Barriers and Solutions for Lipid Management in Clinical Practice

An expert panel discusses challenges and provides solutions to managing patients with hypercholesterolemia.

Erin D. Michos, MD, MHS, FACC, FASPC: Alison, you’re in a very busy cardiology clinical practice. With a lot of these barriers we face, with co-pays and prior authorizations, what’s your approach in trying to overcome some of those barriers? Do you have advice for other practices?

Alison Bailey, MD, FACC: It’s important. What Bob said is probably the most important thing we can take away: you have to have bidirectional communication with other members of the care team. Sometimes physicians, other nurse practitioners, and PAs [physician assistant] are afraid to start a medicine because they’re afraid it will insult another member of the team—the cardiologist, the endocrinologist, the primary care doctor. I don’t think that ever happens. I’m glad when an endocrinologist starts a medicine in 1 of my patients. I also have a large heart failure practice. We do a lot of SGL2 inhibitors. I don’t think anybody ever calls and says, “I’m sorry you tried to help this patient.” That’s the first key: to do the right thing for the patient that’s in front of you.

It’s important to have templated clinic notes, like for PCSK9 inhibitors. When they first came out, they were challenging to get for our patients. If you had that templated note and you knew how many statins they had failed, what the adverse effects were, what their current LDL [low-density lipoprotein] is, their initial LDL, then your nurse or whoever helps you with prior authorizations could easily go through and do that. It’s the same thing with SGLT2 inhibitors, GLP1 receptor agonists, and some other drugs outside the lipid realm. We’ve done the same things with templated notes. We know what our prescribers or insurers need to get that prior authorization.

The ACC [American College of Cardiology] and other professional societies are working on prior authorization reform. That’s important too because that takes a lot of our time. We know these medicines work, and our patients should have access to medications. That probably requires more than what we can do with prior authorization in our offices. It requires reform on a higher level.

Jorge Plutzky, MD: It’s relevant for people in practice who say, “I’m not in an academic setting. I’m not going to have all those resources.” Consolidating expertise in the process can help with picking someone in your practice—an admin or someone working with patients—and let that 1 person handle your requests and your authorization. They very quickly come up to speed and help facilitate instead of asking everyone to do it piecemeal. It’s the same thing with advanced practice providers who can do titrations, spend more time with patients, and often have a very good relationship with them to create a rationale to push on. You need combination therapy, you’re at high risk, and we want to keep you out of trouble. It’s helpful that consolidating integrates efficiency for physicians, who can contribute to the inertia, either because they’re busy or the next patient is waiting. Here comes that flood of things to do to parse that out to people who can help move the ball down the field.

Erin D. Michos, MD, MHS, FACC, FASPC: Bob, do you have any tips about overcoming a nursing practice?

Robert Busch, MD: The prior authorization is the bane of our existence other than the electronic record and pointing and clicking. Many specialty pharmacies—you can find 1 in your community, like a hospital-based 1—have prior-authorization people who specialize in that. They know all the buzzwords and everything that’s needed. We’re very spoiled working in a medical center. They have 2 people in our practice, and it’s their entire job to do the prior authorizations. If it’s the nurse, who’s not usually doing it, they might find other tasks that are more interesting and more patient focused. Remember, helping the patient get the drug approved is a key obstacle, especially with any nonbranded drug—GLPS, SGLT2, PCSK9. Whatever it is, get that drug to the patient. Usually, that can be accomplished with someone who’s good at the prior-authorization process.

Erin D. Michos, MD, MHS, FACC, FASPC: There are some patient-assistance programs. Some companies have coupons to get discounts for medications. It’s important to be familiar with those and to reach out to the companies for these patient-assistance programs.

Transcripts edited for clarity

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