Cost and Utilization Profile for a Patient With HF

Jaime Murillo, MD, reviews the cost and utilization profile for a typical patient with heart failure.


Neil Minkoff, MD: I’d like to open up the conversation and bring in another perspective from Dr Murillo. You’re looking at this as a cardiologist by training. You practiced for quite a number of years, and you’re now looking at it from a population point of view and through a payer lens. What are you looking at from a payer perspective regarding patients with heart failure, around cost and utilization? How are you looking at these populations?

Jaime Murillo, MD: Thank you for that question, because that essentially is part of the crux of that intersection. There are so many pathophysiological phenomena in different demographic groups, comorbidities, and sets of patients that ultimately result in what we have today, which is huge spending in the growth category of heart failure. Before I actually answer more of that question, I want to include a group that somehow we don’t pay a lot of attention to, except when we start looking at the analysis. I went back and looked at the different categories for the past 3 years, looking at what is trending up and what is not trending up, and there’s 1 particular group that caught my attention. That is what the CMS [Centers for Medicare & Medicaid Services] classifies as hypertension with complications. The 2 main groups were hypertension with chronic kidney disease and hypertension with heart failure.

That is just striking. Think about it: hypertension with complications. What does that mean? We as a country have not done a good job controlling something as simple as blood pressure. Everyone knows the statistics: 40% of people are without blood pressure control, and how many of them are undiagnosed? If you also look at the CDC [Centers for Disease Control and Prevention] statistics, you see how the mortality is trending up in most of that, secondary to hypertension, stroke, and so on. Hypertension can also lead to hypertensive heart disease with either reduced ejection fraction or preserved ejection fraction. I wanted to make sure we also look into that specific group, because that tends to be a younger demographic, and talk about how can we act earlier and start doing something about it. That’s a group where we have a huge opportunity.

In terms of how we look at it, we look at the 5 top causes of spending in the cardiovascular environment. You’ll find the group that I just mentioned, and you obviously will find the pure CHF, or congested heart failure, group. We also find that chronic kidney disease is 1 of the biggest areas of spending, and not surprisingly, we’re going to touch on the diabetes group. Those alone are about 3 of the 4 highest-spending areas in cardiovascular disease. They’re there, and this is critical to this conversation.

Steven Nissen, MD: Jaime, you made a really great point, particularly in adding this thought about hypertension. Again, the observation is that we are not, as a society, doing a good job of identifying and treating hypertension, particularly in minority communities. Cleveland has a very large African American population. Often, we see them coming in with very thick ventricles and with heart failure, and you realize they’ve had hypertension for many years. Perhaps they are middle-aged, and to some extent, the horse is out of the barn and we probably need to intervene much earlier. There have been a lot of innovative programs over the years to try to identify, particularly in the African American community, this problem of hypertension and intervene early enough. Heart failure is a disease that’s sometimes best prevented rather than treated.

Jaime Murillo, MD: Correct.

Neil Minkoff, MD: Let me follow up with you just a bit, Jaime, about how your organization looks at this population and what you’re doing to monitor them, improve treatment, reduce hospitalizations, and so on.

Jaime Murillo, MD: Yes, thank you. As you can imagine, everyone is doing the same around the country. There is some good news from that standpoint. If you look at the category of congestive heart failure, of the top 10 categories, that’s the only 1 where there seems to be some progress that we’re making. Every hospital, every health care system, every doctor, and obviously health plans are working toward to control that. The key part moving forward, for us to continue successfully, which Dr Nissen alluded to, is that we need to go beyond just the concept of heart failure and move a bit more broadly. We do have quite a few initiatives. Some of them have been more successful when we employ them utilizing the more than 500 ACOs, or accountable care organizations, that are affiliated with UnitedHealthcare. We work with them in terms of, can you proactively treat this person? Can you follow them. Are they hospice? Are they on the so-called continuum of care? We have not done a good job with that in general. Also, you have, previously and still, a prevalent fee-for-service system where I treat the patient in the hospital and the rest is up to you. Then the primary care doctor or the cardiologist outside the hospital takes it on. There’s no continuum of care. We’re actually making an effort.

We’re also introducing technology into this concept. We recently bought a company called Vivify Health Inc, and heart failure was the first broad diagnosis we incorporated into the Vivify concept. We have enrolled about 20,000 patients in that digital component, and obviously we continue to expand and hope that everyone who has a diagnosis of heart failure will be digitally touched for us to keep in touch with.

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