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Ensuring Timely and Appropriate Access to Therapy


A key opinion leader considers how to ensure patients with HFpEF and HFrEF receive therapy in a timely and appropriate manner.

Jaime Murillo, MD: When it comes to how to ensure timely and appropriate access to therapy, that is another area where we have to do a better job. That goes back to my comment about whether that patient is waiting to be seen in the office, or if we waited too long such that they had to go to the emergency department because they didn’t have access. Access is the key word, and that’s why we need to modify the system. I want to speak as someone from a health plan provider and say we need to change the way we look at patients in the long term.

In our fee-for-service environment, we have a very transactional view of medicine. The patient is seen in the office, a bill is created for the visit, and there’s no accountability as to what happens to the patient. I don’t mean to say that the doctors are not doing what they truly believe they need to be doing, but we’re not supporting a long-term strategy because they are rushed to see patients because it’s about volume. In other words, they need to see patients quickly, and they don’t have the time to talk about nutrition or to think about the social conditions.

If we agreed, both on the provider side and on the health plan side, and say, “What we really care about is how the person in front of you right now is going to be doing in 6 months. We’re going to pay for that performance. We’re going to pay based on outcomes.” We agree on the terms and understand that this is not a “gotcha” kind of approach where 1 year from now, someone will say, “I made a bad deal.” We need to look at it as a long-term approach, and we need to change that approach. I bet we’re going to change that because right now, the doctor can feel comfortable calling the patient or having the nurse call the patient to say, “How are you doing today, Mr. Smith? Is there anything we can do for you? How are you feeling? What are any changes in your system? I want to make these recommendations to your therapy.” They don’t have to think about that within 10 minutes because they have someone else waiting for them in the office. In fact, the patient doesn’t even have to come into the office.

Can we also, on the health plan side, provide that? IT [information technology] has infrastructure for patients to be able to connect with their providers. That’s part of the responsibility that we have. We [at United Health Care] recently consulted with well-recognized academic institutions to provide a consulting program for the management of heart failure, and one of the recommendations was that we need to provide that IT infrastructure for the providers. Not everybody has the ability to invest in that. We should do it, and we are doing it. We’re driving some of those initiatives, but we also want to partner with the provider and say, “Please do it. Here’s the infrastructure. Please connect to the EMR [electronic medical record]. Let’s interface in a way that will benefit the patient, so that you don’t have to worry about whether you saw the patient and couldn’t bill for it. It’s not about that. It’s about how they’re doing in the long run.” I know that was a long spiel about what we should be doing, but I truly believe that’s what we need to do, and we cannot wait 5 years to do it.

From the formulary standpoint, the strategy is similar to what I mentioned earlier, which is that we recognize that there are several lines of therapy that are beneficial. This has already been demonstrated in previous research trials. We believe that patients should have access to it. Then obviously, the considerations are different when you talk about medications that have different co-pays. That’s certainly a significant barrier for many patients. If we take an approach where, if we go back to the outcomes I was talking about before, we don’t have to worry about whether somebody’s paying X or Y co-pay.

If someone is doing well in 6 months and if the total cost of care is reduced, then we should factor the cost of that medication into that approach, so that we don’t have to worry about how many times they went to the emergency department. We will have to worry about it, but in terms of cost, when we look at total cost of care and include all those variables, then it becomes less transactional, and people will have more access to their medications and won’t have to worry about the co-pays, or if they have high deductibles, for those who are reaching the donut hole coverage gap for Medicare patients.

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