Managed Care Decision Making in CVD and Lipid Control

Peter Salgo, MD: One in every 3 healthcare dollars is spent on cardiovascular disease. The number I have is 800,000 deaths a year in cardiovascular disease. This is big stuff. When we actually look at this with this much at stake in this country, with this many people involved, we’re actually looking at payers. We’re looking at the folks who have to foot the bill. What are the implications of cardiovascular disease (I know you alluded to it going forward) for the payer community? For managed care? What’s the cost burden?

Gary L. Johnson, MD, MBA: Obviously, it’s tremendous. Along with oncology and immunologic diseases, cardiovascular disease is one of the top 3. But when you say payers, ultimately, the payers are society.

Seth J. Baum, MD: I was going to say that.

Gary L. Johnson, MD, MBA: We’re basically an intermediary to manage those dollars.

Peter Salgo, MD: Sure, the American public has to bear this, but when it comes down to it, the doctor sitting across the table from a patient is going to go to one of you and say, “I want to do A, B, or C.” You’re the guys and women who have to approve or disapprove. You’re the sieve, the filter, so, to some degree, you’re going to make these decisions.

Gary L. Johnson, MD, MBA: Well, we’re going to make the decisions about coverage. I don’t disagree with you.

Howard Weintraub, MD: How do you make those decisions?

Gary L. Johnson, MD, MBA: We make the decisions based on evidence, which I would hope that, as a practicing physician, all physicians would base their treatment decisions on evidence. We also make the decisions on coverage based on population medicine, which is something that practicing physicians do sometimes, but not all the time.

Seth J. Baum, MD: I’ve got to cut you off, I’m sorry.

Peter Salgo, MD: You said population medicine?

Seth J. Baum, MD: Yes, population medicine. Population medicine drives all of our guidelines. We try to extrapolate from population medicine to the individual patient sitting across from us in the office, and it’s an impossible extrapolation. So, it’s an unfair and inaccurate use of science, and that is what managed care tries to do. But even the guidelines do it.

Gary L. Johnson, MD, MBA: Right. Our obligation is, though, to practice population medicine in terms of coverage decisions. I wear 2 hats. I practice as a physician, but I also work as a medical director.

Peter Salgo, MD: Let me play devil’s advocate for you. If he gave everybody everything that you guys asked him to give, he’d be broke in a week. And if you gave nobody anything, we’d all be dead in a week.

Seth J. Baum, MD: I don’t think that’s true.

Peter Salgo, MD: You don’t think that’s true?

Seth J. Baum, MD: Absolutely not.

Peter Salgo, MD: Why not?

Seth J. Baum, MD: Because I think if every payer gave everything we wanted, then patients would be healthier. And then, in the long-term, they would have fewer heart attacks, fewer strokes, and they would have longer lives. What happens is, and the insurance companies are very honest about this (the ones I’ve spoken to), they understand that patients switch from the insurance company to insurance company, and they don’t want to bear the burden of a particular medication that’s going to have its benefit 10 years down the road when the patient is going to be with a competitor. I think that’s a major part of the problem.

Jennifer Strohecker, PharmD, BCPS: I’m going to take this whole different angle.

Peter Salgo, MD: Please do.

Jennifer Strohecker, PharmD, BCPS: I feel that it’s not just about coverage decisions that we’re looking at, but really the benefit design for patients so that they have access.

Peter Salgo, MD: What does that mean, “benefit design”?

Jennifer Strohecker, PharmD, BCPS: For example, I’m a pharmacist and I straddle, also, the clinician perspective. I oversee a group of clinicians who practice within a managed care setting. But there’s also the benefit structure that says, “Okay, the first step in managing cardiovascular disease is lifestyle modifications as well as access to appropriate therapies.” So, when you look at this from a managed care perspective, you want to make sure that your disease management models within managed care complement what the physician and evidence-based guidelines are trying to do so that you can help your patients achieve their outcomes—not just disease management, but also your formulary structures.

Peter Salgo, MD: That means you’ve got to do some stratification, right? You can divide those at risk for cardiovascular-related events, especially high-risk people, into 2 groups, it seems to me. The modifiable group, that is to say, they’ve got risk factors you can fix, and then the nonmodifiable risk factors, right? And that’s sort of what you were talking about. You’ve got to identify what you’re talking about.

Jennifer Strohecker, PharmD, BCPS: Well, for example, I feel that if you have a benefit structure that, for example, wants to promote lifestyle modifications that could be for all stratification groups, then you need to provide access to weight loss programs. You need to provide access to smoking cessation services that are paid as part of the benefit of your health plan.

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