Tattoo You: State faces rising costs from Hep C treatment

The Texas Tribune yesterday had a story on the rising cost of treating Hepatitis C in prison due to changing standards of care surrounding the disease. Reported Brandi Grissom:

Prison health officials estimate that as many as 50,000 of the state’s more than 150,000 inmates could be infected with hepatitis C. The cost to treat Texas inmates with hepatitis C is expected to soar by as much as 380 percent next year, a result of the growing prevalence of the disease among inmates and a more effective, but more expensive, treatment protocol. Legislators, already facing a strained budget, will have to find millions more dollars to pay for this care.

Not all inmates are tested for hepatitis C when they enter the prison system. They are tested if they have other clinical indicators, like HIV or a history of intravenous drug use. In a 2007 report, health providers for the Texas Department of Criminal Justice said they had identified and were managing care for about 20,000 inmates with hepatitis C.

Dr. Stephanie Zepeda, the director of pharmacy services for University of Texas Medical Branch Correctional Managed Care, which oversees treatment of inmates, said she provided medication therapy for about 400 hepatitis C patients per month, at a cost to the state of about $2.8 million per year. Not all patients with the disease receive the medication, and the therapy can last from three months to a year.

The current protocol is composed of two drugs, and its cure rate is about 40 percent, Zepeda said. But new medical guidelines call for the use of a third medication, which can be one of two different drugs. One of them would increase the cost of hepatitis C treatment in prisons to more than $8 million a year, the other to more than $13 million, Zepeda said.

Zepeda said that adding a third drug raised the cure rate to 70 percent. But the drugs are not only expensive, they are also complicated to administer.

“It’s great from a humanistic standpoint,” Zepeda said. “But it’s, practically, a challenge for the correctional system.”

The new drugs must be administered precisely every eight hours. They must be taken with food, and patients risk developing a resistance to the therapy if they miss doses. In prison, where even small diversions from the regimented schedule require additional work for guards, and where inmates frequently move between units, ensuring that the expensive medications are given correctly could be problematic, Zepeda said.

“It just takes a tremendous amount of coordination to do it right and to do it well,” she said.

Perhaps the biggest source of in-prison transmission of Hep C is unsterilized tattooing. For a while, Canada experimented with placing tattoo parlors in prison, with mixed results (it was abandoned out of an ideological shift in government, not because of problems with the program). It turned out some prisoners wouldn't use the program (which obviously wouldn't do gang tats) and more importantly, they discovered most prisoners acquiring Hep C had done so in the free world, either in regular, licensed tattoo parlors, some of which pose a number of underpublicized health risks, or via IV drug use.

In any event, Texas is unlikely to install tattoo parlors in prison anytime soon, and the GOP champion for free-world needle exchange in the Legislature abandoned the idea after the Bexar District Attorney threatened to prosecute those participating in a legislatively approved pilot. So, since the state appears unlikely to embrace preventive tactics anytime soon, the question remains: Will new, more effective Hep C treatments be deemed medically necessary and thus required under prison medical protocols? If so, it's yet another factor boosting costs for prison healthcare, which the Lege last session underfunded in the budget by nine figures. And since Texas policy toward most prisoners on Hep C has been "don't ask, don't treat," if they ever actually began testing everyone for the disease, those costs would go even higher.