Systemic Change to Support Care of Patients With HF

Cardiologists provide an overview of the efforts needed to drive systemic change to support care of patients with HF and the appropriate use of SGLT2 inhibitors.


Neil Minkoff, MD: Let me follow up on that and drill down a bit. You talked about a need for systemic change, in terms of uptake. There are a couple of things that that opens up. Rather than be very prescriptive with the question, I’m going to throw a couple of topics out there that I’d like to understand from both the provider and payer perspective on this systemic change. We’ve been talking about it from a cardiology point of view. What are the roles of endocrinology and primary care? Are those doctors going to be blocked from usage of these drugs? Will they be prescriber-dependent in terms of the specialty and level of training? What are you doing, in terms of the different perspectives, what are you doing to educate other clinicians about changing the standard of care here?

Steven Nissen, MD: You make a very good point, which is that, and please correct me if I’m wrong, Jaime may have better data than any of us have. Most patients with diabetes in America are not taken care of by either an endocrinologist or a cardiologist. They’re being cared for by an internist or a family practitioner. We may need to do a better job of speaking to those audiences. They have professional societies. They have meetings, and they have other things, but we have to be careful that we’re not just talking to each other. We have to talk to the people who are actually on the front lines caring for these patients, and that’s where clinical inertia is strong. I’d be interested in Jaime’s comments about this. Am I right that diabetes is mostly being treated by primary care physicians?

Jaime Murillo, MD: Yes, you’re absolutely right about that. You touched on something that is close to my heart. I think all of us recognize that a lot of the work that we do, let’s say as cardiologists, can be perfectly done by the team approach to care. In a fee-for-service environment, you have a cardiologist or an endocrinologist seeing every patient in the office because that’s the only thing that pays. What if engage, like many ACOs [accountable care organizations] do, for instance, a cardiologist or endocrinologist working closely with the primary care community to say, “Just call me. I’ll give you directions. I’ll educate you.” At the end of the day, we’re all together, and what really matters is that we keep this person out of the hospital, they have a better quality of life, and that we prevent them from developing kidney disease. That’s the winning formula. We need to avoid that compartmentalization of care that we have today, because it’s incentivized by our fee-for-service system. The moment we say, “Everyone wins in this,” that’s when we’re going to see that collaboration.

Neil Minkoff, MD: Clarification question: Is that for patients with diabetes and heart failure, or just all heart failure patients?

Jaime Murillo, MD: I think Dr Nissen was asking about diabetic patients, in general, being taken care of mostly by primary care physicians.

Steven Nissen, MD: Yes, right. But I would say that the same thing is true for people with heart failure. We have a group of heart failure doctors at the Cleveland Clinic. They’re very good, but mostly it’s primary care that’s taking care of it. It’s true for both of these. Collaboration is a wonderful idealistic goal, but I’m going to say that it’s pretty challenging. I don’t know how many patients the average primary care physician sees a day, but it’s a lot, and we’re all under that time pressure, as well. This cross-disciplinary care takes time. It’s not necessarily paid for. We all try it when we can to get on the phone to our colleagues and say, “I saw your patient with X, Y, or Z, and I’m making these recommendations,” but it is hard to manage that collaboration.

I wanted to make one additional point. As you said, Nihar, we can use the EHR [electronic health record], and I agree with you completely. For some diseases, we now have pop-ups. When a patient has a constellation of signs and symptoms, something pops up on the screen that says, “Have you considered X, Y, or Z?” or, “Why is this patient not on an ACE [angiotensin-converting enzyme] inhibitor?” We have to leverage the power of the EHR much more effectively to manage this problem of the underutilization of effective therapies.

Nihar Desai, MD, MPH: That is a key point, that we have systematically underinvested in doing real implementation science. What are the elements that drive adoption of high-value therapies? How do you engage with providers? How do you use the EHR? What do patients want? What kind of shared decision-making do we have to put in place to get to that system that we all want? Relatedly, from a system-level perspective, there has to be some reformation in our quality measurement. If your quality measures are still around blood glucose and A1C [glycated hemoglobin], that reinforces this mindset of, “All you need to do is lower the A1C, and you can use 1 of these 7 different things that are available to you,” versus, “How do you improve outcomes for the patient?”

The quality metrics have to incentivize things that are very well-aligned with clinical outcomes, and, relatedly, the payment system has to do that, too. We’ve all touched on this. If you got to a new system where you were incentivized to take care of a population of patients, and if the patient did better, then everyone did better, that would enable the use of high-value therapies, even if the drugs cost a little bit more. But if the total cost of caring for that patient was dramatically reduced, then you would create a milieu where the patient wins, the pharmaceutical manufacturers that are developing high-value therapies potentially win, and the health systems, providers, and payers win. That’s what we’re going for. That’s the real potential of the SGLT2 [sodium-glucose cotransporter-2] inhibitors. You can get to that win-win-win scenario because they’re so effective.

Neil Minkoff, MD: Would that be what drives earlier adoption in heart failure, independent of diabetes?

Nihar Desai, MD, MPH: Neil, absolutely. For us, if you think about our ACO patients, the patients who are in the bundled payment program, and you have an intervention that reduces the risk of rehospitalization by 25% or 30%, that’s an incredibly high-value intervention for those patients. The patients love it because they get to be at home and carry on with their lives. The providers are delivering best evidence-based therapy, and the health system is winning because it’s a novel idea. When the patient does better and they have better outcomes, you’refinancially rewarded for that, too.

Neil Minkoff, MD: Great. Are there any other comments before we start to move on?

Steven Nissen, MD: I have one more last comment on Nihar’s point. The cost of 1 heart failure hospitalization can pay for an awful lot of drugs for an awfully long time. Add it up. Maybe Jaime can tell us what the average cost is for a heart failure hospitalization now in America. It’s a lot of money.

Jaime Murillo, MD: Yes, it is a lot of money. Obviously, it depends on where you are, and so on. But I will throw a number out there: $22,000 is not unreasonable.

Neil Minkoff, MD: Yes, the Medicare range is between $20,000 and $25,000.

Steven Nissen, MD: That’s an incredible amount of money. If you look at the cost of drugs like SGLT2 inhibitors, you have a value proposition here that’s worth thinking about.

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