Q&A: CKM Care, IRA Policy, and Specialty Silos with Rishi Wadhera, MD, MPP, MPhil

Measuring cardiometabolic outcomes has long defaulted to siloed, disease-specific metrics.

Frameworks like cardiovascular-kidney-metabolic (CKM) syndrome, advanced by the American Heart Association, challenge clinicians to recognize cardiovascular disease, metabolic syndrome, and kidney disease as a pathophysiologically interrelated syndrome requiring integrated management rather than sequential single-disease treatment.¹

Cross-specialty prescribing has historically lagged behind the evidence. SGLT2 inhibitors and GLP-1 receptor agonists carry proven benefit across cardiovascular, renal, and metabolic domains, yet their use has long been siloed within endocrinology.

The CKM framework is accelerating a shift: cardiologists and nephrologists are increasingly prescribing across traditional specialty boundaries, with accountability for optimal therapy now expected across all clinicians managing these patients.¹

The policy environment shapes both the ceiling and the floor of what the care cascade can achieve. The Inflation Reduction Act introduced Medicare drug price negotiations and a $2,000 annual out-of-pocket cap, 7 of the first 10 drugs selected for negotiation treat cardio metabolic or cardiovascular conditions. Offsetting this tailwind, the recently passed HR 1 is projected to cut $1 trillion from Medicaid, with the Congressional Budget Office estimating approximately 16 million people will lose health coverage, directly threatening medication access for patients managing hypertension, diabetes, and dyslipidemia.¹

At the 10th Annual Heart in Diabetes Meeting, Rishi Wadhera, MD, MPP, MPhil, associate professor of medicine at Harvard Medical School and associate director of the Smith Center for Outcomes Research at Beth Israel Deaconess Medical Center, continued his conversation with HCPLive, addressing performance metrics, specialty silos, and the policy forces reshaping the cardio metabolic care cascade.

Q&A: CKM Care, IRA Policy, and Specialty Silos, With Rishi Wadhera, MD, MPP, MPhil

HCPLive: Do current performance metrics adequately capture integrated cardio metabolic risk, or do they incentivize siloed disease management?

Rishi Wadhera, MD, MPP, MPhil: We can't improve what we don't measure, so measurement — though imperfect — is an important first step toward improving screening, treatment, and control of cardio metabolic risk factors. Frameworks like cardiovascular-kidney-metabolic syndrome, or CKM syndrome, have moved us in the right direction.

They recognize we can no longer treat these conditions in silos — cardiovascular disease, metabolic syndrome, and kidney disease all amplify one another and are interrelated from a pathophysiologic standpoint. As clinicians, we need to think about the syndrome and the conditions within it together. The AHA frameworks released recently are trying to accomplish exactly that, pushing clinicians and health systems to manage these conditions as a whole rather than in isolation.

HCPLive: Has cross-specialty prescribing responsibility for SGLT2 inhibitors and GLP-1s started to break down in this new era?

Rishi Wadhera, MD, MPP, MPhil: Frameworks like CKM syndrome are breaking down barriers and silos between specialties. As clinicians, collectively, we need to take responsibility and be accountable for care delivery and optimal treatment for our patients. We are seeing those barriers broken down. Cardiologists are increasingly prescribing therapies for obesity and kidney disease that also protect the heart. Nephrologists are doing the same. That is exactly how we should be practicing and delivering medicine, and frameworks like CKM have helped drive that.

HCPLive: What policy tailwinds and headwinds are most relevant to the cardio metabolic care cascade right now?

Rishi Wadhera, MD, MPP, MPhil: When we think about the cardiometabolic care cascade, we have to think about policy tailwinds and headwinds.

One significant tailwind is the Inflation Reduction Act — major legislation that for the first time in the country's history directly addressed high and rising prescription drug costs. It caps Medicare out-of-pocket drug spending at $2000 per year and begins to negotiate prescription drug prices with manufacturers. Seven of the first 10 drugs selected for negotiation treat cardio metabolic risk factors or cardiovascular conditions. When you think about access, affordability, and adherence across the care cascade, the IRA has real potential to get therapies to patients.

The headwind: the recently passed HR 1, the One Big Beautiful Bill Act, will deliver $1 trillion in cuts to Medicaid. The Congressional Budget Office estimates about 16 million people will lose health insurance coverage as a result. For the cardio metabolic care cascade, this could meaningfully erode our ability to help patients access therapies, adhere to them, and achieve control of hypertension, diabetes, and high cholesterol.

Editor’s Note: This transcript has been edited for grammar and clarity using artificial intelligence tools.

References

1. Ndumele CE, et al. 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome. Circulation. 2026. doi:10.1161/CIR.0000000000001453

2. American Heart Association. First-ever guideline on cardiovascular-kidney-metabolic syndrome issued. American Heart Association. Published June 9, 2026. Accessed June 24, 2026. https://newsroom.heart.org/news/first-ever-guideline-on-cardiovascular-kidney-metabolic-syndrome-issued

3. Connor Iapoce. HHS Targets 15 Drugs for Medicare Part D Negotiations, Including Semaglutide. Hcplive.com. Published January 17, 2025. Accessed June 24, 2026. https://www.hcplive.com/view/hhs-targets-15-drugs-for-medicare-part-d-negotiations-including-semaglutide