HJBR Jul/Aug 2024

multiple chronic conditions including hyper- tension, diabetes, CKD, and all forms of CVD. Not So Simple Though But as in all things related to U.S. healthcare, it is not currently that simple. Expense of these drugs and clinically unwarranted practice pat- tern variation both come into play. While ARBs and ACE inhibitors have been generic and rela- tively inexpensive for many years now, they are still not being routinely optimized to the maxi- mum dose possible in patients with elevated UACR. And the SGLT2 inhibitors are not yet generic and still priced at around $400 to $500 per month. The price of finerenone, mean- while, averages $600 to $700 per month and is many years away from being available in a ge- neric formulation, which typically precedes any significant drops in price. And finally, as of May 24, 2024, an article published in the New Eng- land Journal of Medicine now demonstrates the efficacy of semaglutide (better known as Ozempic) in improving CKD outcomes as well, at a cost of nearly $1000 per month. Therefore, if patients develop CKD at an age less than 65 years while still insured by a commercial payer, their ability to gain access to these medications is limited by the coverage decisions of com- mercial insurers. These coverage decisions are influenced by multiple factors including their ability to negotiate pricing discounts, their ability to extract rebates from the pharmaceu- tical manufacturers (which typically happens in partnership with a pharmacy benefits manager and can keep prices for these drugs elevated), and their willingness to invest in the long-term health of their members when many of their members cycle in and out of their plans — meaning that they are sometimes hesitant to bear financial costs that will only yield a return on investment years down the road when they no longer bear the risk for total cost of care. Regarding clinically unwarranted practice variation, we have asserted in prior articles that it can take as long as 17 years for clini- cal evidence to become fully translated into actual clinical practice. That data was first demonstrated with the use of ACE inhibitors in patients with heart failure. Even now, a re- cent study looking at patients with heart failure with reduced ejection fraction who were pre- scribed evidence-based drugs in the absence of contraindications to those drugs revealed some abysmal performance with the following results: 68% of patients eligible for ACE/ARB/ ARNI were actually prescribed one, and while 93% of patients eligible for beta-blocker were prescribed one, only 32.5% of patients eligible for an MRA were prescribed one, and, even worse, only 4.6% of patients eligible for an SGLT2 were actually prescribed one. 2 Studies like this one confirm what is already well known in healthcare — that significant variation exists among providers and requires them to be up- to-date with the latest knowledge in the man- agement of chronic conditions. The recently published 2024 guidelines on the management of CKD strongly suggest SGLT2 inhibitors in any patient with an eGFR < 60 mL/min and a UACR > 30, but I suspect that very few provid- ers are currently aware of these recommenda- tions, thereby robbing their patients of the very favorable benefits of this class of medications. Making it Simpler Systems that deliver health are constantly striving to make the complexity of healthcare simpler for their providers and their patients. An example would be the investment in digital solutions that help improve the reliable deliv- ery of evidence-based care for their patients. Performance in the management of hyperten- sion and diabetes control rates for my own system’s digital solutions exceeds 90% control rates for both across a large population while also reducing healthcare disparities among tra- ditionally marginalized populations who suffer from impaired social determinants of health. Digitizing the management of CKD is therefore next on the agenda because it becomes an ex- tension of ensuring the routine and reliable de- livery of evidence-based care for chronic condi- tions. Reducing clinically unwarranted practice variation is both a goal and an outcome of this type of program development. Not only is it the right thing to do for our providers and “These traditional health systems are quick to assert that Medicare reimbursement fails to cover their total cost of care for these patients, all the while ignoring the potential to innovate by figuring out how to generate a profit margin on these patients by doing something almost unheard of in traditional healthcare — measuring and improving health outcomes.”