Ty J. Gluckman, MD, FACC, FAHA, who is medical director of the Center for Cardiovascular Analytics, Research, and Data Science at Providence St. Joseph Health in Portland, Oregon, spoke at the 2022 Congressional meeting of the American Society for Preventive Cardiology in Louisville, Kentucky.
With health care costs in the United States already representing 20% of gross domestic product (GDP), every stakeholder in the system (patients, providers, pharmaceutical industry and payers) not only has a role to play in the curvature of the cost curve, but will also face what Ty J. Gluckman, MD, FACC, FAHA, has called the coming cost “tsunami” thanks to COVID-19.
Gluckman, who is medical director of the Center for Cardiovascular Analytics, Research, and Data Science at Providence St. Joseph Health in Portland, Oregon, addressed the 2022 Congress of the American Society for Preventive Cardiology (ASPC), meeting in Louisville , Kentucky, with a lecture, “Cost of Prevention—How Much is Too Much?”
The economic toll of atherosclerotic cardiovascular disease (ASCVD) is “staggering”, he said; it’s the biggest killer in the United States, “so it’s no surprise that it has substantial direct and indirect costs.”
Through 2018, the direct annual costs of CVD are $225 billion, and the indirect costs are even higher. One approach could be to look at ways to reduce those expenses, Gluckman said, or “one could have the opposite view, and [ask] how to invest more to be able to bend the risk curve and therefore mitigate the risk of downstream costs? »
Unfortunately, Gluckman said, the fallout from COVID-19 could create a “tsunami” in healthcare, according to a recent paper. The post-lockdown period will be marked by increased admissions for the indigent, increased costs to keep healthcare workers and an increase in the number of people suffering from cardiovascular events.
Already, Gluckman said, the loss of workplace wellness programs and lack of activity during the pandemic has triggered a rise in hypertension and obesity. He shared charts with data on these points and added, “The trends are quite worrying.”
Pre-pandemic results, based on a cohort enrolled in the MESA study, show that over a 10-year period, low-risk patients accrued less than $7,700 in direct costs, but high-risk patients could result in over $35,800 in costs.
Thanks to the pandemic, the United States should have more high-risk patients.
New therapies, higher OOP costs
A central balancing act facing cardiologists today is how to prescribe patients enough medication — and the right medication — without causing them to be unable to afford out-of-pocket costs.
“We have a range of drug therapies that aim to move the needle in the risk factors that we are addressing,” he said, noting that other speakers had discussed the need to use more, not less. , sodium glucose co-transporter 2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists.
In many cases, patients would benefit from multiple drugs, but OOP would be unaffordable.
As early as 2014, the American College of Cardiology and the American Heart Association offered guidance on how to approach the cost-value equation, but one of the main obstacles has been the lack of data to demonstrate cost-effectiveness.
In the class of SGLT2 inhibitors, for example, cost-effectiveness studies are being redone in light of clinical trials that show that drugs first approved to treat type 2 diabetes can also treat type 2 diabetes. heart failure and chronic kidney disease. A just-published study from Japan claims that, given all of their indications, SGLT2 inhibitors are cost-effective when initiated without metformin, a departure from long-standing first-line treatment.
Gluckman also noted that increasingly, clinical trials are segmenting how new therapies work in specific high-risk subgroups. This was seen in the FOURIER trial for evolocumab, a PCKS9 inhibitor; drug benefit managers had backed down from the initial price, over $14,500 per year, and imposed onerous pre-authorization requirements. Prices are now around $5,850 for these therapies, and some clinicians at the PHAC meeting report that they rarely meet with a refusal these days.
Although trials may report an average effect, for the individual patient, “there is no average treatment effect,” he said. “Instead, as many have suggested today, we should research our population to find out how we disproportionately use therapies, especially therapies that may be more expensive.”
Just as physicians should advocate for approval of therapies for patients who will derive the most benefit from them, they should withhold therapy if little benefit is seen. Such an approach will require cooperation between stakeholder groups, including industry and payers.
Gluckman ended with a call for better health plan design to ensure access not just to therapy, but to all high-value health services. “I think our insurance companies — our payers — bear a special responsibility in this regard,” he said, citing principles developed at the Center for Value-Based Insurance Design at the University of Michigan. (A. Mark Fendrick, MD, co-editor of The American Journal of Managed Care®, is director of the V-BID Center.)
Gluckman shared an excerpt from an article he co-authored on the ACC Leadership forum on this topic:
“While many insured patients with ASCVD are ostensibly ‘covered’, they often face high out-of-pocket payments, in part to ensure they have ‘skin in the game’. An unintended consequence of this cost sharing is that it indiscriminately limits the use of all clinical services, including those that are both high-value and low-value.
“Beyond certain preventative services, which are often exempt from deductibles, co-payments and coinsurance, current health plan designs do not provide similar access to many evidence-based therapies known to reduce risk. adverse cardiovascular events. Even for the most at-risk patients, where use is likely to have the most impact, these therapies paradoxically remain subject to traditional, non-values-based plan designs,” they wrote.
Small wonder, then, that adherence is compromised and “the promise of valuable care is lost to those who need it most.”
The prevalence and cost of cardiovascular disease will continue to rise, with “an end in sight,” Gluckman said. The benefits of prevention should therefore be “most fully realized in those at greatest or highest risk”.
With the increased availability of new therapies, more and better data is needed to inform the value discussion, so that the right patients receive treatment. “Finally, insurance schemes need to be redesigned to ensure access to low-cost, high-quality, easily accessible health care.”