Paradigm Shifts in Lipid Lowering - Episode 17

Shared Decision Making and Value-Based Care

Keith C. Ferdinand, MD

Tulane University School of Medicine

,
Linda Hemphill, MD

Massachusetts General Hospital

,
Dean Karalis, MD

Thomas Jefferson University Hospital

,
Norman Lepor, MD, FACC, FAHA, FSCAI

Cedars-Sinai Medical Center

,
Manesh Patel, MD

Duke University School of Medicine

Importance of shared decision making and value-based care when making treatment decisions for cardiovascular patients.

Keith C. Ferdinand, MD: Linda, I’m going to ask you about value-based care and how that will affect our use of agents going forward. It’s a concept, but I don’t know how it’s been manifested thus far throughout the country. I don’t really feel that in my practice in New Orleans. But before we do that, let me make 1 point. Even if we have value-based care, we’re going to have to talk to our patients and do what’s called shared decision-making. The days are gone where we could scribble in our bad handwriting something on a prescription pad and say, “Take this to the pharmacy. This is your drug. I want you to take it.” 

We have to discuss with patients the medication, the indication, and some of the potential adverse effects. How bad are those adverse effects? Are they intolerable? Are they going to be short-lived? Is this something I really need to do, Doc? If we don’t do that, they’re going to take their prescription. They’re going to smile and never take the medication or stop—about half of them—with statins after 1 year.

That’s my take on shared decision-making. We’ve got to do it. Patients demand it. They’re going to get information from other sources or, even worse, misinformation. Linda, value-based care: Is it a reality? Should we be concerned? How is that going to affect our treatment of high-risk patients with hypercholesterolemia?

Linda Hemphill, MD: You nailed it, Keith. The clinician-patient discussion is critical, having the patient understand how important this is to their future health. Honestly, the makers of the monoclonal antibody inhibitors of PCSK9 have had wonderful programs to support our Medicare. The whole cost thing is mainly in the Medicare population.

In the ideal scenario, both companies making the monoclonal antibodies have a support program and the medication is provided for free. I really have to give them kudos for doing that.

Keith C. Ferdinand, MD: But I think you will agree that inclisiran is investigational. But if it comes on the market and does not take into account access issues and affordability issues, it’s going to have the same problem that the PCSK9 inhibitors had early on, the problem of uptake and actual use. Regardless of how great the studies are that Norman Lepor has done with this particular agent, how good is an agent if it’s not going to be used? Would you agree with that?

Linda Hemphill, MD: Absolutely, yes.

Keith C. Ferdinand, MD: All right, anyone else?

Manesh Patel, MD: I was going to share that in the value-based world, we have gone through a few pilot programs—we call them these bundle payment care initiatives with the Medicare group. We agree on a price for a patient from PCI [percutaneous coronary intervention] to 90 days, or bypass to 90 days. More of these things are going to be coming.

If we could figure out a way to really engage that process—if I’ve taken the time to put a several-thousand-dollar stent in, or a procedure in a patient who’s had a heart attack, if I could inject that patient on the catheterization lab or make sure they got an injection before they left, whether it was every 2 weeks or every 6 months—that would certainly change the care paradigm and probably would become a way in which we would demonstrate effectiveness for that patient.

Those are going to be places in secondary prevention where we have opportunities—at the time of events, before we get them to clinic or right after, when we get them to clinic and we’re through cardiac rehab—and we’ll demonstrate some of the best value.

Keith C. Ferdinand, MD: Dean, do you have any views on that?

Dean Karalis, MD: Yeah, value-based care is here and it’s going to become even more common in our practices. As Manesh said, we’re already working with bundle payments. As physicians we’re being graded on the quality of care, blood pressure control, lipid control, etc. So it’s here.

Most physicians and clinicians know the guidelines. The question is, how do we translate those guidelines and implement them in real-world practice? That’s the challenge we all face. Some of that answer is in technology. We’ve got to be careful how we use it with our electronic medical records but prompts and cues in the electronic medical record address physicians’ issues but also patient issues. That’s where the technology can help, addressing both physicians’ issues and patient issues.

Linda said it: Right now, most patients with commercial insurance can get a PCSK9 inhibitor without much of a preauthorization process. Yet we’re still underutilizing them in real-world clinical practice. Can we use prompts or cues? Can we use technology to help physicians recognize when they should be using these agents? Then we use that same technology to help educate and move the discussion with the patient about why physicians are choosing these medications.

Keith C. Ferdinand, MD: If you enjoyed watching this HCPLive® Peer Exchange, if you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your in-box. Thank you very much for listening to this program.

Transcript Edited for Clarity