Rishi Wadhera, MD, MPP, MPhil, is a cardiologist, health policy researcher, and associate professor at Harvard Medical School and the Harvard T.H. Chan School of Public Health.

Rishi Wadhera, MD, MPP, MPhil

Rishi Wadhera, MD, MPP, MPhil
Credit: Harvard T.H. Chan School of Public Health

 has long defaulted to siloed, disease-specific metrics. 

cardiovascular-kidney-metabolic (CKM) syndrome, advanced by the American Heart Association

, challenge clinicians to recognize cardiovascular disease, metabolic syndrome, and kidney disease as a pathophysiologically interrelated syndrome requiring integrated management rather than sequential single-disease treatment.

Cross-specialty prescribing has historically lagged behind the evidence. SGLT2 inhibitors and GLP-1 receptor agonists carry proven benefit across cardiovascular, renal, and metabolic domains, yet their use has long been siloed within endocrinology. 

The CKM framework is accelerating a shift: cardiologists and nephrologists are increasingly prescribing across traditional specialty boundaries, with accountability for optimal therapy now expected across all clinicians managing these patients.

The policy environment shapes both the ceiling and the floor of what the care cascade can achieve. The Inflation Reduction Act introduced Medicare drug price negotiations and a $2,000 annual out-of-pocket cap, 7 of the first 10 drugs selected for negotiation treat cardio metabolic or cardiovascular conditions. Offsetting this tailwind, the recently passed HR 1 is projected to cut $1 trillion from Medicaid, with the Congressional Budget Office estimating approximately 16 million people will lose health coverage, directly threatening medication access for patients managing hypertension, diabetes, and dyslipidemia.

, Rishi Wadhera, MD, MPP, MPhil, associate professor of medicine at Harvard Medical School and associate director of the Smith Center for Outcomes Research at Beth Israel Deaconess Medical Center, 

 addressing performance metrics, specialty silos, and the policy forces reshaping the cardio metabolic care cascade.

Q&A: CKM Care, IRA Policy, and Specialty Silos, With Rishi Wadhera, MD, MPP, MPhil

HCPLive: Do current performance metrics adequately capture integrated cardio metabolic risk, or do they incentivize siloed disease management?

 We can't improve what we don't measure, so measurement — though imperfect — is an important first step toward improving screening, treatment, and control of cardio metabolic risk factors. Frameworks like cardiovascular-kidney-metabolic syndrome, or CKM syndrome, have moved us in the right direction. 

They recognize we can no longer treat these conditions in silos — cardiovascular disease, metabolic syndrome, and kidney disease all amplify one another and are interrelated from a pathophysiologic standpoint. As clinicians, we need to think about the syndrome and the conditions within it together. The AHA frameworks released recently are trying to accomplish exactly that, pushing clinicians and health systems to manage these conditions as a whole rather than in isolation.

HCPLive: Has cross-specialty prescribing responsibility for SGLT2 inhibitors and GLP-1s started to break down in this new era?

 Frameworks like CKM syndrome are breaking down barriers and silos between specialties. As clinicians, collectively, we need to take responsibility and be accountable for care delivery and optimal treatment for our patients. We are seeing those barriers broken down. Cardiologists are increasingly prescribing therapies for obesity and kidney disease that also protect the heart. Nephrologists are doing the same. That is exactly how we should be practicing and delivering medicine, and frameworks like CKM have helped drive that.

HCPLive: What policy tailwinds and headwinds are most relevant to the cardio metabolic care cascade right now?

 When we think about the cardiometabolic care cascade, we have to think about policy tailwinds and headwinds. 

One significant tailwind is the Inflation Reduction Act — major legislation that for the first time in the country's history directly addressed high and rising prescription drug costs. It caps Medicare out-of-pocket drug spending at $2000 per year and begins to negotiate prescription drug prices with manufacturers. Seven of the first 10 drugs selected for negotiation treat cardio metabolic risk factors or cardiovascular conditions. When you think about access, affordability, and adherence across the care cascade, the IRA has real potential to get therapies to patients. 

The headwind: the recently passed HR 1, the One Big Beautiful Bill Act, will deliver $1 trillion in cuts to Medicaid. The Congressional Budget Office estimates about 16 million people will lose health insurance coverage as a result. For the cardio metabolic care cascade, this could meaningfully erode our ability to help patients access therapies, adhere to them, and achieve control of hypertension, diabetes, and high cholesterol.

Editor’s Note: This transcript has been edited for grammar and clarity using artificial intelligence tools.

Ndumele CE, et al. 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome. 

American Heart Association. First-ever guideline on cardiovascular-kidney-metabolic syndrome issued. American Heart Association. Published June 9, 2026. Accessed June 24, 2026. 

https://newsroom.heart.org/news/first-ever-guideline-on-cardiovascular-kidney-metabolic-syndrome-issued

Connor Iapoce. HHS Targets 15 Drugs for Medicare Part D Negotiations, Including Semaglutide. Hcplive.com. Published January 17, 2025. Accessed June 24, 2026. 

https://www.hcplive.com/view/hhs-targets-15-drugs-for-medicare-part-d-negotiations-including-semaglutide

Articles

Cardiometabolic care is shifting from disease-specific metrics toward integrated assessment under the cardiovascular-kidney-metabolic (CKM) syndrome framework, reflecting shared pathophysiology and mutually amplifying risk. Measurement remains an imperfect but necessary lever to improve screening, treatment, and control. Specialty boundaries around SGLT2 inhibitors and GLP-1 receptor agonists are eroding, with cardiology and nephrology increasingly accountable for cross-domain prescribing. Policy dynamics will strongly influence access and adherence: the Inflation Reduction Act improves affordability via negotiation and caps, while HR 1 Medicaid cuts threaten coverage and medication continuity.

Rishi Wadhera, MD, MPP, MPhil, addresses performance metrics, cross-specialty prescribing, and the policy forces reshaping the cardiometabolic care cascade.

Despite decades of therapeutic advances, the cardiometabolic care cascade remains fractured at nearly every stage. 

Awareness deficits are substantial: among adults aged 20 to 44 with hypertension, nearly 40% are unaware of their diagnosis, and only 1 in 3 adults with diabetes knows they have the condition.

 therapies have widened the gap further. SGLT2 inhibitors and GLP-1 receptor agonists reach only about 1 in 5 eligible patients with diabetes. The barriers are multilayered: coverage limitations, out-of-pocket costs, and clinical inertia each contribute, and no single intervention will close them.

The gap between what evidence recommends and what clinicians deliver has never been wider. Closing it requires simultaneous action at the clinician, health system, community, and policy levels from EHR-embedded decision support and AI-guided care tools to population health dashboards, remote monitoring, and community health worker deployment. 

, Rishi Wadhera, MD, MPP, MPhil, associate professor of medicine at Harvard Medical School and associate director of the Smith Center for Outcomes Research at Beth Israel Deaconess Medical Center, sat down with HCPLive to discuss where the cardiometabolic care cascade is failing most consequentially and what a multifaceted response must include.

Q&A: Cardiometabolic Care Cascade Failure Points, with Rishi Wadhera, MD, MPP, MPhil

HCPLive: Where in the cardiometabolic care cascade do you see the most consequential failure point today?

 We see failures across the cardio metabolic care cascade in every dimension, and it varies from condition to condition. If you think about hypertension, the burden is staggering — 1 in 2 adults in this country has hypertension, and among young adults aged 20 to 44, almost 40% aren't aware they have it. With diabetes, only about 1 in 3 adults with the condition knows they have it. On awareness, we can do better. Across the treatment and control spectrum, we can do better too. Where we are doing better for conditions like hypertension and diabetes is treatment — a lot of people are on therapies. But where we're failing is control: up-titration of therapy, getting people to guideline-recommended goals for blood pressure or hemoglobin A1c, is a major gap right now.

HCPLive: Despite highly effective therapies across diabetes, lipid control, blood pressure, and weight loss, why do population-level control rates remain persistently suboptimal?

 About 70% of US adults with diabetes receive some sort of treatment — that's pretty good compared to many other cardio metabolic risk factors. But it's not about whether they're getting therapy; it's about what type of therapy they're getting, and that's where we're facing challenges. When you think about novel therapies — SGLT2 inhibitors and GLP-1 agonists, newer therapies we know protect the heart and the kidneys and can meaningfully improve outcomes for patients with diabetes — only about 1 in 5 eligible patients are getting them. That is a coverage problem, an out-of-pocket cost problem, and to some degree a clinical inertia problem. Any strategy addressing gaps in novel therapy use needs to be multifaceted: targeting clinical inertia, health system inertia, and the broader policy issues around access and affordability.

HCPLive: How should clinicians navigate the disconnect between guideline-directed cardiometabolic care and real-world implementation?

 The gap between what we know and what we're actually delivering has never been wider, and it is problematic. Some of it is access and affordability for novel therapies — but that is not the case for antihypertensives, so we do have a pure implementation gap when it comes to blood pressure control. Only 1 in 4 adults with hypertension achieves adequate blood pressure control — that's a health system failure, an implementation failure. Addressing those gaps has to be multifaceted. At the clinician level: EHR-embedded decision support tools, and increasingly AI-guided approaches to enhance care delivery. At the health system level: population health dashboards and remote monitoring technologies. At the community level: deploying community health workers and meeting patients where they are for screening and diagnosis. At the policy level — which I think of as one of our most powerful cardiovascular interventions — making novel therapies more accessible and affordable.

Editor’s Note: This transcript has been edited for grammar and clarity using artificial intelligence tools. 

Anderer S. More Than Half of US Adults With Uncontrolled Hypertension Don’t Know They Have It. JAMA. 2024;332(17):1417. doi:10.1001/jama.2024.20117 

Kalyani RR, Neumiller JJ, Maruthur NM, Wexler DJ. Diagnosis and Treatment of Type 2 Diabetes in Adults: A Review. JAMA. 2025;334(11):984–1002. doi:10.1001/jama.2025.5956 

Cardiometabolic outcomes remain constrained by pervasive failures in the care cascade, spanning diagnosis, treatment selection, and attainment of guideline targets. Awareness gaps are pronounced, particularly among younger adults with hypertension and across diabetes. Although many patients with diabetes receive some therapy, control lags due to inadequate titration and underuse of high-value cardioprotective and nephroprotective agents. Uptake of SGLT2 inhibitors and GLP-1 receptor agonists is limited by coverage, cost-sharing, and clinical inertia. Closing the evidence-to-practice gap requires coordinated clinician, system, community, and policy interventions.

Rishi Wadhera, MD, MPP, MPhil, discusses where the cardiometabolic care cascade is failing most consequentially at the 10th Annual Heart in Diabetes Meeting.