Episode 36 – Hypertension Awareness Month

Released March 28, 2023

Mike Stull (0:10) 

Hey, everyone, and welcome to this episode of HR Benecast, your source for expert commentary and insights on current health benefits-related news and strategies. This is your host, Mike Stull. Before we get started with today’s guest, I’m excited to share with you details on the 23rd Annual Innovations and Benefits Conference that will be held May 10th  here in Canton, Ohio, and attendees can expect to gain exclusive insights into benefit trends, network with like-minded professionals, and hear from the best and brightest across the employee benefits industry. 

So, again, May 10th here in Canton, Ohio. Just announced our keynote speaker, Andy Fastow, former CFO of Enron Corporation. So, Andy was at the center of one of America’s largest accounting scandals. 

He pled guilty to two counts of securities fraud and was sentenced to six years in federal prison, but now serves as a guest lecturer at universities and corporations all across the country, consulting on how best to identify potentially critical finance, accounting, compensation and cultural issues. I know it’s going to be an exciting presentation, so I hope that you can join us. You can visit employershealthco.com/events to register for the Innovations and Benefits Conference. 

And if you missed our Pharmacy Benefit Conference last month, don’t worry. All the presentations were recorded, and they were good ones, and are now available on the events page of our website. So, you can check them out, register to hear what’s driving things like high-cost claimants, trends and tools to manage diabetes spend, maximizing the pharmacy benefit value and a lot more. 

All right. So, with today’s episode, let’s get started. I’m joined today by Jenn Roberts. 

She’s the vice president of employer health strategy at Hello Heart. Jenn’s a former professor of health at her alma mater, the University of Houston, an exercise physiologist by training. Jen began her career in clinical research on multiple national institutes of health and biopharma studies that were focused on cardiovascular health, and she was able to generate multiple publications highlighting successful interventions. 

She then moved into the employer space designing award-winning wellness programs, delivering clinical outcomes and ROI. I hope you enjoy our conversation. Welcome, Jenn. 

To get started here today, could you tell us a little bit about yourself and Hello Heart?  

Jenn Roberts (3:03) 

Thanks, Mike. I lead our employer health strategy team at Hello Heart. So, that means I work with our consultants and clients and prospects, making sure they have the right strategies in place to deploy, especially related to heart health. 

Mike Stull (3:17) 

Excellent. And we were talking a little bit before we went live about April being Hypertension Awareness Month, and the stats don’t look good for the country. Nearly half of the adults in the United States have high blood pressure, and that obviously puts them at risk for heart disease and stroke, which is the leading causes of death in our country. 

Can you talk a little bit about, you know, what things or maybe what the one thing is that employers can do to support those employees? 

Jenn Roberts (3:49) 

I think the number one thing is to actually have a strategy in place for heart health. I think often we look at vendors and they’re kind of a single solution, or maybe they’re a little bit of everything under the sun, but we know that your heart is the root to your physical well-being and including emotional well-being. So, if you put in a strategy for heart health, not only are you going to help people with hypertension and high cholesterol, prevent heart attacks and strokes, it’s going to improve a lot of different chronic conditions, and especially related to depression and anxiety. 

Mike Stull (4:23) 

Yeah, I think sometimes we get very siloed when we think about these conditions. And I saw a video just this past week, you know, where it was a psychiatrist talking about the connection between the brain and the heart, really all of your other organs and major systems as well. So, we know that heart disease definitely impacts a lot of other areas of your health, which employers have an interest in helping employees with. 

When it comes to, we talked about the stats not being all that good for the United States, do we see that in other countries, or how does the U.S. compare to other countries in terms of incidents and outcomes for heart disease?  

Jenn Roberts (5:14) 

Well, this is an area where America likes to be a leader. And myself, you know, I’m in Texas, and we like to lead in Texas also. So, I would say typically in more Western cultures that have sedentary lifestyle and ridiculous access to, you know, all of the kinds of foods, if that makes any sense.  

Mike Stull (5:34) 

Absolutely. And I know Texas, I’ve been down there a good bit, even the beginning of this year, and they definitely like their good food.  

Jenn Roberts (5:43) 

Oh, Krispy Kreme donuts, my goodness. It’s a staple around here, that’s for sure.  

Mike Stull (5:50) 

Absolutely. And I was thinking about it, even when I was going through the checkout line at grocery store the other day, just how much bad food and bad drinks are just surrounding the checkout counter. 

And it’s like, if you try to exert willpower and not buying the bad stuff while you’re in the aisles, by the time you get to checkout, it’s absolutely terrible in terms of what they try to push on you as you’re going out the door. 

Jenn Roberts (6:23) 

When I was in consulting, and I also did work in schools, public schools, what we would do is we would put fresh fruits and vegetables right at the register, and then they would be like 25 cents or 50 cents, or if you buy a sandwich and you buy milk, then you get the free fruit. So, there could be something to that. 

I mean, even Whole Foods, you go in there and there’s all the chocolate and the stuff that’s not kind of in the regular aisles for the impulse buys. So, it could just be, I like what you’re thinking there, maybe like a little switcheroo psychology on those last minute impulse buys could be the healthy ones instead.  

Mike Stull (7:00) 

Yeah. At least at Whole Foods, it’s dark chocolate.  

Jenn Roberts (7:04) 

Yeah, it is dark chocolate, which is actually, depending on the year, good for your heart. There’s always a study out. 

Dark chocolate, is it good? Is it not? Valentine’s Day, red wine, yes or no for your heart health. So, we’re just going to say yes for today, for both.  

Mike Stull (7:18) 

Excellent. That’ll make a lot of people happy. So, heart disease, we talked about the fact that it’s the number one cause of death in America, but cardiovascular claims in general are often the top area spent for employers. So, how can employers not only support their employees, but also reduce their costs as it relates to these types of claims?  

Jenn Roberts (7:42) 

You know, it’s interesting to me, I think in part because you don’t necessarily feel your hypertension or feel your cholesterol, that there’s a lack of awareness. And so, when we look at claims trending over time, you start out at say $6,000 or something dollars a year, and then you creep up to $6,500, then $75, then $85. The average cost is about $10,000 a year for people with cardiovascular disease. And then at some point, could be today, could be a year from now, they become your high-cost claimant, and that’s when employers start looking at it. 

However, they’re your high-cost claimant for, you know, a very complicated inpatient admission for heart surgery or for stroke and rehab. And it doesn’t really, you know, lend to backing up for a second, like what could we do to actually prevent that high-cost claimant? Some things, you know, accidents, you can’t prevent, but this is absolutely 100% something to prevent. So, we’re really just trying to get the message out that prevention is the way to go to avoid the high-cost claimants. 

And we see it on the pharmacy side also. So, when you look at specialty drugs, and people who are kind of in advanced states of cardiovascular disease, I mean, these are not a joke, they’re very expensive, they’re essentially required for life for those people to continue to survive, and it really, what are you looking at right now around 45% of your total costs are related to pharmacy in particular specialty right now. 

So, a good way to kind of impact your pharmacy trend is to look at what are the root medical causes, and then what programs can we put in place to address those?  

Mike Stull (9:22) 

Yeah, and certainly from a pharmacy perspective, the cholesterol lowering drugs, the hypertension drugs are very cheap. Most of them are generics. And so, you know, just getting patients to be adherent with their medications is really important. 

Kind of moving forward a little bit in terms of what we wanted to talk to. So, since I mentioned adherence, you know, why is it so difficult to keep at-risk individuals adherent to their medications? And kind of to follow on that, how important are lifestyle changes in helping to, you know, combine with the pharmaceutical intervention to try to change and reduce heart disease?  

Jenn Roberts (10:15) 

When I worked as an exercise physiologist, you know, this was kind of one of the biggest issues that I would have with patients is that only around 50% of people get their medication filled. So, let’s just think about that for a second. 

They need it, but they don’t want to get it filled. And why? Like, what is the psychology going on behind that? So, think about a recently person diagnosed with diabetes or high cholesterol or blood pressure. You’re like, now I’m going to have to take this the rest of my life. Now I’m this person, right? And it really is a hard shift to adjust to. I mean, there’s other issues, you know, in terms of cost and access and things. But like you said, these are really cheapest chips types of drugs. 

So, that generally isn’t an issue, maybe $3 at CVS to get it filled. So, it’s something about the psychology related to taking it. Like, I’m a sick person and people, one, don’t get it filled and if they do or not complying, we look at the fill rates and they’re poor, right? If you get 80%, 85%, that’s great, but, you know, you really need 100% or those are your potential high-cost claims people lurking behind. And one of my favorite features about Hello Heart is actually the medication adherence module. So, you’re going to put your medications in, but then there’s really this gamification to encourage you and provide positive support and coaching related to adherence. 

You’re also able to kind of hover over the medications that you’ve put in. Why am I taking this, in layman’s language at a low literacy and low health literacy level. You can get contraindications, med reconciliation is done through the app as well. And then let’s say that you are compliant and you’re taking that drug, you know, every single day, you’re indicating that you took it on your reminders and let’s say your blood pressure still is not going down, then you’re going to be prompting the app to send this report to your provider and make an appointment.   

And then the app will actually help you make an appointment if you need that as well. And I think, you know, having worked in clinics, you give someone this diagnosis and you give them a script, and then you’re like, come back in six months, and we’ll see how you’re doing. And we’ll shoot, what just happened in that six month period? Did it actually work? So, if you’re not measuring, you don’t know if it’s working. 

That means your doctor doesn’t know if it’s working. So, you kind of can be in this limbo area until you get the right dosage and the right combination of meds to help you stabilize. And then to your second point, you’ve got to work on lifestyle. 

So, you can’t reverse certain conditions and you can’t repair, let’s say, structural damage to your arteries and things like that. But you can get yourself in a nice homeostasis. So, exercising, nutrition, reducing risky behaviors like smoking and alcohol and then stress reduction. These are all things that are part of lifestyle change coaching that’s within the app as well.  

Mike Stull (13:07) 

Yeah. I wish there was the miracle drug where you didn’t have to change lifestyle in order to…

Jenn Roberts (13:12) 

Oh, I thought you were going to bring up the miracle drug, the GLP-1s. 

 Mike Stull (13:16) 

Yeah. Well, certainly the GLP-1s, they’ve been one of my favorite topics recently. So, like Ozempic and Wegovy, obviously a lot of headlines, a lot of social media in their ability not only to treat type 2 diabetes, but also to help with weight loss. But we know that the price tag’s pretty high. We know that the universe of people that are eligible for these drugs can be really high. 

And so, curious what you guys are thinking about as it comes to strategies for employers in evaluating this drug class.  

Jenn Roberts (13:56) 

I was actually recently at a meeting with some top 100 employers and this conversation came up. And it was interesting to me that these employers were actually putting in the highest level of prior authorization for this drug, meaning you actually had to have a diagnosis for diabetes. 

There was no off-label use. And then even in the case for the ones that are marketed directly for obesity, that there was some kind of step therapy or different things that you had to do before you could get the script and then stay on the script. So, with that, I would say, from my clinical background, it’s not a magic pill. 

You stop taking it, you’re going to gain weight back. When you go off that med, if you haven’t changed anything in your life, everything just comes right back. And then that can even lead to like depression and stress. So, I feel like that’s, it’s risky. It’s a risky strategy. That being said, you know, maybe some people just need kind of to get over a hump or to get a jumpstart. 

And so, maybe it can be effective for them in the short term. But what these employers were saying is that, but I’ve got to give the employees something. When they come and complain, you know, and you have that kind of member issues, like, ‘why can’t I get this drug filled? You know, I really want to make a change in my health’ so to have something to offer them. 

So, the core of that is actually lifestyle change. So, I think it’s somewhere where Hello Heart could really slip in and kind of support those, whether it be step therapy or a replacement, but we are still offering something that will help you on your lifestyle change journey.  

Mike Stull (15:24) 

Yeah. I know a lot of the PBMs, you know, the labeling is in conjunction with some type of lifestyle program, but I mean, how are they going to, how are you going to prove that outside of attestation? So, you know, I think employers are going to be challenged if they want to cover these medications and they want employees and dependents to be in some type of program. It’s probably something they’re going to have to provide as well. 

Jenn Roberts (15:57) 

I think they’re a real pitfall kind of in the advent of wellness programs, especially web-based or app-based ones where, on the surface, they sound great. Let’s incentivize people for doing it. And then as soon as the incentive is achieved or the incentive goes away, you end up with like 5% participation, right? And that could be, they’re just kind of looking stuff up on the, you know, health education, different things like that. So, to really move people into something actionable that’s measuring outcomes. 

So, something like blood pressure, pulse, weight, physical activity, and then actually coaching the members on where those levels are and how to move them in the right direction, helping create this dot-to-dot connection between, you know, you walked five more minutes a day every day this week than last week and look at your blood pressure has reduced. You know, those are things that are tangible and something people can do right now instead of saying, ‘Oh, you need to get 10,000 steps a day every day for the rest of your life. That’s a mountain to climb, right? But could you walk five minutes more, even if you didn’t walk at all yesterday, or you ran five miles, can you do five minutes more and it’ll make an impact?  

Mike Stull (17:07) 

Yeah, I like that idea. You talked a little bit about specialty medication for different cardiac conditions. Could you talk a little bit more about that?  

Jenn Roberts (17:20)  

Well, an interesting one to me is Leqvio. So, I’m seeing commercials for it. 

I don’t know what I’m watching that I’m being targeted with all of these commercials. But what’s interesting to me is typically those commercials are for, you know, with the exception of maybe dermatological, they’re for a very, very small percentage of the population. And you’re like, ‘wow’. 

And then the side effects are insane, right? You’re like, who would ever take that? That does all of those things as a side effect. But this to me is like the first kind of mass marketed drug that what’s going to be 50, 40% of all adults in America are actually eligible for. And the prescription is actually if you’re on a statin and it’s not working, then you add this injectable around $18,000 the first year. 

So, if you think about it from an employer’s perspective, that’s just this huge risk that’s sitting there. You know, I think it’s popular, like the off-label use of weight loss drugs. Can you imagine the impact to your pharmacy plan if half of the eligible people went on it and doctors went on a tear prescribing it to everyone under the sun? And at the end of the day, if you’re on a statin and you’re not making any improvements, you probably need to get off the couch and move a little bit and stop eating at the end of the checkout aisle and go in the back where the fruits and vegetables are. 

I mean, that’s actually what you need to do. It’s not working because you have some, typically some biological thing and you’re special and a statin doesn’t work for you. You’re not doing the lifestyle factor. 

So, I think that’ll be interesting to see. You know, right now there’s all kinds of strategy in pharmacy relating to these GLP-1s because obesity is, you know, prevalent in our society. Essentially, everyone could be eligible for the most part, you know, the majority of adults anyway. 

But here’s another one right behind it in terms of hyperlipidemia. So, I think that’s one to be watching for, for sure.  

Mike Stull (19:11) 

And I know some of the criteria for being eligible for these drugs, especially the GLP-1s for weight loss has to do with BMI. 

And we had, it was interesting, like one of the thinnest people in our office, you know, comes up and we had listened to a presentation where they were talking about if you have a 27 BMI plus some other condition that you would be eligible for one of these. And he’s not at a 27, but he’s getting closer and he was just outraged. Like, how in the world? That’s crazy. 

And so, we’ve heard for years that BMI isn’t necessarily an accurate measure of, you know, obesity and being overweight because there’s so many other factors. So, to use that as kind of the main criteria of whether or not you’re eligible for these seems to be a little bit misplaced.  

Jenn Roberts (20:09) 

And it’s tough because at the end of the day, biopharma is out to make money, right? So, they want as many people on them as they can. 

And even when we look at our PBMs, they want that fill rate to be as high as possible. Those aren’t like wrong on the face, but there definitely is some overprescribing. I think we saw this in the, say, the 90s with late 2000s with Prozac and teens and young college kids. 

I think when I was in college, we were the Prozac nation. And then you see it with Adderall right now with people who really don’t need it, but find the competitive edge. And I think you’re probably seeing this on your members’ plans also. 

Like, to see that class of drug be in the top 10 when 10 years ago, you would have whatever single digit numbers of kids who, young kids who actually really have severe ADHD on it. And now it’s just like, you can get it like that. Anybody is essentially eligible.  

Mike Stull (21:10) 

So, when it comes to plan design, what are some of the best practices that you’re seeing from employers that they can put in place to help employees improve their cardiovascular health? 

Jenn Roberts (21:22) 

I think the number one thing is to kind of look at it more from a longer term perspective and not just a year to year perspective. So, especially for employers, like in the government sector where they retain their employees longer, they may even have them on their plans after retirement, including their members, even if it’s a dual plan with Medicare or Medicare Advantage. Like, you’re invested in these employees’ health, right? There’s an impact related to your medical plan and your pharmacy costs.  

But what actually surpasses that is productivity and absenteeism. So, if you’re in an industry like, let’s say, schools, that’s a real finite cost that we can measure if your people are out and what you’re paying for substitute. I had a client that was a school district, and their bus drivers were not passing the dot physicals. 

So, they literally had to rent out thousands of dollars a day of coach buses, like rockstar buses, to go do their routes and pick up the kids. So, I would say you want to look at not only medical and pharmacy, but how does that impact productivity in terms of absenteeism? And then think about the strategy. So, if I decide today that I want to lose weight, just because I decided it’s not going to happen tomorrow, it’s going to take me time to work through that behavior change arc and to really make an impact. 

If my weight goes down five pounds next week, I’m not better, right? It’s going to take a while for my body to adjust. So, really think of it more in the long term and how many people this is going to impact. So, I think fertility is a good example where it’s a very small percentage of your population that could utilize that service. 

I mean, it is generally an expensive service, but the kind of destination employer benefit of that really drives a lot for recruitment and retention. You know, in the case of cardiovascular disease, I don’t have to look at your data to tell you you have a problem. We know, everybody does. It’s the number one killer. It’s the number one highest cost in America. So, to just kind of ignore it, like individuals ignore, you know, their own hypertension or high cholesterol is really the wrong direction. 

So, thinking about putting in a multi-year strategy approach that incorporates what we know works, which is lifestyle change, as well as medication adherence and keeping people going to primary care. So, we don’t want those medically homeless people, so they have insurance but haven’t been to a doctor in three years because you see them and then you see them on your high-cost claims when they show up at the EC or the UC. So, a strategy that’s going to drive primary care, a strategy that’s going to drive medication adherence and focus on those lifestyle factors that are going to improve not just your heart health, but really any and all chronic conditions. 

If you’re healthier today and you get the flu, you’re going to have a lot better experience than if you have out of control blood pressure and diabetes and you get the flu. I mean, we saw that with COVID as well. So, I think it’s a general health and wellness strategy to put in a heart strategy at your employer. 

Mike Stull (24:17) 

And we know that employers are, you know, getting messages from third-party solutions all the time. And a lot of them are siloed to focus on a specific condition or healthcare disease or therapy. And so, you know, one of the thoughts that I had was, you know, you think about how much we spend just in general on healthcare services. 

So, it makes me wonder, you know, why are the gaps occurring in the first place? So, if cardiovascular deaths are at the top of the chart, I would think that the healthcare system, and I use ‘system’ lightly, would prioritize fixing it. Is it because we’re paying only when people get sick, and so there’s all these gaps on the preventative side? Or why is this such a big issue that it seems like we need all these different entities to try to fix it?  

Jenn Roberts (25:24) 

I think it’s so prevalent that we almost forget about it and dismiss it. So many people have it. 

We’re just kind of like, of course, their blood pressure’s high too. I can give you a really good example if you feel like talking about women, Mike.  

Mike Stull (25:40) 

Go right ahead. 

Jenn Roberts (25:43) 

Okay. So, the deadliest gap in healthcare is actually in women’s health related to cardiovascular. So, women are two times more likely to die of a cardiac event. 

I was just like, stop for a second. I’m a woman, you’re a man. We have someone joining us who’s also a woman. 

We’re two times more likely to die. Why is that? Part of that is that symptoms are different biologically based and what is out in commercials and sitcoms and even in some kind of respected institutions are the typical male symptoms of a heart attack. So, women’s symptoms are much different. 

They feel generally unwell. They may feel anxious. They may feel like they’re having an arrhythmia, but not sure. So, there’s really like this self-doubt because the public message is not out there. Now that’s on the individual. Then the second thing is when they go into the provider, the provider also dismisses those symptoms as anxiety. 

You’re much more likely to be diagnosed with or even hospitalized with blood pressure if you’re a man versus a woman. And this goes besides the gender of the provider as well. You’re also going to take seven minutes longer to actually get a stent when they diagnose a problem because they’re still like, oh, well, maybe this is this and not that. 

Yeah, their blood pressure is high, but it’s probably not a cardiac event. And then people actually get sent home and die from it, frankly, which is leading to that two times greater. So, there’s bias in healthcare systems. There’s bias in providers. There’s bias in medical education training. I think that contributes to it. I think another issue is just the individual, like we talked about earlier, psychology. I don’t want to be a sick person. I can’t feel this. 

It’s not stopping me from doing anything right now. So, I’m just going to, you know, blinders on and move forward type of a thing. So, kind of on the individual, but also on the system. 

Mike Stull (27:38) 

That’s great information and a great point and a great perspective that I’m glad you brought up. So, we talked a lot about all things cardiovascular today. Anything we missed?  

Jenn Roberts (27:54) 

Well, we’re working on a campaign right now, and it’s Sense Something, Say Something. 

So, it’s specifically for women and related to Women’s Health Week. Yes, that’s right. We only get a week. So, that’s kind of cool. But for Women’s Health Week, that’s coming up. And it’s like, if you feel these symptoms and they’re kind of unidentified, then to actually say something and go see your provider. Better to be safe than sorry. We want to make an impact on that two times more likely to die from a cardiac event. And that means you have to be in charge of your own health. 

So, helping empower your employees and your family members, your mom, your sister, your daughter, your friends. Like, get this message out and really we can make an impact.  

We’ve seen this with breast cancer. Rates have gone down. Mammogram rates are up. Thank you for the pink ribbon. So, we need something like that for heart health and especially for women.  

Mike Stull (28:47) 

And is there a website or is there somewhere they can go to learn more?  

Jenn Roberts (28:51) 

Yeah, you can definitely go to helloheart.com. And then I would always steer people. There’s a lot of great personal resources you can use for yourself or for your employee base at the American Heart Association. 

Mike Stull (29:03) 

Excellent. Well, thank you, Jen, for joining us. I really appreciated the conversation today. 

Really enjoyed it. And hopefully we’ll have you back again.  

Jenn Roberts (29:12) 

Thanks, Mike. 

Mike Stull (29:14) 

Thanks, Jen. It’s always great talking with you and the team at Hello Heart. Before we end today’s episode, I want to thank our sponsors for helping us not only make the podcast possible, but really supporting us and providing great employee benefits related content throughout the course of the year. 

So, thanks to our annual supporters, CVS Health and OptumRx, and our executive supporters, Delta Dental, the Diabetes Leadership Council, Hello Heart and Pfizer. You can visit employershealthco.com/supporters for a full list of all of our sponsors. There’s always something new going on here at Employers Health, so be sure to follow us on our social media pages including LinkedIn and Twitter to stay up to date and be sure to subscribe to HR Benecast.