The attendees heard from Kimberly Beavers, MD. She noted – among other things – that The Centers for Disease Control and Prevention (CDC) has recommended expanded HCV testing to now include anyone born between 1945 and 1965. “While this expanded testing is projected to prevent more than 120,000 deaths from HCV, it is also likely to surface more than 800,000 additional infections, the cases of which both payers and providers will have to manage,” Beavers said.

Points of Emphasis
Dr. Beavers emphasized the following points:

  •     The majority of cases occur among baby boomers, most of whom were infected in their teens and 20s
  •     HCV can take up to 30 years to develop, and it is difficult to identify and conclusively diagnose because most patients are asymptomatic
  •     In addition to the 1945 to 1965 age group, the CDC also recommends testing for people who injected drugs, those with certain conditions (such as abnormal ALT levels), healthcare, emergency medical and public safety workers, and children born to HCV-positive mothers
  •     While many health plans cover the new HCV therapy, some plans may require patients to meet stringent criteria, including diagnosis of a specific HCV genotype, proof of no history of previous therapeutic failure (such as with HCV protease inhibitors), absence of HIV or Hepatitis-B co-infection, and no history of liver or other solid organ transplant

Treatment Regimen
The new standard of care of for HCV, outlined in a new white paper by AllMed, begins with antibody, viral load, genotype, liver function testing and liver biopsy. Subsequently, a combination-therapy regimen is followed, which includes administration of pegylated interferon alfa (PEG-IFN) and ribavirin, plus the two new FDA-approved viral protease inhibitors: boceprevir and telaprevir. Duration of the therapy is 12 to 48 weeks, depending on patient’s HCV-RNA levels.

“Patients receiving HCV treatment should be monitored for adherence to therapy, which is critical since non-compliance can lead to drug resistance and treatment failure,” Beavers said. “It is also important to monitor for evidence of side effects, including anemia and neutropenia, and to understand that these can add to the complexity and duration of the treatment,” she added.

Primary goal of the new treatment is an undetectable HCV-RNA level six months after completion of therapy. Achievement of this goal is dependent on numerous factors, including virus genotype and viral load, age of the patient, period between infection and treatment, weight, race, sex and presence of fibrosis and cirrhosis of the liver.

IROs Help Payers Make Specialty Care Decisions
Health plans can benefit from outsourcing the review of complex cases such as HCV to an independent review organization (IRO). Payer organizations increasingly rely on IROs to improve their care management decisions on HCV and in other specialties where therapies and procedures are continuously changing.

Specialties where IROs are actively involved include hematology, oncology, transplant surgery, interventional radiology and hepatology, noted Andrew Rowe, CEO of AllMed. “IROs use actively practicing specialists in advanced areas of medicine to help health plan care managers gain immediate access to specialty knowledge, which improves the quality and integrity of authorization and denial decisions.“

“IROs are increasingly being seen as a critical business process outsourcing (BPO) solution that helps payer organizations improve quality while reducing costs,” Rowe added.

About AllMed Healthcare Management
Founded in 1995, AllMed is a medical review outsourcing partner to leading health insurance payers, third-party administrators, medical management and claims organizations, nationwide. Its BPO services cover all levels and types of medical review services for payers. Services are delivered through PeerPoint®, AllMed’s state-of-the-art medical review portal. PeerPoint provides a state-of-the-art, secure, workflow platform that streamlines all physician review processes. Reviews are conducted by AllMed’s team of more than 400 licensed, board-certified physician specialists who are in active practice. For more information, visit

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Andrew G. Rowe

Bill Trainer
The Public Relations Project, Inc.
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