January 07, 2020
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Losing the battle against heart disease

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by Dharmesh Patel, MD, MBBS, FACC, FACP, FASPC, FNLA

Dharmesh Patel

A recent Wall Street Journal article, titled “Heart disease roars back,” reported that one of America’s “greatest achievements” in the past 50 years had been “a huge decline” in death rates from heart disease and stroke.

No longer. The newspaper reported the death rate for CVD has fallen just 4% since 2011. That’s after dropping more than 70% during the previous 6 decades. Even the author notes that her June 2019 headline is a far cry from a 1996 Science headline that pondered “Heart attacks: Gone with the century?”

We’re far from it. In fact, CDC data show that CVD death rates rose 4% between 2011 and 2017 for people aged 45 to 64 years. It is not hyperbole to say that we are losing the battle against CVD.

There are many reasons why we’re losing this fight, as my colleagues reading this article know. Obesity and diabetes are on the rise, reaching epidemic proportions. Americans do not eat well and do not exercise enough.

But any clinician who has been working in medicine for more than a decade knows that the practice of medicine has really changed, and I can’t help but believe that how clinicians are forced to practice medicine today has contributed to the decline in patient outcomes that we’re currently seeing.

Access to treatments

Paradoxically, this challenge comes at a time when our understanding of the science of CVD and the options for medications and devices to treat heart conditions has never been greater. We have seen breakthrough therapies in recent years, and we are on the crest of a wave of new treatments that can change, and save, lives. But getting patients access to these treatments has become increasingly difficult. New therapies are frequently denied, switched or are otherwise out of reach for the most vulnerable heart patients.

Put simply: Patients are often not getting what the doctor ordered. And when they do, it’s usually because staff have dedicated hours to overcome the utilization management barriers that insurance companies erect.

Every clinician is familiar with prior authorization, where a therapy must be justified through additional paperwork before it is covered by a payer. There are other techniques, however, that keep patients from getting what the doctor ordered. Step therapy, also called “fail first,” is one example. It requires patients to fail on a less-expensive medication before insurance approves coverage for the drug prescribed by their physician. Nonmedical switching, when insurers force patients to change their medications because of cost instead of best care, is another problematic policy.

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Insurer policies that focus on short-term cost-cutting jeopardize patients’ health. They are driving up the overall cost of health care, too. It’s estimated that prior authorization alone costs the U.S. health care system between $23 billion and $31 billion each year.

Harmful policies

An FH Foundation study, published in Circulation: Cardiovascular Quality and Outcomes, demonstrates the harmful effect of prior authorization: It found that denial or abandonment of PCSK9 inhibitors led to a 16% increased risk for MI and stroke in patients with familial hypercholesterolemia or other high-risk conditions. Despite this alarming statistic, patients across the country are continually being denied coverage for PCSK9 inhibitors. Denial rates for PCSK9 inhibitors top 60% nationwide. The largest payer in Mississippi, where I practice, had a complete block on PCSK9 inhibitors until June 15 of this year. Meanwhile, MI and stroke account for more than one-third of deaths for Mississippians every year. Its position was indefensible and I’m thankful it finally changed its policy.

To clinicians who have been practicing for some time: You know well the barriers I’ve described are not specific to PCSK9 inhibitors. My patients are denied, switched and “stepped through” multiple medications for HF, high cholesterol and high triglycerides. Name the medication and there’s a barrier to access it. I’m sure you see it in your practice too.

To those who are newer in your practice of medicine: It was not always this complicated, especially in cardiology. Having worked in medicine for 20 years, I feel I have a good grasp of what therapies patients should be on. But the patient-physician relationship has been seriously compromised in recent years. Unless clinicians speak up, advocate for change and work to protect patient-centered care, we will become merely cogs in a giant health care machine, where patients are pigeonholed into standardized treatment courses that ignore the idiosyncrasies that make each patient’s situation unique.

It seems obvious, but it is important to highlight that utilization management policies are just that — policy. It’s important to point out because policy can be changed. And input from patients and providers can drive that change. That is why I serve as the president of the board of the Partnership to Advance Cardiovascular Health (PACH), a nonprofit coalition of patient and provider groups that advocate for patient-centered health policy specifically for heart patients. I encourage you to join us in our effort to put the patient — not the “cost” — back at the center of medical decisions.

If we are going to make transformational change and reverse the harmful trends in access related to care of our heart patients, we have to advocate for policies that support patient-centered care at all levels. It’s important work, and I would argue, part and parcel of being a top health care provider today.

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References:

Brown MS, et al. Science. 1996;doi:10.1126/science.272.5262.629.

Curtin SC. Trends in cancer and heart disease death rates among adults aged 45-54: United States, 1999-2017. National Vital Statistics Reports. 2019;68:5.

McKay B. Heart disease roars back. Wall Street Journal. June 22, 2019.

Myers KD, et al. Circ Cardiovasc Qual Outcomes. 2019;doi:10.1161/CIRCOUTCOMES.118.005404.

Partnership to Advance Cardiovascular Health. http://www.advancecardiohealth.org/. Accessed Dec. 6, 2019.

For more information:

Dharmesh Patel, MD, MBBS, FACC, FACP, FASPC, FNLA, is with the Stern Cardiovascular Foundation, president of the board of the Partnership to Advance Cardiovascular Health, president of the Alliance for Patient Access (AfPA), past chairman of medicine at Baptist Desoto Hospital, member of the Southeast board of the National Lipid Association and member of the Greater Southeast board of the American Heart Association. Patel can be reached at dpatel@advancecardiohealth.org.

Disclosure: Patel reports he is a consultant/advisory board member for Amgen and Janssen and speaker for Amarin, Amgen, Boehringer Ingelheim and Novartis.