Aligning Value Statements and Cost-Effective Coverage In Accordance With ACC Guidelines

Ryan Haumschild, PharmD, MS, MBA, leads a conversation regarding value statements and their alignment with cost-effective care.

Ryan Haumschild, PharmD, MS, MBA: As part of some of this innovative care that we’re able to provide and new medications that are being recognized, with that comes the value of total cost of care and thinking about the pharmacoeconomics of these therapies. For a while, we had lower-cost medications, using beta blockers and diuretics and others to treat the disease, and innovative treatments were requested for a while. How can we improve outcomes? Now that we have these therapies, we have to be more thoughtful about the value, not only to the organization and our payer colleagues, but also to the patient.

When we look at the guidelines, one of my biggest takeaways was the value statements. We’ve started to see value care pathways in oncology. We’ve seen it sometimes in the dermatology space with some of the different biologics, but seeing this for cardiology piques a lot of people’s interest. Now the guidelines have included these value statements for recommendation, where high quality but cost-effective studies on the interventions have been published. Including those data is important to us as clinicians that we’re evaluating the whole treatment of the patient. With that comes the curiosity of how these value statements start to impact coverage decisions. Dr Murillo, as a managed care executive and knowing managed care across the board, how do you think some of these value statements might start to be incorporated in organizations across the country in terms of the impact for coverage decision determination and for the recommended interventions?

Jaime Murillo, MD: Great question. I was very excited when I saw the inclusion of value statements within the guidelines for several reasons. One, it helps those in training think more about aspects that are related that are critical to treating patients. It isn’t about knowing only what the diagnosis is and what medication to give. But are those patients able to take those medications? If they aren’t, it’s important to find a way to help them from a cost standpoint.

For those who are already practicing, it’s another way to integrate that into their conversations with their patients on a daily basis. Many of us who have practiced for many years have had that experience of handing out a prescription and then a month later finding out that people weren’t taking it because they didn’t have the money to pay for it and were shy about telling their doctor, “I don’t have the money for that.” It’s extremely important that they do that. From the payers’ standpoint, it provides one more tool for the payers to start making or helping make those decisions.

I also want to take the opportunity to clarify that contrary to the perception that health plans make decisions about coverage based on cost, that isn’t the case. It factors in, but at the end of the day, it’s whether the medication is effective, safe, and efficacious to treat conditions. Being approved by the FDA is incredibly important when those medications are put in the guidelines because it gives the health plans the opportunity to say, “This is solid information and data, and therefore we should make sure that patients have access to those medications.” Value statements are good for the practicing clinicians’ standpoint and the health plan.

Ryan Haumschild, PharmD, MS, MBA: I like what you said. It’s the plan, but it’s also the employer [responsibility] to manage that cost of care.

Jaime Murillo, MD: Yes.

Ryan Haumschild, PharmD, MS, MBA: They need to be making sure if their spending goes up per member, per million, that they understand what they’re getting back in value. You’re right, it’s not like it’s just the payer making the decision. They’re just trying to be a steward of the medication cost to make sure the patients are getting the best outcome. That was a great comment. Acknowledging that we think about the health care providers’ standpoint, Dr Uppal, I think of you as someone who’s actively practicing, so what are your thoughts on these value statements? What are some of the strategies that organizations can do to better implement and align some of these value statements within their guidelines or internal pathways?

Rohit Uppal, MD, MBA, SFH: Thanks. Even though these value considerations may be relatively new to practice guidelines, as a hospitalist, delivering high value care has always been part of the fabric of our clinical practice. We’ve been on the front line of managing costs within the hospital and across transitions. The relative value of different therapeutic options is pretty commonplace for us in evaluating that value. Having these value statements embedded in these guidelines creates more transparency and supports clinicians who are making efforts to weigh these value decisions. I’m glad that progress is being made in terms of being more explicit and transparent in assessing value, especially given the criticality of the accelerating cost of health care.

In terms of specifically the CHF [congestive heart failure] guidelines, as a hospitalist, I don’t see that there’s a significant impact on practice at this point. The value statements provide information. They aren’t prescriptive. It’s interesting that all of the goal-directed therapies that we’re focused on and that we target in our protocols are classified as high value. As Dr Murillo mentioned, our efforts are focused on reaching higher levels of compliance and adherence to evidence-based therapies. The way we align with value is by preventing hospitalizations, improving morbidity and mortality, and then skillfully using palliative care when appropriate. At this point, these value statements are only going to be pertinent in more exceptional cases. Although, I see a lot of potential in the future for these value statements to impact clinical decision-making.

Ryan Haumschild, PharmD, MS, MBA: It’s almost like it’s shifting the culture a little to where we’re recognizing the value. Because you’re right, a lot of hospitalists, internists, and cardiologists have recognized that it’s important to think about the total cost of care and to make sure they’re adding value to mortality outcomes and patient-reported outcomes, while also being a good steward of health care spending. What I’d like to see now is we’re starting to officially see this incorporated, where we don’t have to go externally to the…to look at the qualities and improvement of the quality of life, but that they’re actually in front of us. That’s a strong statement to make because, like you said, a lot of our leading practitioners thought this way and were including this in their practice, but it had never been included within the guidelines.

Jim Januzzi, MD: One of the things to add to that is the growing recognition of the importance of patient-reported outcomes. Each of the therapies that have been incorporated as a class 1 for treatment in heart failure, as well as in HFpEF [heart failure with preserved ejection fraction] or class 2a, have been shown to improve health status. In addition to reducing health care costs, patients also feel better. That’s another recognition that the guidelines have moved to the forefront in emphasizing the importance of remembering that there’s a patient in the equation, and we can not only reduce their risk for rehospitalization but also improve their quality of life and everyday function.

Transcript edited for clarity.

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