This year, I availed myself of the opportunity to once again attend the Annual Scientific Sessions of the American College of Cardiology in San Francisco. It was a special year because a former mentor and current friend from my Cedars-Sinai days, Dr. John Harold, was inaugurated as the incoming president of the ACC.
The meeting was an opportunity to reconnect with old friends, and to learn a lot about the state of the art in cardiology, as well as explore some of the current challenges.
Too much of a good thing?
The cardiology community has anxiously been awaiting JNC-8 and ATP-4 for some time now. These expert consensus statements will serve as updates to our guidelines on the treatment of high blood pressure and high cholesterol, respectively. Nobody knows yet (except the writers) what the recommendations will be, but certain themes are beginning to emerge.
One of the themes that I saw emerging quickly was the idea of “overtreatment”. While the well intentioned writers of previous guidelines recommended very strict control of blood pressure, for example, a plethora of recent data has suggested that lower may not necessarily be better. In fact, there is now a preponderance of data suggesting a “J shaped curve” for blood pressure control in cardiac risk reduction; meaning that as blood pressure goes lower than a certain “sweet spot”, cardiac risk may actually increase. This may be especially true in the elderly. There are many theoretical reasons to have believed in this relationship, but the interesting findings is to show that we begin to see it even at “normal” readings.
Ends don’t always justify the means
Similarly, cholesterol control has often focused on getting bad cholesterol (or “LDL”) down by any means necessary. The most effective method of doing so has always been HMG-CoA reductase inhibitors (“statins”), but many adjunctive therapies exist that also lower LDL. The problem is that while these therapies lower LDL, they have not been shown in any large-scale way to significantly reduce cardiovascular risk.
These meetings held particularly bad news for Niacin, a popular B vitamin, which failed in its second consecutive large-scale clinical trial to have benefit. CETP inhibitors, another promising new therapy, fared no better (so far) though they simultaneously lower LDL and raise HDL (good cholesterol). Combine these findings with the findings that statins benefit even those with low cholesterol levels who have had heart attacks, and you have fairly convincing evidence that statins reduce risk over and above their ability to lower cholesterol. Thus, I believe the newer recommendations should focus on statin therapy rather than LDL reduction, with the addition of adjunct cholesterol medications only in cases where statin therapy is impossible or insufficient. For those concerned about adverse consequences of statins, it has been conclusively shown that for most people on statins the benefits clearly and massively outweigh the risks. In addition, newer therapies to counteract the muscle aches with statins are showing more and more promise.
Another reason that LDL lowering may not track risk is that we are focusing on the wrong endpoint. Most cholesterol particles contribute to the deposition of cholesterol in artery walls, with the notable exception of HDL. Thus, measuring LDL is only measuring a subset of these harmful particles. I am hopeful we will see a shift in our guidelines towards increased recognition of “non-HDL cholesterol” as a primary goal of treatment, so we can be sure to address risk at every possible level.
The future is now
The past two decades have seen tremendous changes to healthcare delivery and economics. While it is convenient to blame “Obamacare” for many of these changes, the fact is that there is plenty of blame to go around for both political parties, from SGR adjustments, to Medicares C and D, to the PPACA. The upshot of all of these changes is the attempt to achieve substantial cost savings to Medicare by cutting physician reimbursement–this is a rare area of agreement for both political parties. Physicians have long warned that this would lead to future reductions in physician accessibility, and that future has now arrived.
The same story was heard and overheard time and again at this conference. Physicians leaving medicine to pursue other careers. Physicians leaving insurance based practice to go to “concierge” or cash practices. Physicians fretting over making ends meet in the era of unfunded mandates and regulations combined with almost continuous cuts to reimbursement.
I think much of the public doesn’t realize that the average physician in practice is basically a government employee. We work for no money upfront and then petition the government or another agency to please pay us whatever it thinks our work (already completed) was worth. As most private insurances are pegged to Medicare rates, however, every cut in government spending translates into a direct cut in our reimbursement. At the same time, mandates such as electronic health records and insurance pre-authorization for every activity increase our bottom line significantly. This is not a model for a successful business, and is the main reason that more and more doctors are abandoning the field completely (one of the best doctors I trained with is now in the fashion business). Many of those that stay are forced to cut overhead by cutting accessibility or services offered, or worse yet forced into gimmicky side businesses and unnecessary testing.
It has now gotten to the point that the most popular seminars and symposia at this conference were not so much about medicine as about business–cutting costs in an era of declining reimbursement. It is an unfortunate truth that many of the most promising innovative technologies and treatments at this conference may never become available because of an economic climate which deters access, innovation, deliberation, or collaboration. We can only hope that going forward, our legislators are able to wriggle free of the iron grip of the insurance and hospital lobby, and recognize the engine that makes health care run, the physicians.