Ryan Haumschild, PharmD, MS, MBA: We talk about early diagnosis, and I love the passion among everyone here that we need to get early treatment. We need to diagnose without a click and utilize these labs and leverage the information. I’m completely on board. I think, too, as we look to our payer managed care audience, we’re also looking at treating the patient but also stewarding health care expenses. One of the key things I’ve taken away here is if we have early detection, early treatment, we can decrease the progression of disease and potentially avoid some of those higher costs that are well known within end-stage renal disease. Dr Cohen, someone that’s got a lot of familiarity with cost-effectiveness and analysis, the question I have for you is, how can payers and providers ensure that CKD [chronic kidney disease] is being treated appropriately on the front end, reducing the need for some of those higher costs that come later in disease and even those exacerbations? [Are] there any strategies that you’d like to share or some things that we should be considering that we’re not?

Ken Cohen, MD: I think again, it comes down to how our health care system is structured. We predominantly exist in the health care structure that treats illness as opposed to prevents illness and progression. If you can shift accountability for cost of care to a physician or a hospital organization, it changes the paradigm. It then becomes the right thing to do to invest up front, to prevent things that may not have a quick time window.... For example, for type 2 diabetes, now we’re building a clinical decision support model for prescribing so that when a [primary care pediatric nurse practitioner] or [physician assistant] is prescribing to a patient with type 2 diabetes, it’ll look at all their comorbidities, it’ll look at their potassium, their A1C, whether they have an existing diagnosis of CVD [cardiovascular disease] or multiple CVD risk factors, and it will recommend the next best therapy. That has to be overridden so that the optimal therapy hopefully will be prescribed. Now, that’s expensive to do. Unless there is an ROI [release of information] to do that, thereby being accountable for a budget for a population, it’s hard to invest in that infrastructure. I think the solution is changing how we have designed our payment systems. I think ultimately, we will get better patient care when we allow physicians to make the next best decisions based on the entire budget for a population of patients and not on a fee-for-service world.

Ryan Haumschild, PharmD, MS, MBA: That that is a great point. Focusing on the value, how do we drive people towards the outcomes for reimbursement? I think that is probably the future of health care when I think about it. As the growing expenses continue to occur—and I think we’re going to see a huge focus on that as we’ve already have been in some of these accountable care organizations. Dr Nicholas, if you also can talk about the cost of care or maybe just the burden of…suboptimal treatment. A provider may select the right treatment, whether it be an SGLT2 [sodium-glucose cotransporter-2 inhibitor] or a GLP-1 [RA] [glucagon-like peptide-1 receptor agonist]. But nonadherence also impacts the economic burden because now we’re paying for a high-cost therapy [and] we’re not seeing the benefit. How do you contextualize that for the viewing audience as well as the importance of encouraging adherence in this patient population?

Susanne B. Nicholas, MD, MPH, PhD: Great question. Currently, there are over 800,000 individuals with kidney failure in the United States. That’s a lot of patients. When we think about that, [we’re] thinking about where a patient is heading. You really need to be more inclined to make that early diagnosis and to make sure that the prescriptions [are] written, [and] the patients are taking the medication. You really stick with that and communicate with the patient [in order] to find out what barriers might exist [that could] prevent the patient from being adherent to their regimen. I think that’s key. We’ve already talked about the impact of cardiovascular disease in our patients. Those patients who have advanced kidney disease—a majority of them die before they reach kidney failure. That’s important. Suboptimal care results in high mortality. We can’t afford it. Really, that’s the bottom line. Maybe we can implement some of the things that Dr Cohen mentioned in terms of these…and finding out where we could optimize care. But it’s something that I think needs to be very widespread—having that cognizance and that mentality that I need to make sure this patient does not die from heart disease by managing their chronic kidney disease.

Ryan Haumschild, PharmD, MS, MBA: Excellent. When we think about some of these high-cost therapies, sometimes it can be difficult as a payer when developing a medical policy. How do we make sure that we’re covering the right therapies, [while] also decreasing the risk of progression? I think sometimes as we design these medical benefits or pharmacy benefits, step edits and things can get in the way. I like to reference the example Dr Green mentioned earlier, in some patients that might have type 2 diabetes and chronic kidney disease might be in SGLT2 earlier, or if they have a cardiac predisposition plus CKD, how do we get them that SGLT2 earlier?… Dr Cohen, if you could comment on this, what are potential barriers that we see with medication utilization, and what can payers be thinking about as they’re designing these medical benefits or these policies to make sure the right patients get access to the right therapies early on instead of having to step through therapies where their condition potentially could get worse over time?

Ken Cohen, MD: Again, being on the provider side and not on the payer side, we’re not the ones within our organization who determine what these step edits are. You know, in the SGLT2 example, you could argue that most of those patients should be on cotherapy with metformin plus an SGLT2. That may not be the best example, but a good example would be eplerenone vs finerenone. Would there be a step that would suggest eplerenone would need to be used first? I don’t know. I haven’t seen that yet. You could argue that there’s rationale just based on cost, but unfortunately, the literature to answer that question hasn’t been provided. We don’t have head-to-head trials of eplerenone vs finerenone. We only have placebo vs finerenone. A lot of the times, the evidence that we need to make these decisions, frankly, isn’t available. When the evidence is not available, then health plans will default to the current evidence, and therefore they will use more expensive drugs. I haven’t seen step edits really be a major barrier to our patients being able to acquire drugs. Maybe with the exception of obesity and GLP-1 RA, wherein some health plans it’s just not a covered benefit. You know that’s a serious issue. But other than that, I don’t think that that’s the major barrier because frankly, an expensive drug will be used and in the next year all of our premiums will go up. The problem is value and are we getting value for what we’re paying? I think that’s really the major question.

John E. Anderson, MD: And one of the things I haven’t heard mentioned, even if the GLP-1 receptor agonist is covered in many of my Medicare patients, come donut hole time, about this time of year, it’s August, September, [and] we’re off of it until January.... We talk about persistence and adherence and finding those gaps in therapy. It’s an issue that’s difficult to address in a primary care world. I imagine endocrinology world as well.

Ken Cohen, MD: Well, the donut hole will get better next year with the Inflation Reduction Act because that’s been a significant improvement. But even on the commercial side, just the coinsurance, even if it’s an approved drug, can be prohibitive.

Ryan Haumschild, PharmD, MS, MBA: But it is interesting, especially to work up patients for financial toxicity. You know, some of the [electronic medical records] actually have a social determinant of health wheel, where you can evaluate a patient based on food insecurity, transportation vulnerability, [and] financial toxicity. But we’re even seeing some payers now manage a benefit where they’re putting more coinsurance on the patient and driving that patient to pay the out-of-pocket expense, go to grants and foundations, or get pushed to the free drug program with the manufacturer. But we’re not sure how long that’s going to last as manufacturers starting to tighten down some of those qualifications. I think you’re correct, working up a patient, understanding…their financial and economic background and making sure they can have treatment throughout the continuum is going to be important and to make sure that if there are any programs, we can get them enrolled in, like low-income subsidy to complement the Inflation Reduction Act. That’s going to be important as well.

Transcript is AI-generated and edited for clarity and readability.