HJNO Jan/Feb 2024

CHANGING THE CARE: LIVER DISEASE 22 JAN / FEB 2024 I  HEALTHCARE JOURNAL OF NEW ORLEANS   back, with return of obesity’s harm to her meta- bolic health, including her A1c returning to double digits. Only now, she is also suffering from osteoporosis at the relatively young age of 54 due to years of chronic vitamin D and calci- um malabsorption. She now has secondary hy- perparathyroidism as a result and also requires periodic infusions of intravenous iron because of recurrent iron deficiency, all of which are di- rect consequences of her weight loss surgery. She came into my clinic a few years ago and has since lost all of her weight again, getting back down to a normal body mass index and achieving an A1c < 7 for the first time in her diabetic life. She achieved her success because of an approach that utilized unlimited behav- ioral therapy to deal with her maladaptive eat- ing habits, ongoing health coaching, nutritional support counseling, and longitudinal care de- livered by a multi-disciplinary care team. The type of care she received would not have been possible if her insurer was a commercial health plan that paid for care through typical transac- tion-based financing through encounters, while placing limitations on the number of times she could see a dietitian or a behavioral therapist, and while not paying at all for health coaching. While her story is anecdotal, it is also illustrative because I have seen too many patient stories like hers to believe that bariatric surgery is the answer for everyone. Having said that, it is the answer for some. For reasons discussed in this and prior articles, the economic forces of trans- action-based financing are still aligned against this type of “advanced” primary care becom- ing the normative standard. I am optimistic that the situation can change, but only when payers and providers learn how to hold themselves ac- countable a shared mission focused on achiev- ing long-term health outcomes improvement in the populations they serve. Doing so will mean commercial payers eventually changing how they pay for care, transitioning away from fee-for-service for primary care and toward risk- adjusted population-based payments that in- centivize providers to reduce total cost of care through innovations in how care is delivered. Managing MASH Optimal management of MASH first depends on recognizing it. Depending on the geogra- phy, about 40% of people suffer from obesity. When I see a patient with obesity, it has be- come my habit to carefully scrutinize their re- cord to see if they have ever had an abnormal liver enzyme measurement. Concomitantly, I also scan their record for any history of abdom- inal ultrasounds, CAT scans, or MRIs. Finding evidence of hepatic steatosis on an imaging study provides the diagnosis of MASLD. Even if they only have one remote, isolated mildly elevated liver enzyme, I perform an abdominal ultrasound looking for evidence of fat in the liver. If fatty liver is present, then I diagnose them with MASLD, and I screen them for dia- betes if that has not already been done. Next, I calculate their NAFLD fibrosis score, along with a Fibrosis-4 score, using clinical data to identify those patients at highest risk of advanced fibro- sis. Regardless of the scores, I follow these pa- tients very closely; but if their score is indeter- minate or high, then I perform elastography to measure liver stiffness, which is a measurement of fibrosis and its stage. I believe that vibration controlled transient elastography (Fibroscan) or MRI elastography are the most sensitive tests to detect fibrosis, with Fibroscan being a little easier and less expensive. The measurement informs us about the severity of their steatosis but more importantly whether or not they have fibrosis and its stage. For patients with F0-1 — the earliest stage — fibrosis, I simply repeat elastography at intervals of every one to two years to monitor for progression. Patients with F2 fibrosis warrant annual assessment of various labs including liver enzymes, bilirubin, albumin, platelet count, and prothrombin time/INR as well as annual ultrasound screening for early detection of liver cancer. Alpha fetoprotein levels can also be considered for liver cancer screening but do not obviate the need for ultra- sound screening. If the patient has F3 fibrosis, then these same labs and imaging are repeat- ed every six months. I create reminders in the electronic medical record of when these tests are due to make sure that there is no chance of these patients falling through the cracks with resultant lapses in disease monitoring. Meanwhile, rather than wish for the release of a drug that helps reduce the amount of fi- brosis in the liver, my focus turns in full force toward trying to achieve > 10% reduction in their weight. Use of drugs like semaglutide (Ozempic and Wegovy) or tirzepatide (Moun- jaro) can prove very useful to help patients achieve weight loss but remain quite expen- sive and outside the reach of many patients because of lack of insurance coverage or ex- orbitantly high co-pays, even as the drug com- panies, PBMs, and payers play a rebate game that keeps prices elevated. In these cases, I rely heavily on less expensive, generic combina- tion therapy with phentermine/topiramate or bupropion/naltrexone but explain to patients that all these medications, including the newer more expensive agents, are like life preservers or rafts that will help them get across turbu- lent waters but will not help them learn how to swim. I then explain to them that unless they are actively conditioning themselves and tak- ing “swimming lessons,” they will inevitably become dependent on this “raft” for the rest of their life, meaning they will gain all their weight back as soon as they stop taking the medica- tion. Drug manufacturers and PBMs certainly prefer this latter option. But if these patients put the work into correcting their maladaptive coping mechanisms and stress-related eating patterns through behavioral therapy, while en- hancing self-efficacy and forging healthy habit development through ongoing health coach- ing, they can successfully implement lifestyle modifications and get to a point where they no longer need a life preserving raft to get across turbulent waters. And, at least to me, that type of care becomes the medically appropriate life- saving therapy that warrants long-term invest- ment by those who ultimately pay for care. n REFERENCES 1 Muoio, D. “Nearly a quarter of hospital stent procedures are unnecessary, fueling billions in low-value spending, Lown Institute finds.” Fierce Healthcare, Nov. 1, 2023. https://www. fiercehealthcare.com/payers/22-hospital-stent- procedures-are-unnecessary-fueling-billions- low-value-spending-lown 2 The Commonwealth Fund. “U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes.” Issue briefs, Jan. 31, 2023. https://www.commonwealthfund . org/publications/issue-briefs/2023/jan/us- health-care-global-perspective-2022 3 Shah-Neville, W. “Biotech’s battle against NASH: The ongoing pursuit of an effective treatment.” Labiotech, Oct. 19, 2023. https://www.labiotech . eu/in-depth/biotech-nash-treatment-pursuit/