Balancing Payer Utilization Strategies With Clinical Effectiveness in HF


Jaime Murillo, MD, outlines payer utilization management strategies identified by the PARADIGM-HF study.

Ryan Haumschild, PharmD, MS, MBA: I want to transition and get more of a managed care perspective for these questions. Dr Murillo, I’m coming your way with this question. Multiple high-quality analyses use data from the PARADIGM-HF study to evaluate the economic value of ARNIs [angiotensin receptor-neprilysin inhibitors] compared with ACE inhibitor therapy. The findings consistently found less than 60,000, which would probably be considered high value according to the adopted benchmarks for our clinical practice. How do the results from these analyses impact the payer utilization and management strategies of these therapies?

Jaime Murillo, MD: As I said earlier, these considerations are an important part of the evaluation. The health plans in general think of the clinical efficacy and safety of these medications. Are those medications already approved by the FDA, including the guidelines and so on? Then the financial impact of that becomes a secondary consideration. That doesn’t mean it isn’t important. It’s very important. We’re talking about a health care environment, insurance companies, and so on. It would be naive to say that they aren’t important. But my point is that they aren’t the primary reason that medications are or aren’t covered from that standpoint.

You asked a question about management, and I want to make a point about how health plans are transitioning from having a transactional relationship with providers to [being more present] as part of the transformational health care. “Can we help in any way with your management strategies by providing IT support, administrative support, or facilitating value base?” That’s the point I want to make in this conversation, because we talked about population health strategies for management of heart failure.

If you think about it, there are 2 points that we discussed earlier. No. 1 is the importance of taking care. We now have a cardiologist, a primary care physician, and nurses. We haven’t talked about the importance of including pharmacy in this management. We talked about how we can transfer a lot of this care into the community. Transfer doesn’t mean without supervision. It means putting the physician or the provider in a position where they can supervise. We don’t have enough. We’ll never have enough doctors, at least for the next 30 or 40 years, to care of every patient we want to care for. We need to make every effort to ensure that those themes are available for the care, and that the cardiologists and primary care do the initial evaluation for the patient and [choose] the right medication. Then we can have other members of the team do the quick titration. We can also use technology to help us with that.

A lot of health systems have adopted clinical decisions with poor systems. In the case of heart failure, that would be helpful to titrate those patients very quickly, because doctors don’t have the time in the offices to see them that quickly, but we can establish that communication. Especially if you can interface with the IT [information technology] strategies. We can monitor patients safely from home. That’s another strategy we haven’t talked about, which is also critical in the population health management of these patients. Ultimately, if you’re in a value-based care environment, then there’s a significant effort to go upstream. Because we know that if you’re in a value-based care environment, and you want save on the total cost of care, then you save only by going upstream, by focusing on those that we have discussed: patients at risk and patients who are in the pre–heart failure stage.

Ryan Haumschild, PharmD, MS, MBA: Excellent thoughts. Thanks for giving that overview of the team-based care, because that’s the future direction we should go.

Transcript edited for clarity.

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