Liver clinic group searches for funding as health system changes

A London-based network of clinics for liver disease outpatients says it may be forced to close locations across Ontario if it can’t secure sustainable funding from the province.

Liver Care Canada offers free treatment, monitoring and support to patients with hepatitis C and other liver diseases at its more than 20 clinics throughout Ontario.

The London-based business funds its clinics through routine pharmacy payments offered by the Ontario Drug Benefits program for eligible hepatitis C patients, but margins have been gradually reduced by current and previous provincial governments.

“We’ve been able to partner with many pharmacies to get (hepatitis C) patients educated and provide the treatments to them,” said Karim Ragheb, a pharmacist and chief executive of Liver Care Canada.

“We work on a not-for-profit model. The full margin that we were able to collect from the partnering pharmacies that we work with, we were able to put towards the operation of the clinic and looking after patients with other liver conditions, not just hepatitis C.”

Pharmacies receive payments from the Ontario Drug Benefits program to help them cover the cost of doing business. Hepatitis C patients often require expensive treatments, increasing the amount paid by the Ontario Drug Benefits program to pharmacies, Ragheb said.

For example, the benefits formulary shows the Ministry of Health will pay $797.61 for the hepatitis C drug Harvoni, a combination tablet that’s 400 milligrams of one antiviral drug and 90 milligrams of another. By comparison, the ministry will pay about 18 cents for a 300-milligram tablet of penicillin.

The majority of doctors and liver specialists at Liver Care Canada’s clinics are part-time, Ragheb said. Many have posts in hospitals. They bill Ontario’s health insurance plan for patient visits and pay Liver Care Canada rent for the days they work at the clinic, he said.

The rent payments alone are not enough to keep the lights on at clinics five days a week, he said, leading to the need for other revenue streams.

Liver Care Canada, launched in 2015, says it has about 40,000 patient visits across Ontario each year. About 10 per cent are by hepatitis C patients. Its mission is to provide quality care and treatment to patients with all types of liver disease, reducing the need for emergency room visits.

Ragheb said Liver Care Canada has been asking the province since 2016 for sustainable funding that doesn’t depend on the Ontario Drug Benefits pharmacy payments.

“We took it upon ourselves to find a solution to the hallway medicine problem the government is very aware of. We found a path to that solution,” Ragheb said. “This model of clinics that are outside of the hospital is saving the system a lot of money. . . . Our system is very lean and very specialized.”

In a statement, the Ministry of Health said it will be up to new regional health-care entities to implement liver care and hepatitis C programs that meet local needs.

“We have shared with Liver Care Canada that Ontario health teams are a new way of organizing and delivering services for patients,” the ministry said in a statement.

“As the Ontario health team model will fundamentally change how health care is organized in Ontario, the ministry has encouraged Liver Care Canada to be aware of this change so that they can collaborate effectively with local health partners.”

Diagnosing, treating and curing liver disease, especially hepatitis C, has been hampered by a lack of political will, said Jordan Feld, a hepatologist and board member of the Canadian Liver Foundation.

“Liver disease is hugely under-recognized as a significant medical problem,” said Feld, an associate professor of medicine at the University of Toronto.

“I always say to my patients, the best thing about liver disease is it causes no symptoms and the worst thing about liver disease is that it causes no symptoms. . . . Liver disease is really the silent killer.”

Feld said liver disease is stigmatized because people assume it’s almost always alcohol-related. Patients aren’t prompted to get routine screening tests for liver disease like they are with some cancers. Viral infections such as hepatitis B and C are often under-diagnosed, Feld said.

“In Ontario, about a third of people who develop complications from hepatitis B or C are diagnosed for the first time with those infections within six months of that complication. That’s an infection that’s been there for decades,” Feld said.

Hepatitis C treatments have undergone a “transformational” change in the last five years, Feld said. Patients on some daily pill regimens for up to three months have a cure rate of 95 per cent, he said.

“One of the things we’ve tried to really push is, now that hepatitis C treatment is so easy, it doesn’t really need to be done by specialists,” Feld said. “It can be done by primary care providers.”

Feld has never worked with Liver Care Canada, but said the clinics and others like it are responding to a demand.

“There are a number of different groups that have taken different approaches to trying to increase primarily hepatitis C diagnosis, really trying to provide opportunities for people to get screened and receive care in simplified ways,” Feld said.

“Things like Liver Care Canada, where they’re making access greater for people living in rural or remote sectors by using telemedicine, by engaging primary care providers to do the treatment, I think is really important.”

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