A Population Health Approach to Managing Heart Failure - Episode 18

Patient and Provider Perceptions Surrounding Affordability for HF Treatments

Experts share their thoughts on payer and provider perceptions surrounding affordable HF care, as well as strategies to manage care-associated costs.

Ryan Haumschild, PharmD, MS, MBA: Affordability is another consideration. Dr Anderson, from your perspective, what are the patient-provider perceptions around drug affordability in heart failure?

John E. Anderson, MD: It centers around ARNI [angiotensin receptor-neprilysin inhibitor] therapy and SGLT2 inhibitor therapy. Those are the 2 newer, expensive medications. I’ve found that commercial and Medicare populations are covered. Sometimes you have to dance a little and jump through a couple of hoops, but you can almost always get it. But in the primary care world, if you get turned down for these medications or the patient gets sticker shock at the pharmacy window, it will take you 5 times before you may try that again. We have to make sure these patients have access and that you don’t overburden the nursing staff and working staff of an office to get something for a patient. The other part of this is getting it, affording it, and then finding out later in the year that they’re falling into the Medicare gap. That happens a lot. It’s a huge problem for our patients during the latter part of the year.

Ryan Haumschild, PharmD, MS, MBA: Yes, the Medicare gap is something we always have to focus on. How do we get support for them so we don’t lose adherence? Because we don’t want to see patients revert. That’s a great comment.

Dr Januzzi, for patients on Medicare, out-of-pocket costs are generally low for drugs in heart failure. But in 2022, the coverage gap kicks in after the patient in the prescription plan has total combined drug spending of over $4000. Although enhancements have been made over the years to reduce the patient out-of-pocket burden with the coverage gap, most patients will still have increased cost during the timebefore they jump into that catastrophic coverage period. How do the new guidelines, which include strong recommendations for several of these brand medications, potentially impact those individuals who have entered the coverage gap?

Jim Januzzi, MD: This is probably one of the most heartbreaking struggles I deal with at work every day when patients tell me that they have to make choices in which medications they’re going to take. Just today, a patient told me that their coverage for one of the heart failure therapies that we’re talking about was inadequate and that they needed to discontinue it. That’s problematic because it’s imperative that we not only recognize that there’s a social commitment that we should be making to our patients, but in a larger sense, the health care system can only benefit from our patients receiving these medications because it reduces the huge costs of care related to heart failure hospitalization and all the morbidity that accompanies that. The fact that it gets passed on to the patients is problematic to me.

There are things that we can do to try to address this. Whenever possible, we can obviously consider utilizing generic equivalents for different GDMT [guideline-directed medical therapy] possibilities. Unfortunately, sacubitril/valsartan and SGLT2 inhibitors aren’t generic, although both are approaching generic status within the next couple of years. That will largely address this issue moving beyond this. Working with a pharmacist, social worker, and patient navigator, depending on your institution, to identify and address assistance programs for our patients is one thing that we found to be very useful.

Pill splitting [can help]. Depending on how the medication is priced, going to a higher dose but then splitting pills to stretch the prescription is one of the tricks that we use for our patients. And of course, identifying where there are overlap opportunities [can help]. For example, use of an SGLT2 inhibitor for diabetes care to allow for removal of other high-cost therapies, such as a DPP-4 inhibitor, which has little or no benefit in heart failure and in some cases may worsen outcomes. Those are ways to streamline care.

Ultimately, in a perfect world, we wouldn’t have to struggle with this. But I go to bat every single day for my patients filling out prior authorizations and trying to find approaches to reduce the cost of care. Because in the end, it benefits everyone. It benefits the patient, health care systems, and payers that we approach this problem.

Ryan Haumschild, PharmD, MS, MBA: Yes. That was a great summary statement. By getting patients on the right medication and improving their adherence, you increase their motivation for therapy, achieve good outcomes and reduced hospitalizations, and help with those population health goals.

As we wrap up here, Dr Uppal, we’ve talked about so much that’s going on, and you’re involved in not only the frontline treatment but also population health. What are some of the unmet needs of this heart failure population that can potentially be addressed through additional studies or initiatives as we continue to move forward in our advances in treatment?

Rohit Uppal, MD, MBA, SFH: When I think about what hasn’t been addressed in research, one of the underrepresented areas is the patients we see in the hospital with multiple comorbidities. You don’t often see these patients included in large clinical trials. Future trials focusing on how we optimize strategies for elderly patients with CHF [congestive heart failure] and multiple comorbidities would be helpful. We haven’t talked much about this, but there are also disparities based on race and gender. We know that Black men develop CHF at a younger age, have more rapid progression, and have a higher mortality rate. Women are less likely to be on recommended therapy and much less likely to have referrals to cardiology, even in the hospital. Only 20% of clinical trial participants are women.

The last thing that’s a big challenge is these complex medication regimens and the polypharmacy when patients have CHF and multiple comorbidities. Medication nonadherence is a real obstacle we see. [It would be helpful to have] future trials testing the effectiveness of patient empowerment in real-world settings. How do we activate patients and optimize their medication adherence?

Transcript edited for clarity.