Dr. Dan Blumenthal is the Chief Quality Officer of Cardiovascular Associates of America. He is also a practicing board-certified non-invasive cardiologist and an instructor at Harvard Medical School.
Dr. Blumenthal joined the show to discuss exciting topics like:
– Cardiovascular procedures in the ambulatory surgery center.
– Patient adherence (not compliance!) in value based care arrangements.
– How GLP-1 agonists (like Ozempic) can be a miracle for the right patients under the care of their physician.
– Strategies to lower the risk of cardiovascular and metabolic diseases across patient populations while remaining mindful of social determinants of health.
We also covered some of the exciting use cases for AI in healthcare and how they can/will positively impact patient outcomes.
Click to expand and read this episode's transcript.
[00:00:00]
Erik Sunset: All right. Hello and welcome back. I’m Erik Sunset, your host of the DocBuddy Journal. Here at DocBuddy, of course, we deliver healthcare solutions that take the pain and cost out of broken workflows like with our Op Note solution, which gives ASCs and their affiliated clinics the power of instantly generated operative reports.
Erik Sunset: You can learn more about that at docbuddy.com and I’m really excited to reintroduce Dr. Dan Blumenthal to you, our listeners. He is the Chief Quality Officer of CVA USA, and that is the Cardiovascular Associates of America.
Erik Sunset: And with all that, Dr. Blumenthal, thanks again for joining
Dr. Blumenthal: Oh, thank you, Erik. It’s a pleasure to be back.
Erik Sunset: We’re psyched to have you. Um, and in the time since there’s been a lot happening for CVA USA, there’s been a lot happening for you now as the Chief Quality Officer. What’s new since we last spoke?
Dr. Blumenthal: Yeah, well, we, um, we continue to grow and, um, you know, continue to advance our value based care mission. Um, we’ve, we’ve, I think when we spoke, we had [00:01:00] entered into, to, you know, a, um, a few risk contracts. We’ve since continued to, to expand the number of value based care contracts that we’ve, um, that we’ve signed and, um, are doing value based care in multiple states now.
Dr. Blumenthal: Um, uh, from a quality standpoint, you know, we’ve, We’ve advanced a lot of our work around quality measurement, um, both looking at, um, looking at transitions of care and, and rehospitalizations, um, and, uh, measuring patient satisfaction, systematically measuring quality and MIPS performance, um, that’s been a big area of focus for us this year from a quality standpoint, um, and, um, continue our work to, to build out evidence based, um, Um, Protocols for for managing, um, cardiovascular conditions and and care efficiently and in an evidence based fashion.
Erik Sunset: Love it and love to hear that folks like you and [00:02:00] CVA USA are sort of turning the paradigm on its head. The paradigm being, you know, strict fee for service. There isn’t a physician in the country that doesn’t care about their patients and want better outcomes, but this is a systemic approach to, uh, to healthcare in the U.
Erik Sunset: S. So really glad to have you back on.
Dr. Blumenthal: Thank you. Yeah.
Erik Sunset: Going back to our, uh, our show in January, one of our hotter topics was discussing the cardiovascular procedures that were coming off of the IPO and being allowed to be, uh, performed. We did in the A. S. C. So we’ve got now eight or so months, the better part of 2024 . It’s a little bit less in the headlines, though.
Erik Sunset: That doesn’t mean that momentum isn’t still building and gathering and excitement still isn’t there. So one of the things I wanted to hear from you are over the course of 2024. What are some of the best practices that you’ve seen for bringing these cardiovascular procedures to the A. S. C.
Dr. Blumenthal: Yeah, so it’s a great question. And, um, [00:03:00] you know, I mean, I think fundamentally, um, there are, um, you know, there are a variety of procedures that are already approved. Yeah. right for to be performed in ambulatory surgery centers or office based cath labs. And, um, and, um, and, and so once the, the procedure is approved can be done in an ASC or an OBL, then it’s really, you know, uh, uh, up to the physician and the patient about, um, whether that patient Has certain clinical criterion, right?
Dr. Blumenthal: That that would warrant doing the procedure or procedural criterion that would warrant doing the procedure in, uh, outside of an A. S. C. Or whether you know they’re appropriate for an A. S. C. Or office space lab. And we’ve Um, we’ve started to put together some, um, some suggestions, guidelines right around, guidance around how to, how to make those decisions.
Dr. Blumenthal: But, [00:04:00] um, we, we trust our physicians, our clinical partners to, to know what’s best for their patients. Um, you know, the, the, the criterion, uh, sorry, the, the, You know, this year, Medicare had several procedures that were on that list, um, that, that were up for comment, um, to be moved from, you know, the HOPD setting or to be eligible to be performed in ASCs, um, and by and large, most of those after comment were removed from the, from the suggestion list, and, and so didn’t make it into the final rule, um, and most notably, Um, ablations, right?
Dr. Blumenthal: Um, AF ablations and, and SVT or supraventricular tachycardia ablations. Um, we are seeing payers start to, non Medicare payers or Medicare Advantage payers start to contract for those anyways. Um, in a season, select circumstances. Um, and, and we, you know, [00:05:00] and we know that payers have been doing that for years and in certain parts of this country.
Dr. Blumenthal: Um, we also saw HRS, the heart rhythm society and the American College of cardiology come out with a joint letter endorsing, um, the, uh, safety of, um, AF ablations in ambulatory surgery centers for appropriate select, appropriately selected patients. And so while those are not yet approved, um, by Medicare to be done in ASCs, you know, we, we do anticipate that it’s only a matter of time before, before some of those procedures migrate to ASCs, um, um, for traditional Medicare patients, Medicare approves them.
Dr. Blumenthal: The, um, You know, we, we, the Heart Rhythm Society also did its own survey of, um, electrophysiology, kind of surveyed some of its members about what, what services and procedures they thought, um, were appropriate for ambulatory surgery centers and asked them about [00:06:00] the percentage of procedures that they were, of those procedures they’re doing in the hospital outpatient setting as a same day procedure.
Dr. Blumenthal: Um, and, um, and those, those numbers. data are, they were published by HRS, the journal of the heart rhythm society. Um, but the, the full results of that survey, I think are also available through the HRS website, even including some of the data that they didn’t publish. So that’s just an interesting, um, tidbit.
Dr. Blumenthal: And I think this has been an area of, of intense and growing, um, interest among, among cardiologists generally and EP physicians in particular.
Erik Sunset: Well, it’s, it’s interesting you mentioned that and we’ll of course track down a link to the, uh, the Heart Rhythm Society, uh, data and get that into the show notes like we always do. Uh, as a, as a vendor, we see a lot of ambulatory surgery center society events across the country, whether they’re state shows or a Becker’s event or with ASCA, the, the national or ASCs.
Erik Sunset: And we ended up talking to a lot of the specialties that [00:07:00] you’d expect, a lot of eyeballs, a lot of retina, a lot of ophthalmology, a lot of GI, your traditional, uh, You know, more traditional specialties in the ASC. When we ask about cardiovascular procedures, the multi specialty clinics often say, we would like to do that, but we’re not totally sure what we should be doing.
Erik Sunset: And there’s about a variety of stakeholders there, from the surgeon, to the patient, to the actual facility. It put to me this way recently that more of the same type of procedure is just more, you can scale that you can kind of know what you’re doing and just expect more staffing and more throughput and more supply usage and things of that nature.
Dr. Blumenthal: Yes, that’s right.
Erik Sunset: Cardiovascular is different though. That’s not more of a procedure that you’re already doing. So you have any words of wisdom for those that are seeking to bring cardiovascular cases, whether that’s
Dr. Blumenthal: Yeah. And you mean. Yep. And again, I think you have to start with, you know, you always start with, is the procedure appropriate, necessary, [00:08:00] appropriate for the patient, right? Um, and, um, and, um, and I think that, um, Maybe I think there are a few reasons why cardiology is difficult to for for multi specialty clinics to kind of wrap their brains and their arms around that.
Dr. Blumenthal: The 1st, I think, is that, um, is that, you know, it requires expertise, which is. Pretty varied, right? You know, there are a bunch of different procedures. It’s not just cataracts, um, or colonoscopies, um, these are, these are a wide variety of, of not just kind of, um, coronary procedures or device, electrophysiologic device procedures, implants, but also peripheral procedures, um, that involve, you know, lower pretty complex and, and, um, um, and extensive, um, Peripheral vascular work, um, at least in office based [00:09:00] labs.
Dr. Blumenthal: Um, and, um, and so, you know, if you’re not trained in those, in that specialty, it’s hard to perhaps wrap your arms around in your head around how the risks and the benefits vary across those different procedure types, um, based upon, um, the characteristics of the patient. And because there’s so much nuance around, around making kind of decisions based on who the patient is and what that patient’s particular clinical comorbidities are and the reason for the procedure, you know, you do need to, you do need to really have expert guidance from somebody who’s trained in, in those procedures.
Dr. Blumenthal: I, I think, um, you know, I’d want that if I were talking to an ophthalmologist about whether or not a cataract surgery should be done in an ASC or OBL, but I, um, you know, but I would, Imagine that, that, you know, almost all of those can be done in an ASC in the same way that almost all colonoscopies can probably be done in an ASC.[00:10:00]
Dr. Blumenthal: So, um, that’s the first reason. I think the second reason is, is obviously it’s your heart, right? It’s, and, um, and so there’s a level of risk aversion, I think, again, amongst people who aren’t trained in cardiology, um, and about whether or not it’s safe to do these procedures in ASCs, which it, For the vast majority of patients, for those that are approved, it is, um, and, um, and I would say almost all, um, right, we, the physicians who I’ve met who work in ASCs tend to make very wise and conservative choices about who to, you know, about who to, who to do a procedure on in an ASC versus doing it in the HOPs setting, or even in the inpatient setting, if, if, if they’re extenuating circumstances, it’s, it’s really, um, You know, when it’s your patient, right?
Dr. Blumenthal: And, and your, your judgment, um, you know, you, you really have a, uh, you really feel a [00:11:00] responsibility, um, to, to the patient, to your oath, et cetera, to, to the patient. to do the right thing. So, um, I think that I think that those are, um, two important reasons. Um, um, you know, the third is that there are lots of state level nuances right around regulations in terms of, um, um, not just CON, but what procedures can be done in ASCs.
Dr. Blumenthal: If, if you can do cardiology procedures in an ASC, there’s some states where you can do EP procedures, but you can’t do coronary procedures. There’s some states where you can do coronary procedures and EP procedures. Um, there’s some states where, you know, you can do it all, but there are CON laws. And so that limits your ability to actually, you know, get approval to build an ambulatory surgery center in, in, um, in a place that’s convenient to you and your patients.
Dr. Blumenthal: So a lot of nuance here. And I think that also can, can make it challenging for people to understand. And then the final piece is that, you know, [00:12:00] we generally need our own, um, equipment. Right. Outfitting a, a, an EP suite in a cardiac or an interventional suite requires a C arm and some different materials, different, not just different catheters, but, you know, different training for your staff and techs.
Dr. Blumenthal: And so that, that can present some, some challenges, um, um, in terms of understanding, right. If you’re, if you’re not, if you’re not a cardiologist,
Erik Sunset: That’s too true. All that’s too true. More is more different is very different
Dr. Blumenthal: that’s right.
Erik Sunset: it’s it’s satisfying to see progress being made. We want to go just generally speaking as fast as we can, but still maintaining that the safety number one quality outcomes number two. So with with all of that said, do you think more could be done in less time?
Erik Sunset: Or are we kind of on schedule from your point of view?
Dr. Blumenthal: Um, I certainly think I think that I think that, um, [00:13:00] I think that there’s probably more that can be done. Um, I mean, I think, um, whether we’re on, uh, I would like to see, for example, you know, um, ablations be, be approved to be done in ASCs, particularly, you know, right sided ablations make all the sense in the world.
Dr. Blumenthal: I mean, we’re doing, you know, 90 percent of those as outpatient procedures. In, um, in, on hospital campuses in the HOPD setting, um, you know, AF ablations, I think can be done safely for, for a substantial minority or if not a majority of patients with, with atrial fibrillation who need a, who need a PVI, um, um, and, um, you know, and I, and I think we will, um, I, I think that we will continue to see, um, I mean, my predictions will continue to see slow, steady progress, right?
Dr. Blumenthal: And I think that we’ll probably see those procedures approved in ASCs in the next two years would be certainly [00:14:00] my hope.
Erik Sunset: Sure. Yeah. And I’m right there with you. You know, we fly the flag for, for our friends at ASCA and for the ASC generalist, a great venue of care. And when it makes sense, it makes the most sense, at least my humble little opinion. So then looking out to either 2025 or to that second year that you mentioned, 2026 or over the next two years, rather, is there anything in particular that you think either cardiologists or the ASCs that are interested in cardiovascular procedures or, uh, The Novo facilities looking to be built for cardiovascular procedures.
Erik Sunset: Is there anything you’re keyed in on in particular in sort of this near ish term?
Dr. Blumenthal: Yeah, you know, there’s, there’s a little bit, there’s one thing I think there’s a little bit of, of I’m actually, you know, trans esophageal echocardiograms, right, which are basically echoes with endoscopies, um, you know, are, are, I think, Um, have been an area of controversy because they really should be allowed to be done in and, um, [00:15:00] and, um, and there’s been some resistance to adding them.
Dr. Blumenthal: Um, I think, um, you know, we did see, um, I’ll be curious to see whether the addition of, um, you know, PA catheter, PA monitors. Which were added to the ASC eligible list this year, whether, um, whether we see movement of that procedure and, you know, a substantial way to ASCs, um, um, it’s a, it’s a pretty, um, Um, you know, it’s a, it’s a relatively speaking, no procedure is benign.
Dr. Blumenthal: I don’t want it. So I don’t want to misuse the term benign, but, but it’s, um, for, for a cardiovascular procedure, it’s, it’s a, on the lower end of the risk spectrum. Um, and, um, and we’ve seen growing use of those procedures. I think things like Watchman’s, um, when, you know, again, inappropriately selected patients.
Dr. Blumenthal: Um, I think that [00:16:00] the crossing of the I mean, I’m not entirely, you know, I would think that those, if you’re, if you’re going to look at approving ablations, then approving Watchman’s would make sense. Um, so, um, those are, those are left atrial appendage closure devices.
Erik Sunset: So it sounds like there’s still a lot of reason to be excited about the momentum that it’s going to carry
Dr. Blumenthal: A hundred percent. Yep. A hundred percent. Um, and I’m just, um, and I think, you know, down the line, is there, is there a world in which, um, we’re doing TAVRs in ASCs? Or Mitra clips, you know, um, that’s it. We’re not, we’re not quite there yet. Um, I, I do think they’re, you know, for low risk patients, I think there’s probably at some point a world where, um, you know, in the next 5 to 10 years, Five plus years where we [00:17:00] start to move some of those into ASCs, um, with, with the right safeguards and the right patient selection, but we’re not, we’re not, we’re not there yet.
Erik Sunset: to that point, not there yet. Is that a legislative or a regulatory hurdle to be cleared? Is there a technological hurdle that needs to be cleared before those make? the most sense to be done in the ASC, like what would be the slowdown
Dr. Blumenthal: Yeah, I mean, you know, those, well, typically you need to, you need to be doing the, the procedure needs to be able to be done in a substantial number of patients as a same day procedure. that like the progression is typical, at least in my in my observation has been, you know, when for for for reasonable appropriate reasons, clinicians.
Dr. Blumenthal: When, when we are learning how to do something, when it’s higher risk, right, when there’s any uncertainty, we want to monitor patients after [00:18:00] the procedure to make sure that they are safe and that we can identify complications, um, and that that they get any necessary post procedural care that they need.
Dr. Blumenthal: Um, and, um, and then as we, you know, as we kind of improve operational performance and efficiency and get better, you know, get better at doing the procedure and delivering all the necessary post procedural care and identifying complications quickly. Um, and, um, as the technology improves, generally, you know, those lengths of stay shorten, and then in some cases you can do the procedure same day, right?
Dr. Blumenthal: And, um, but, but we, you know, for obvious and appropriate reasons, I think we’re incrementalists. We don’t like to make big, um, Leaps in terms of changes in practice without kind of being methodical and making sure that that those steps make sense And, and so we’re, we just have to go through the progression, I [00:19:00] think, for, for, for those other, you know, those other procedures and, and learn which patients are appropriate again for shorter lengths of stay for perhaps same day discharge.
Dr. Blumenthal: And then after that, which, which of those patients could be appropriate for being moved off of a hospital or health system campus.
Erik Sunset: Sure. Yeah, that patient selection aspect is obviously huge for all ASC based procedures. And that kind of, that kind of turns our conversation a little bit towards patient adherence because in order to be a good candidate for a procedure in the ASC, whether it’s cardiovascular or otherwise, um, there are some things that need to be done.
Erik Sunset: Uh, to be considered like you already mentioned, and I’ll get way out of my depth here really quickly, but comorbidities. Are you healthy enough? Are you going to be able to go home in one day? Should you go home in one day, even if that’s likely and flashing back to our to our prior conversation from January?
Erik Sunset: I was fascinated. around everything that you shared and would [00:20:00] really truly recommend if you didn’t hear that show, go back and listen to it, but we went really deep that there are patients that despite the physician and their care team’s best efforts are just not doing the right things for themselves, whether that’s for an inpatient procedure where they’re staying a night or two or whether it’s done at the A.
Erik Sunset: S. C. C. D. This is kind of a long walk for a short drink of water, Dr. Blumenthal, but what have you seen over the course of this year and really over the course of your career and best practices that as a physician, you want the best for your patients. We know that that’s absolutely true, but Mr. Patient, Mrs.
Erik Sunset: Patient, you have got to either do this or stop doing this.
Dr. Blumenthal: Yeah, so it’s a great, it’s a great question. And it’s a really hard question to answer. I mean, obviously, if we had easy, scalable answers to it, we would be in a different place. Um, um, but, but I think there are a few themes, right? Um, that, that kind of continually [00:21:00] come up. What one is, you, you need to understand the motives of the person.
Dr. Blumenthal: Patient and their and their belief system. And often, um, you know, often when a patient doesn’t take your recommendation, it’s not because they, uh, it’s, it’s, it’s very rarely because they don’t believe you or that they don’t think they don’t trust you or they, Don’t think that, or they think you don’t have their best interests in mind, right?
Dr. Blumenthal: There are a whole host of other factors that come into play that I think, you know, in our busy, um, productivity. You know, minded, um, health care delivery model. We often either overlook or don’t have the time to talk about and really investigate and and, you know, it often it comes down to a lack of understanding right of of why you’ve suggested that somebody do something, um, a cultural or [00:22:00] religious or language related.
Dr. Blumenthal: Conflict, um, um, with language, you know, often being linked to lack of understanding, um, or education being linked to lack of understanding, um, um, or, um, an inability to pay, right? So, you know, thank you, doctor, for recommending this. 200, um, service that I could use to help me lose weight, but, you know, I’m living on 600 a month or 800 a month and I just can’t afford that.
Dr. Blumenthal: I have, I have other more elemental basic needs that I have to attend to before I can handle this. Um, so, you know, that’s a very long winded way of saying social determinants of health. Right. One of the, one of the factors that I think we don’t do as good a job of, of managing as we, and, and intervening upon to try to correct as we could, um, and should, um, but I think that there, there are also factors related to [00:23:00] understanding, um, right.
Dr. Blumenthal: Related to education, um, related to cultural upbringing, ethnic upbringing, right. Um, not good or bad, just different. That that we don’t do a good enough job of really delving into and trying to address and these are time consuming, you know, getting getting to that 2nd layer right of and addressing the skepticism is is time consuming and requires a lot of effort and work and um, and I think anything that requires effort and work and time is something that You know, unless you’re, unless you’re, you’re really committed to it and you prioritize it is, is harder to get done consistently.
Erik Sunset: Well, and to that, to that point, I mean, there’s, there’s situations where household finances are really tight and to pay in our hypothetical pay a third of my monthly take home for this service that makes me healthier. I got to put gas in my car. I have to feed my family. There’s just no way that’s going to happen.
Erik Sunset: So when you, when you hit [00:24:00] that, you know, just that reality that that’s just in this situation, they’re not going to do that 200 a month service. What, what have you seen Or what’s the best chance to get adherence to a plan? And obviously, let’s keep that big picture. Adherence to the plan is making a patient healthier.
Dr. Blumenthal: Yeah, absolutely.
Erik Sunset: you want satisfaction. I
Dr. Blumenthal: That’s right. So, so it’s, um, so I think, um, honestly, it’s the easiest thing in what I do in my own clinical practice is, is to try to understand, right? Because I think when people are resistant, there’s often a reason and you just have to, there’s almost always a reason and you have to understand that it’s not a, I very rarely come across somebody who has said no to something or I don’t want to do this just because.
Dr. Blumenthal: Um, right. And so it’s about understanding that reason and coming up with a with a with a way to help the person to understand why you’re recommending it. Um, and there are times where the trust is an issue. And so you have to try to delve into that trust. You [00:25:00] know, I think, I think there are, um, there are other members of the extended care team who can play a role here, right?
Dr. Blumenthal: So this doesn’t have to all fall all on the hands of the, of the physician or the nurse practitioner or the physician’s assistant who is, who is seeing the patient. for their clinical needs. There are, um, you know, you can train a medical assistant or a community health worker or a nurse, right? To help probe for and understand how to, you know, provide guidance around how to address some of these, some of these concerns, um, and some of the barriers.
Dr. Blumenthal: Um, there are services for addressing social determinants of health. Um, Aunt Bertha’s is one. You know, there are a handful of others like it that, that provide access to, recommend, you know, lists of social workers, shelters, you know, um, guidance on how to, how to navigate. food insecurity, um, all sorts of, of kind [00:26:00] of, many of the things that we need to get better at trying to address to improve population health.
Erik Sunset: that food insecurity piece is, is a really tricky one.
Dr. Blumenthal: Yeah.
Erik Sunset: You know, not to simplify it too greatly or to come across as out of touch, but if you are able to afford some food, and you’re in a spot where household finances are tight, that’s You know, you may be hitting the drive through on the way home, and that’s fine.
Erik Sunset: We all do it. Who doesn’t love that once in a while? Um, but Getting, getting the patient and getting the, the population at large to understand, Hey, that’s an easy choice today, but that’s a bad choice for tomorrow and the day after. And then eventually you’re going to come see me with an emergency. And, you know, you’re not going to say I told you so.
Erik Sunset: But do you remember all these things we talked about that this is preventable? Only if you make a different choice, that’s got to be incredibly difficult,
Dr. Blumenthal: It is. [00:27:00] And, and, um, and it, and it’s a, and it’s a, um, as, as hard as this is to hear, it’s a person, it’s a situation by situation intervention. Right, because, because, um, and that’s why it’s, um, and I don’t want to say it’s not, there’s no scalable approach. I think there are, there are ways to scale approaches, but I think fundamentally, it’s you have to, you have to personalize that scale, that, that approach.
Dr. Blumenthal: that set of interventions in order to make it successful. Um, and you have to do so without prejudice or judgment, right? Um, because, um, um, you know, and I think, um, so, so when I talk about it here, you know, a lot of people use the term compliance, right? Somebody is noncompliant, um, with X or Y. I, Um, I, I rare, I almost never use the term compliance.
Dr. Blumenthal: I use [00:28:00] the term adherence because compliance a plot implies volition, right? Um, adherence is, is just a statement of yes or no, right? Somebody is either doing something or not doing something. It says nothing about motive or, or desire to not do something. And so I think removing the, the, the stigma around.
Dr. Blumenthal: Why people are doing or not doing what we are recommending that they, that they do is very important for starting to get at some of the root causes.
Erik Sunset: Sure. This is going to pivot us a little bit. Once again, um, in the time since we last spoke and certainly these, these drugs were on the market, uh, in January, but things like Ozempic and these injectables that are being hailed as like miracle weight loss, uh, solutions. And again, through the lens of healthier patients for procedures to be completed, uh, immediately at the ASC.
Erik Sunset: Do you have any thoughts on those or what are you, what are you seeing?
Dr. Blumenthal: yeah, I mean, um, um, so [00:29:00] the GLP um, are, um, I mean, are, are being used so widely now. Um, and I think we’re still early in their, in their uptake. Um, You know, uptake in my experience has been limited by, um, frankly, by availability, right? Not by not by the need. Um, and, um, and I think as, and the more we learn about these, this class of drugs, the more, the more benefits we discover, um, I mean, there was a really important study, which was presented, it was either at the 2020, I think it was, I think it was at the 2024 American College of Cardiology meetings looking at, you know, reductions in cardiovascular outcomes amongst patients with obesity, without diabetes, without cardiovascular disease, who were treated with this class of [00:30:00] medicines.
Dr. Blumenthal: And we, um, you know, we, we, that study showed, it was a really a landmark trial, showed that, um, treatment with this class of medicines reduced the risk of cardiovascular events, even among people who had no disease and among people who had no diabetes. Um, So, um, you know, really remarkable outcome. Um, and, um, I think, you know, we are going to see, um, the continued battle between payers and, and the manufacturers of these classes of medicines, um, um, over price and prior auth criteria.
Dr. Blumenthal: Um, because the, the potential uses of these medicines are just so broad. I mean, I. I, I’m the last time that I was kind of, you know, the last time that I, I, I, there was this much, you know, concern about [00:31:00] uptake of medicines of this type of, you know, about basically such wide use of this class of medicines that we would bankrupt, you know, our, our healthcare system was with the PCSK9 inhibitors, which were a class of medicines, um, you know, that we used to treat high cholesterol
Erik Sunset: Hmm.
Dr. Blumenthal: and those came out in kind of the 2015 2016 2017 period.
Dr. Blumenthal: And there was a lot of speculation that, you know, at their price point, which at that time was 13 to 15, 000 a year. you know, and the eligibility criterion, we were just going to see, you know, hundreds of billions of dollars go into buying these medicines, and it was gonna bankrupt, bankrupt our health care system.
Dr. Blumenthal: Um, that didn’t happen, of course. Um, and, um, part of what happened is the cost of those medicines Was eventually, um, cut, you know, from, from that 13 to 15, 000 range to somewhere in the 5 [00:32:00] to 7, 000 range. Um, and, and that was in large part due to the fact that payers were putting up such, um, such Substantial prior off barriers to use that that people weren’t getting access to the drug.
Dr. Blumenthal: Um, I haven’t, you know, these drugs are priced at a lower price point. Um, and I’ve seen generally broader approvals and uptake. Um, and I think, um. Um, and they don’t have major I mean, they have some side effects, but they’re there. People do do certainly experience side effects. Um, but the demand for them has just been so dramatic that, um, um, I don’t I think they’re.
Dr. Blumenthal: They’re going to be, they’re, they’re one of the major tools in our clinical arsenal right now for managing obesity, coronary artery disease, even congestive heart failure and kidney disease.
Erik Sunset: And I certainly don’t have a clinical opinion to offer on, [00:33:00] on anything as a matter of fact, but it seems like such a breakthrough and in a slightly cynical way, I can’t help but say, you know, what, what an American way or what a showcase of the American way inject me and I healthier. That’s, that’s about as good as it gets.
Dr. Blumenthal: Yeah. And yep. Well, I, I think, um, yes, I, I, um, I, I think, um, You know, it’s a, it’s a, it’s, it’s a, it’s really a stunning breakthrough. It will be really helpful for patients. I mean, you know, if you think about just the treatment of obesity, I mean, you know, prior to the, prior to these medicines, you had lifestyle interventions and then weight loss surgery.
Dr. Blumenthal: And, um, and, and so, you know, weight loss surgery is still, is still around, still being used. It’s still. A very important part of the treatment paradigm, but, um, but it’s certainly [00:34:00] obviously more invasive, um, you know, requires more recovery time than just using some, you know, using, using an injection. So, um, we’ll probably we’ve already seen some oral formulations of those of.
Dr. Blumenthal: Of, um, somaglutide come out that’s ozempic and, uh, or we go V and then, you know, I suspect we’ll see some other oral formulations for some of these other agents over time and probably some other versions of, of, of this class of medicines continue to come out and get, get tested in clinical trials.
Erik Sunset: And just what, uh, I can’t help but stay like, what a miracle for, for the, for me. For those that need it
Dr. Blumenthal: For those that need it, it’s a huge, yes, absolutely a miracle. And, and for a hundred, absolutely.
Erik Sunset: And on the other end of this, before we started to record, we, we even were discussing how, you know, exercise is a really important pillar to overall health, though not necessarily bullets. So we’re going from one end of the spectrum where an injection and even an oral solution now, it sounds [00:35:00] like can be, you know, your ticket to better health.
Erik Sunset: Um, that’s, that’s good. That’s as easy as it gets. Love
Dr. Blumenthal: a pill, pill. Not a, not a, not a, not an, I don’t think, not like a solution, but yes, sorry, oral formulation. Yes, a pill. Yep.
Erik Sunset: Excellent. And then on the, on the other end, you know, if you can, I guess if you can swipe your credit card, you can get these medicines and that’s as easy as it gets. But
Dr. Blumenthal: Yeah, there are some companies out there that are, that have started to basically, you know, just, just focus on prescribing, managing, you know, metabolic, cardiometabolic drugs. Um, um, um, conditions, right? Obesity, diabetes, you know, obesity, high cholesterol, high blood pressure. But, you know, the, at the core, I think of the treatment approach or the intervention is the ability to prescribe these, these class of medicines.
Dr. Blumenthal: And I, I, I don’t know much about those. I’ve just read about them, you know, heard a little bit about them. These medicines do have a, you know, side effects and they need to be [00:36:00] titrated. Um, um, from, you know, the starting dose up to, uh, Up to their steady state dose. And some people can’t get all the way up to that dose because they’re limited by side effects.
Dr. Blumenthal: So you really should you should make sure just as a. Um, just as a point for patients or who are listening, you know, you should make sure that when you start one of these medicines, you’re starting it with somebody who you have a longitudinal relationship with, who’s going to follow you, um, who will help manage you through any side effects, right?
Dr. Blumenthal: Not just somebody who’s going to write a prescription and then and then say, you know, say, I’ll see you later like that. That I’m not saying those those exist, but I think, um, you know, in general, management of prescription medicines should always be done and in, um, under the care of a, you know, not just a qualified professional, but somebody who you who can follow you longitudinally.
Erik Sunset: very, very well put. Talk to your doctor that you have a relationship with. If that wasn’t clear, talk [00:37:00] to your doctor before embarking on a GLP one agonist
Dr. Blumenthal: That’s right.
Erik Sunset: And on the, on the other end of the Ozempic spectrum for, for better health, you know, we’ve, we’ve talked a little bit about food, social determinants of health, Exercise obviously key, you know, back through the lens of CVUSA, cardiology procedures in the ASC, just being a healthier person or a healthier patient and having access to maybe more effective treatment if you take your health into your own hands.
Erik Sunset: Um, I can’t imagine there’s a whole lot of news and if it is, it’s old news. I exercise good for you, but
Dr. Blumenthal: Exercise great for you, right? Like there’s a reason why it is in all of our guidelines as a class one recommendation. Um, and that is that we have tremendous evidence that exercise is beneficial. Um, there will always be that one person who says, you know what? I don’t exercise. Look at me. I’m 95. I’m doing everything that I want to do and I’m living, living a [00:38:00] great life and I’m not saying that that person is wrong about what’s right for them.
Dr. Blumenthal: But when you look at a population level, um, exercise saves lives. It prolongs life. Um, it’s, it’s, you know, one of the best medicines that we have. And, um, and I think a great example of that is cardiac rehabilitation. Right. Which is indicated after you’ve had a heart attack or a stent, or if you have congestive heart failure, um, or, you know, you’ve had a valve replaced, um, we do a terrible job in this country generally of giving, helping people to access cardiac rehab, despite having tremendous evidence that if you go through cardiac rehab after one of those events or, or procedures, um, your likelihood of returning to the hospital is lower.
Dr. Blumenthal: For a year. Your likelihood of dying is lower. Um, um, and, um, and so, you know, this is kind of, uh, it’s an area of intense focus for us at CVA [00:39:00] USA, um, improving access to cardiac rehab and making sure that, that our patients who need, Kind of supervised exercise therapy are able to receive that whether it’s through a center or frankly increasingly in the comfort of their homes using, using a home based cardiac rehab solution.
Erik Sunset: I’d be curious for your thoughts on this. Um, obviously cardiac rehab is one thing that’s, uh, that’s post facto. You, you have to do this to remain as healthy as possible. But before you get to that point of needing cardiac rehab to kind of flash back to the socioeconomics of this. Not everybody can either want or afford the Equinox or the Lifetime Gym membership.
Erik Sunset: Uh, not everybody can, can or wants to buy a Peloton for their home. However, and this may be a little crass, you know, you already have shoes, and you certainly have a place that you can walk. Somewhere, somehow, someway. So, without putting words in your mouth, what’s the recommendation to those that go, Man, I’d love that gym membership, but I, I [00:40:00] can’t have it, I can’t afford it, I don’t want it.
Erik Sunset: What do you tell that patient?
Dr. Blumenthal: Yep. Two things I think first talk to your doctor to make sure it’s safe for you to exercise. Um, which for the vast, vast majority of people, the answer will always be yes. Um, but again, I don’t want to give a blanket recommendation without, um, because there is that, that, you know, that small, tiny percentage of people who, who probably should really stick with it.
Dr. Blumenthal: Make sure they they run everything by their physician first. Um, and then, um, build it, build a short walk into your into your daily routine and do it early in the day when you’re generally fresh and have the most energy. Um, and, um, don’t set other worldly expectations for yourself. Just do it. Start with 10 minutes or five minutes or 15 minutes, whatever you think you can do in a way that’s not going to make you hate exercise and start, get, start doing it consistently and then build up slowly from there.[00:41:00]
Erik Sunset: Wise words. And I know we’re, we’re coming up to the end of our time today. Dr. Blumenthal pivoting hard here. Once again, uh, we talked about how cardiovascular procedures in the AFC made a bunch of headlines earlier this year, and they’re still there, but excitement in the press has waned a little one thing that hasn’t waned at all this year.
Erik Sunset: It probably will remain a hot topic for the foreseeable future is AI or artificial intelligence and healthcare. What are you seeing? What are your thoughts? What was useful to you?
Dr. Blumenthal: Yeah, so, um, I think we have started to use, um, I mean, I, I think we’ve, we’ve seen some, some potential value in, in AI solutions that can automate, you know, back office, operational tasks, workflow, uh, streamlining workflows, those, those kinds of things. You know, when it comes to clinical care delivery, um, obviously, I think, you know, when you’re, whenever you’re touching a patient or, [00:42:00] or, um, intervening on a patient, you have to have a higher level of scrutiny than, than you would just for doing administrative work, um, and a higher level of evidence, not, not just of safety, but also of efficacy.
Dr. Blumenthal: So I think, you know, for, for clear reasons, we are, Um, we’re not quite as far along there, at least in terms of getting, getting, you know, interventions that move the needle in the clinic. Um, but there are a few technologies that I think, you know, are, are, are really neat, um, that are making their way through various approval processes.
Dr. Blumenthal: I mean, one is a, you know, an AI based, um, EKG review tool, which can help just analyze an electrocardiogram. Um, and. Um, help, help you understand whether a patient has had atrial fibrillation in the recent past or will likely go into atrial fibrillation. To me, that’s a really neat use case. Um, and then some AI based, um, or automated, um, echo [00:43:00] reading.
Dr. Blumenthal: Um, algorithms that, that there are a few companies working on that we’ve seen that I think, um, will help speed up the process of, of reading echocardiograms and preparing those for the physicians who ultimately will read them.
Erik Sunset: I love to hear that. And that, you know, you hit the nail on the head that to be able to get these technologies into the hands of providers. But before you do, they need to be back tested. You need huge chunks of data. So at least in my personal opinion, the really good stuff. Isn’t there yet. There’s some good stuff out there, but the really good stuff is coming just because for it to be really good, it needs to work most of the time, almost all the time, and
Dr. Blumenthal: That’s right. And for, for that, for when we’re talking about clinical care, right? We have to have good evidence that it works. Yep. I think, I think we’re, um, yeah, we’re, we’re making, I mean, I’ve seen really neat, good progress, but it’s, it’s, um, we’ve still got a ways to go. Yep.
Erik Sunset: we were going to get there. And as we, uh, as we wrap up, Dr. Blumenthal, how can [00:44:00] listeners connect with you? Any social medias? Are you speaking at any upcoming events? Where can folks get more
Dr. Blumenthal: great question. So, um, I, um, so you can, you know, reach out to me through LinkedIn, um, or my Twitter, um, or through Z X, um, at Blumenthal DM one, um, or you can email me D Blumenthal at CVA USA. com.
Erik Sunset: fantastic? And as usual, we’ll get all the links to those profiles into the show notes. Dr. Blumenthal. Thanks again. This was fantastic.
Dr. Blumenthal: Oh, I had a great time. Thank you so much for having me on Erik. It was great.
Erik Sunset: It’s our pleasure.
Dr. Blumenthal: Yeah.
Erik Sunset: And on behalf of the entire DocBuddy team. Thank you for listening. Be sure you’re subscribed on Apple podcasts, and we will catch you on the next one.