Roundtable Wrap: Cleveland's Tech Is Ready, Access Isn't

Four rooms running in parallel at a Cleveland population health conference tackled 4 unrelated disease states: obesity, rare glomerular kidney disease, heart failure, and Alzheimer disease. All 4 arrived at the same complaint: the therapy or the test already exists, but insurance, infrastructure, or geography keeps patients from reaching it. Technology surfaced in every room as a possible fix, but panelists split sharply on whether it was ready to deliver one.

The Cleveland Population Health Roundtable, hosted by The American Journal of Managed Care^® (AJMC^®), convened clinicians, pharmacists, nurses, and researchers from Cleveland Clinic, University Hospitals, and MetroHealth on August 18, 2026, for 4 simultaneous track discussions. Many panelists also held faculty appointments at Case Western Reserve University School of Medicine, reflecting the academic ties that run through Cleveland's 3 competing health systems. Ian Neeland, MD, director of preventive cardiology at University Hospitals, moderated the obesity and diabetes track. Salem Almaani, MBBS, MS, FASN, staff nephrologist and founding director of the Cleveland Clinic Glomerulonephritis Center, moderated the rare glomerular disease track. Trejeeve Martyn, MD, a heart failure cardiologist at Cleveland Clinic, moderated the track on heart failure with preserved ejection fraction (HFpEF) and mildly reduced ejection fraction (HFmrEF). Kavita Nair, professor of neurology and pharmacy at the University of Colorado Anschutz Medical Campus and chair of the American Academy of Neurology's coding, payment, and policy subcommittee, moderated the Alzheimer disease track. Each room mixed physicians with pharmacists, nurses, social workers, and administrators rather than a single specialty.

Constructing High-Impact Care Teams for Obesity and Diabetes

The obesity track centered on what happens after a glucagon-like peptide-1 (GLP-1) prescription is written. Scott Yasinow, MD, a primary care physician at University Hospitals, said the drugs work when patients can stay on them. “Of 10 people I start on this medication, 7 stay on it,” he said. “Of the 3 that stop, 2 stop because they can't get it affordably, and the last 1 stops because they vomit everywhere.” Pharmacists on the panel, including Alysha Martin, PharmD, and Michael Duffy, PharmD, described the prior authorization appeals and peer-to-peer reviews their teams absorb so physicians do not have to. The panel also debated what success should look like once access is secured. Kevin Pantalone, DO, an endocrinologist, questioned whether body mass index (BMI) should remain the field's default target now that newer therapies routinely produce weight loss once considered unachievable.

“What is the target? What is the ultimate goal?” he asked. “When we see these patients with BMI of 35, what really should be our goal?”

Steven Nissen, MD, chief academic officer of the Heart, Vascular, and Thoracic Institute at Cleveland Clinic, noted he chairs the ongoing, 15,000-patient SURMOUNT-MMO (NCT05556512) trial testing tirzepatide's effect on cardiovascular outcomes in obesity, underscoring how fast the evidence base is still moving.¹ Yasinow and Maryanne Haddad, MD, separately described how often the conversation itself, not insurance, ends a visit before any therapy is discussed, recalling patients who left in tears after a routine weight check or who never returned to a practice after seeing “obese” documented in their after-visit summary.

Elevating Rare Glomerular Diseases Across CKD Pathways

In the rare glomerular disease room, the barrier was upstream of treatment: identifying patients with IgA nephropathy or focal segmental glomerulosclerosis before kidney damage progresses. Nissreen Elfadawy, MD, a community nephrologist with University Hospitals, argued the fix does not require sophisticated artificial intelligence, just a system willing to flag an abnormal result.

“This is what I'm talking about—flagging this number in the system for some kind of message, pop up—consider that,” she said. “It doesn't have to be complicated or sophisticated AI. It's just a simple thing. If the proteinuria is higher than this threshold, this patient is better seen by [a] nephrologist because a lot of time, [PCPs] don't know is it bad enough to send for nephrology.”

Mahboob Rahman, MD, chief of the Division of Nephrology and Hypertension at University Hospitals, said the framing itself needs to change. “It reframes the problem really nicely,” he said of the push for earlier identification. “It's not a niche nephrology problem any longer. It's really a population-based issue that primary care physicians should be primed to take on head-on, but we are not.”

Tyler Barnett, MHA, said most institutions, his own included, still lack a systemic way to flag these patients, and panelists weighed how to scale referral protocols without overloading nephrology access. Richard H. Cartabuke, MD, proposed going a step further than an alert, automatically triggering reflex testing and the next diagnostic order directly off an abnormal urinalysis, rather than waiting on a primary care referral to set the workup in motion.²

Beyond the Ejection Fraction in HFpEF and HFmrEF

The heart failure track wrestled with why guideline-directed therapy still varied so widely between clinicians treating the same condition, even inside a system with a mature electronic health record.³ Nancy Albert, PhD, associate chief nurse for research and innovation at Cleveland Clinic and an advanced practice nurse in its ambulatory heart failure clinic, said the technology has not closed the gap.

“We have a sophisticated Epic, and we still have the same problem with variability,” she said. “So I don't think Epic is just the only answer.”

Panelists described a web of causes behind that variability, from patients skipping titration visits over transportation costs to physicians assuming another facility had already adjusted a dose. Phoo Pwint Nandar, MD, a heart failure cardiologist at MetroHealth, described checking medication costs with pharmacy before starting an inpatient on a new therapy, holding off on anything requiring prior authorization so patients are not left with a treatment gap, and choosing whichever option is cheapest and covered. Kyia Mountain, a nurse practitioner in the Cinema cardiometabolic clinic, noted that her institution's relatively recent Epic rollout had actually sped up its ability to build heart failure-specific tools, a sign that the technology's usefulness still depends heavily on how long a system has had to configure it. Rob Montgomery, an advanced practice provider at University Hospitals who also serves as an Epic physician lead, added that the vendor's own heart failure registry logic dates to 2012 and has not kept pace with newer guideline-directed therapies, leaving individual systems to build their own workarounds on top of it.

Earlier Identification in Alzheimer Disease

The Alzheimer disease track took the most direct aim at technology's limits. Blood-based biomarkers for amyloid pathology drew enthusiasm for their potential to replace costly PET scans, but Jonathan Haines, PhD, chair of population and quantitative health sciences at Case Western Reserve University School of Medicine, cautioned that any digital or remote fix collides with a basic access problem in Cleveland itself.

“I think I've got the numbers right. About a third of the population actually has access to the internet,” he said. “So online still is not going to work.”

Ann Nguyen, PhD, a professor at Case Western Reserve University's Jack, Joseph and Morton Mandel School of Applied Social Sciences, pushed the panel to look further upstream than the biomarkers themselves. “What we are missing from the conversation so far is who has access to these tests,” she said, noting that many people who could benefit from earlier diagnosis rarely engage with the health system at all. “I think it is also important to back up a little bit and think about, how can we make testing more democratic [and] more equitable, so that more people can have access to testing besides people who are regularly or semi-regularly engage with the health care system.” Nair added that blood tests alone do not resolve the access question. In Colorado, where she practices, only a handful of sites could run PET scans at all, and academic centers lost money on every scan because reimbursement had not kept pace with the cost of the tracer.

The Through-Line

Technology played opposite roles depending on the room. In rare glomerular disease, panelists wanted more of it: a simple proteinuria alert, they argued, could catch patients before irreversible progression. In heart failure and Alzheimer disease, panelists who already had sophisticated tools, a mature Epic build, and emerging blood tests said the technology had outpaced the access needed to use it. Albert's “Epic is not the only answer” and Haines' internet-access statistic both located the real bottleneck downstream of the tool: transportation, insurance coverage, broadband, and workforce capacity. Across all 4 rooms, the unmet need was rarely the clinical evidence. It was getting a confirmed diagnosis, an affordable prescription, or a specialist referral to the patient who needed it.

What It Means for Coverage

For payers and health systems, the through-line suggested utilization management itself is now a frontline barrier to outcomes, not a background administrative step. Prior authorization delays surfaced as a direct driver of GLP-1 discontinuation and of inpatient heart failure therapy decisions, and reimbursement gaps for biomarker testing and specialty referrals shaped who gets diagnosed at all across kidney and neurologic disease.

Content Coming From This Event

This article is part of AJMC’s coverage of the Cleveland Population Health Roundtable. Articles on the heart failure and rare glomerular disease tracks are available now: Cleveland Panel Weighs New HFpEF Pathway, Access to Finerenone and Panel Calls for Earlier Detection, Clearer Pathways in Rare Glomerular Disease. Stay tuned for additional coverage of the obesity and Alzheimer disease tracks from this event.

References

1. Rubino F, Cummings DE, Eckel RH, et al. Definition and diagnostic criteria of clinical obesity. Lancet Diabetes Endocrinol. 2025;13(3):221-262. doi:10.1016/S2213-8587(24)00316-4

2. Rovin BH, Barratt J, Cook HT, et al. Complement inhibitors and B cell-modifying agents for IgA nephropathy—a Kidney Disease: Improving Global Outcomes (KDIGO) commentary. Kidney Int. 2026;110(3):502-507. doi:10.1016/j.kint.2026.03.003

3. Kittleson MM, Panjrath GS, Bates K, et al. Management of heart failure with preserved ejection fraction: 2026 ACC expert consensus decision pathway. J Am Coll Cardiol. 2026;88(15):1817-1846. doi:10.1016/j.jacc.2026.06.018