Multidisciplinary Management of Cardiovascular Disease

Cheryl Allen, BS Pharm, MBA; Bryan Bray, PharmD, CPP; Jeffrey Dunn, PharmD, MBA; Jennifer Reiter, PharmD, BCPS, BCACP, BCADM; and Peter L. Salgo, MD, provide perspective on the collaborative multidisciplinary management of cardiovascular disease.

Peter L. Salgo, MD: You’ve been poking at the edges of this issue, which is cardiovascular disease and the implications of this disease for payers. What percent of all the healthcare dollars is spent on this?

Jeffrey Dunn, PharmD, MBA: Probably 25% to 35% of the overall healthcare dollars are somehow related to cardiovascular disease.

Peter L. Salgo, MD: So, we’re talking billions of dollars.

Jeffrey Dunn, PharmD, MBA: That’s huge, exactly. But, again, I think there’s less emphasis on the pharmacy side right now. It’s the medical side, and it’s the link with the comorbidities that we’ve been talking about—diabetes and weight. I mean, if you combine those disease states, this is really an epidemic, so we have to do a better job. The implications are, we have to do everything we can from a payer perspective to address that, because payers working with providers are in a very unique position because we have the data. We know what the patients are doing. We know if they’re refilling their medications. We know what they’re doing. Again, it’s building out and making sure you have really good therapy management programs—that you have very good disease management programs that are different than the traditional care management or disease management programs. Again, it’s more interventional.

I think the other trend is that a lot of people are moving away from just the traditional longitudinal disease management and are trying to focus more on the interventional component. It’s looking at data. It’s looking at claims to see if they’re not seeing a doctor, if they’re missing medications, and if they have other things going on, and trying to predict if they’re heading to an event and reaching out beforehand (because it’s much easier to prevent than it is to treat).

Peter L. Salgo, MD: What I hear here, which is fascinating to me as a clinician, is the assumption of the clinicians in this world is that they’re providing care and you’re funding it. But what I’m hearing from you is more engagement than that. You’re looking at folks proactively. You’re looking to see who’s involved. Do you feel that from the managed care perspective, you can actually manage healthcare as opposed to just pay for it? What do you think?

Jeffrey Dunn, PharmD, MBA: Well, I’m biased.

Peter L. Salgo, MD: I know you’re biased. What do you think?

Bryan Bray, PharmD, CPP: I think you can. I come from a primary care setting that’s a private practice. There’s busy physicians, and what they simply do is they see 30 patients a day. They prescribe a statin, give it to the patients, and send them out the door. That’s not managing their care. I think the predictive modeling is important so we can try to predict those patients who are going to be at risk for high-cost healthcare, whether it be admissions to hospitals, or emergency rooms, or what not, and manage that care.

Jeffrey Dunn, PharmD, MBA: When you’re looking through their drug profiles and you’re noticing things, it’s also that communication back to the provider—closing that loop. That’s the key, and I think that’s where a lot of people struggle.

Peter L. Salgo, MD: But is there buy-in from the clinician side? In other words, I understand what you’re trying to do, but when you call, do you actually call physicians and say, “I saw that Miss Jones didn’t refill this?”

Jeffrey Dunn, PharmD, MBA: Absolutely.

Peter L. Salgo, MD: What do the physicians say?

Jeffrey Dunn, PharmD, MBA: I think a lot of it’s driven by ACOs (accountable care organizations)—the patient-centered medical home and changes in the healthcare delivery system over the last 5 or 10 years. I think there is a lot more interesting collaboration because the providers realize that they don’t have the resources. We’re not practicing medicine. We’re not telling them what to do. It’s consultive. It’s collaborative.

Cheryl Allen, BS Pharm, MBA: I think that the more we integrate the delivery network, the more we’ll see that collaboration not only focusing in on pharmacy claims but, as you pointed to, medical claims data. And looking, 360 degrees, at what’s happening to that patient, we’ll be able to address total medication and therapy management.

Jeffrey Dunn, PharmD, MBA: And part of that is the spreading of risk. So before, really, players/employers were the ones that bore the brunt of medical costs. Now, we’re trying to figure out how we get the pharmaceutical side in that. We’re figuring out how we get providers into that. So, as risk changes a little bit, the incentives become more aligned. And I think that’s what’s opening the door for us to collaborate better with providers.

Bryan Bray, PharmD, CPP: I agree. In our practice, being part of an ACO (that’s important, now, because we have quality measures we have to meet), if we don’t meet those measures, it affects our reimbursement. So, from that standpoint, it affects it big time. The collaboration is a lot more open than it used to be. Before, sometimes, it could be intrusive in a busy day, and I don’t think it was viewed upon that, at least in the private practice I’m associated with.

Peter L. Salgo, MD: I think, as a clinician, if I were in an office seeing all these patients, I’d like somebody backstopping me. I’d like that phone call coming in, let’s say, at 5, or whenever we come in, saying, “We checked your list of patients. Miss Jones didn’t renew. Mr Jackson didn’t do this. Maybe you want to go back and have a look.” I think that would be great. Are the physicians really buying it?

Jeffrey Dunn, PharmD, MBA: It’s across the board.

Peter L. Salgo, MD: Who wouldn’t want help? Who doesn’t want help?

Jennifer Reiter, PharmD, BCPS, BCACP, BCADM: We actually have taken it almost a step further—having a company that’s doing a lot of this leg work, giving us the data, and then using people like me who are integrated in the practice to relay the message to the physicians. I’ve worked with these physicians for several years, and I bring recommendations to them, firsthand, instead of via fax or via phone, and those things are working.

Peter L. Salgo, MD: So, we’re living in Nirvana now. Everybody who has hypercholesterolemia is getting treated. Everybody is on the right drug, or not. What population of people, in this country, don’t have their lipid levels under control right now?

Bryan Bray, PharmD, CPP: Well, I think speaking from a private practice standpoint, probably the biggest ones I see, of course, are your noncompliant patients, which we discussed. But also, one group is your statin-intolerant patients. So, we have a fairly large population, maybe more so than what the literature would indicate that it actually occurs. And maybe some of that’s fear, patient education, or that type of thing. But those patients that are statin-intolerant have difficulty meeting their goals.

And the other population I think about are the patients that start with a really high low-density lipoprotein. Maybe they have, already, advanced cardiovascular disease. Maybe it’s familial hyperlipidemia. Those patients are difficult to meet their goals, but maybe they’re getting treatment. I think those patients, statin-intolerant patients that are noncompliant, are a big patient population that I see that are not getting treated appropriately. Also, the other thing is it’s a symptomless disease. It’s an asymptomatic disease, and that’s one of the most difficult diseases to get patients to be compliant in.

Peter L. Salgo, MD: Is it that people aren’t getting screened? In other words, a patient comes to your doctor’s office. It’s likely the doctor should be screening for hypercholesterolemia. Are you saying that the doctors aren’t screening? The patients aren’t coming in? Or once diagnosed, patients aren’t doing it?

Bryan Bray, PharmD, CPP: No, I think they’re being screened. In our practice, they’re getting screened. We’re knowing what their low-density lipoproteins are, what their goals are, and so forth. It’s just getting the patient to actually take therapy. Whether it be a fear (maybe they’ve heard their neighbor had an adverse reaction to a statin and they’re not going to take it), or whether they’ve truly had an adverse reaction to statins.

Peter L. Salgo, MD: I just want to throw this one question in because, in my clinical experience (which is hospital-based), the number of people who have actually had a problem with the statins is quite small. But the number of people who claim to have had a problem is quite large.

Bryan Bray, PharmD, CPP: Exactly.

Peter L. Salgo, MD: So, why this disconnect?

Jennifer Reiter, PharmD, BCPS, BCACP, BCADM: Some of it, I think, is the way they’re educated. We educate people because we want them to know the serious adverse effects that could happen. But then, they think they’re having an adverse effect. And I always educate students. We hear it’s a small part. Probably 30% of the people I see actually complain of some sort of myalgia.

Peter L. Salgo, MD: That’s not small.

Jennifer Reiter, PharmD, BCPS, BCACP, BCADM: No, not small at all.

Peter L. Salgo, MD: That’s not small at all.

Jennifer Reiter, PharmD, BCPS, BCACP, BCADM: So, what we’re taught is a small adverse reaction in practice is much larger. Whether it’s real or not is the question.

Peter L. Salgo, MD: It’s a serious problem—not just adverse effects from statins, but the whole rolling patients into an effective treatment program is big.

Bryan Bray, PharmD, CPP: The other thing that’s an issue is just consistent application of the guidelines. We had the ATP III Guidelines. Now, we have the American College of Cardiology/American Heart Association Guidelines. So, it depends. The consistency of the guidelines being applied to practitioners’ practices, I think, is an issue as well, and may cause fragmented care. I see that a lot on the private practice side. The patient goes into the hospital, something happens, they get a stent, and they come back to the primary care practice. The cardiologist that’s managing the stent really didn’t manage their lipids, so there’s a little bit of fragmented care and I think that leads to issues.

Peter L. Salgo, MD: There are things in a silo.

Jeffrey Dunn, PharmD, MBA: That’s an interesting point, because the guideline change was not insignificant, and I think a lot of providers still manage to a low-density lipoprotein. But, the way the guidelines are written, it’s a little bit more difficult to identify a patient and probably manage a patient to a goal.