CV Risk Reduction and Coverage of Therapies

Factors considered by payers in regard to coverage decisions for therapies that have the potential to reduce cardiovascular risk.


Deepak L. Bhatt, MD, MPH: It is a nice framework that Dr Bress has laid out. Perhaps I can turn to Dr Cannon, because in the end it is ultimately the payer who has a lot to do with what gets covered. In terms of cardiovascular risk reduction, what do you consider clinically effective, and what are you willing to pay for that?

Eric Cannon, PharmD, FAMCP: We get that question a lot. What is clinically effective? Unfortunately, I don’t know that we’ve ever come up with a great answer to say, “This is the mark that you need to hit.” And so, as a result, we look to national guidelines. I think icosapent ethyl is a great example, now seeing endorsement by the ADA [American Diabetes Association] and others, and seeing some of the research that is out there as to the reductions and events and those types of things. That all feeds into that cost-effectiveness that Dr Bress talked about. We’re looking at those quality-adjusted life years, and we’re looking at that $50,000 mark, and we’re looking at, is it falling between $50,000 and $150,000? But I think more importantly, we look at how we can drive down the cost of the product. If it’s clinically appropriate, and I would argue and I think you guys have all done a great job reinforcing the importance of a drug like icosapent ethyl, my obligation is to get that product at the lowest possible cost. How do I make sure I’ve reduced the cost to the member? How do I make sure I’ve reduced the cost to the clients that I have? Then we move ahead in making sure that we use artificial intelligence and lots of tools that we have to identify those patients who will benefit most from that treatment. Our goal anymore is to not say anything is not covered, but to help identify those patients who are going to benefit the most from a therapy.

I look at some of the frameworks that we’ve set up with the clinicians in our area. We have guidelines under which we’re going to use those treatments. But then to the point that Dr Navar brought up, she may have a young patient who doesn’t necessarily fit within the framework or the guidelines that we established. And so we’ve built pathways and things so that information can be communicated to us and we can drive that to those patients. Saying, “This is the mark that we’re trying to shoot for in clinical effectiveness, and here’s a magic percentage reduction that we have to have,” I don’t think that exists. But really, it’s a collaboration across many sciences to say, “How do we drive to these effective therapies,” knowing that long term, in regard to the overall cost of health care, we are going to benefit from more effectively treating our patients.

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