Remote Hypertension Monitoring Improved Medication Use, Raised Costs

Emily Harris

doi:10.1001/jama.2023.22936

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November 22, 2023

Remote Hypertension Monitoring Improved Medication Use, Raised Costs

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Article Information

JAMA. 2023;330(22):2146. doi:10.1001/jama.2023.22936

The remote transmission of blood pressure data from patients to their clinicians, or remote patient monitoring (RPM), improved several measures of hypertension management and also increased health care spending, according to from 192 practices that used RPM for many of their patients with high blood pressure (鈥渉igh-RPM鈥� facilities) and 942 practices with little RPM use.

Patients with high blood pressure at high-RPM practices increased their use of hypertension medications, had more medication adjustments, and visited their primary care physicians more often than those who attended low-RPM practices. They also spent more money on total hypertension-related care.

Because most people start hypertension medications during the first months of RPM, insurers such as Medicare could think about limiting reimbursements to those first 6 months to offset the increased costs linked with RPM, the researchers suggested in Annals of Internal Medicine.

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November 26, 2023

Alternative Interpretation of This Observational Study

Joseph Humphry, MD FACP, CPHIMS | Lana'i Community Health Center (retired)

The study design reflects the impact of the COVID epidemic related to remote patient monitoring (RPM) and hypertension management. In 2013 a randomized controlled trial of a highly structured RPM program reported improvement in hypertension control (1). Out-of-office BP monitoring either with remote patient monitoring or ambulatory BP monitoring is the standard of care both for diagnosing and managing hypertension, eg the ACC/AHA鈥檚鈥渙ut-of-office BP measurements are recommended to confirm the diagnosis of hypertension (Table 11) and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions鈥� (2).

The literature supporting the out-of-office recommendation was reviewed in 2021 (3) and the Million Heart Program has established recommendations for self-measured blood pressure (SMBP) (4). All patients who elect to co-manage their hypertension management with RPM should be provided an efficient delivery system such as implementation of SMBP.

The adoption of RPM and telehealth during the COVID pandemic occurred during a substantial drop in patient office visit and provider revenue. The RPM was a valid solution to the management of COVID but may not have been used effectively for management of hypertension. The codes used in the study, HCPCS codes 99453-4, 99457-8, and 99091, are not specific for hypertension, require monitoring more frequently than needed for hypertension management, and cost considerably more than the introduced January 2020, namely, $9 聽for CPT 99473 for educating the patient for SMBP, and $15 for the monthly RPM code 99474. The SMBP codes are undervalued, encouraging providers to use alternative codes. Alternative payment methods would encourage efficient use of RPM and telehealth.

Most patients with well-controlled BP need to monitor their SMBP for 1 week every 3 months like a required office visit for hypertension. SMBP requires team-based care. Patient engagement is substantially improved, and office visits are reduced for patients who are well managed. Phone contact or telehealth visits replace the inconvenience of office visits.

Traditional office BP management results in overtreatment, undertreatment. and treatment of patients with normal resting BP. This observational study indicates that most patients are not managed consistent with current evidence and guidelines. Using SMBP protocols, patients generate high quality data superior to office BPs resulting in improved patient outcomes and lower CVD risk. Current procedural coding provides incentives to require RPM for at least 16 days out of the month. These incentives do not make RPB convenient for the patient and increases the number of readings with no value in the management of hypertension, a chronic condition. Clearly a focus on patient outcomes rather than on the cost of care is aligned with high value care. The adoption of high-quality care needs to come before cost analysis.

References

1.听Margolis KL,听Asche SE,听Bergdall AR, et al. Effect of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Control:聽A Cluster Randomized Clinical Trial.听JAMA.聽2013;310(1):46鈥�56. doi:10.1001/jama.2013.6549

2.听Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC Jr, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71(6):e13-e115. doi: 10.1161/HYP.0000000000000065. Epub 2017 Nov 13. Erratum in: Hypertension. 2018 Jun;71(6):e140-e144. PMID: 29133356.

3.听Home blood pressure monitoring: methodology, clinical relevance, and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension (DOI: 10.1097/HJH.0000000000002922

4. Wall HK, Shantaram SS. Self-Measure Blood Pressure Monitoring (SMBP) Interventions: Resources for Planning and Implementation. https://www.cdc.gov/dhdsp/pubs/docs/cb-march2022-508.pdf

CONFLICT OF INTEREST: None Reported

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