I am happy to contribute to the editorial by Lisa Eramo published in Medical Economics, January 2018. The article is important as it raises physician awareness of Merit-based Incentive Payment System (MIPS) under which hypertension management falls. MIPS, part of 2015 MACRA, will go into effect in 2019.
Addressing hypertension can aid value-based scores
New guidelines from the American Heart Association and the American College of Cardiology mean 30 million more U.S. adults could now be classified as having high blood pressure.
The updated guidance means primary care physicians will be having more discussions with patients regarding hypertension. Meanwhile, physicians who engage patients to monitor their blood pressure, make lifestyle changes and take their medications may receive a bonus for controlling long-term costs. That’s because hypertension is one of many conditions targeted under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the federal law that seeks to reform Medicare payments while improving outcomes and reducing costs.
Beginning in 2019, physicians participating in the Merit-based Incentive Payment System (MIPS), one of two participation tracks under MACRA, will be penalized for costs that exceed anticipated amounts, or rewarded for keeping costs under the projected amounts.
By engaging patients, physicians choosing to report on hypertension measures may boost their quality scores and receive a bonus under MIPS. These three quality measures can help physicians gain points:
- Controlling high blood pressure (i.e., keeping it below the new target of 130/80 mmHG during the measurement period)
- Improving blood pressure (i.e., lowering blood pressure at least 10 mmHG as compared with the baseline or controlling it adequately)
- Screening for high blood pressure and follow-up documented (i.e., screening patients ages 18 years and older, and documenting a follow-up plan when patients are pre-hypertensive or hypertensive)
Many physicians don’t realize that their Medicare reimbursement will directly correlate with patient outcomes, says Glenn Krauss, CCS, CCDS, a reimbursement and documentation improvement consultant in Burlington, Vermont. Physicians who plan to report on hypertension measures need to start thinking now about how to improve outcomes, he adds.
Monitor patients’ hypertension regularly
The electronic health record (EHR) is one of many tools physicians can use to engage and monitor hypertensive patients to improve their MIPS score. For example, Stasia Kahn, MD,an internist at Symphony Medical Group in Carol Stream, Illinois, uses the ’EHR's patient portal to remind patients to make an appointment quarterly. As many as 35% of her patients have the disease, and 75% use the practice’s portal.
“We’re very persistent with our alerts,” she says. Patients receive three automated portal messages reminding them to schedule an appointment. If they don’t respond, a nurse calls them to schedule a day and time. Though she doesn’t have any data that directly correlates the EHR reminders with improved outcomes, she suspects that this method of continual follow-up helps keep patients mindful of their health. Patients who don’t use the portal receive phone call reminders to schedule follow-up appointments every four months.
Every patient should undergo routine blood pressure checks when they’re in the office, says Gerti Tashko, MD, a Washington, D.C.-based endocrinologist and clinical hypertension specialist certified through the American Society of Hypertension. That’s the most effective way to identify cases of hypertension, he adds. This includes cases of borderline hypertension that, with diet and exercise, can potentially improve over time. About half of Tashko’s patients have hypertension as well as diabetes or metabolic syndrome, both of which complicate treatment.
Asking patients to self-monitor blood pressure is another way physicians can improve their MIPS score, says Nancy Enos, CPC, CPMA, coding and practice management consultant in Warwick, Rhode Island. The idea is that by having patients self-monitor their blood pressure, they may be more likely to improve it, she adds.
“When patients see their own blood pressure measurements, it makes them more conscientious about taking their medications,” Tashko says, adding that he encourages patients to monitor their own blood pressure and bring their results with them to the office. “That way, I can see the trend over a period of time,” he says. “That makes the patient more responsible and more aware so they can ask questions.”
Kahn gives patients a blood pressure log to help them track their blood pressure daily. She also provides patients with a list of health apps that can help with the tracking. Some can even take a patient’s blood pressure automatically by collecting and analyzing a photoelectric pulse wave signal.
Tashko also uses 24-hour ambulatory blood pressure monitoring (ABPM) for patients with continually uncontrolled high blood pressure. With ABPM, patients are hooked up to a blood pressure cuff at home that takes a measurement every 20-30 minutes while awake or asleep. After wearing the device for 24 hours, patients bring it to their appointment the next day where staff members download the data, print out the results, and scan that information into the EHR for analysis.
Ask patients to align blood pressure measurements with certain activities (e.g., physical exertion, stress, or anxiety), says Maxine Lewis, CPC, CPMA, a coding and practice management consultant in Cincinnati, Ohio, because doing so helps identify potential causes of fluctuations or spikes.
Address medication non-adherence
Cost is one reason why patients may not take their hypertension medication as prescribed, and addressing this barrier can help physicians improve their MIPS score. For example, Kahn prescribes generic medications when possible. She also directs patients to prescription coupons and savings cards. “You have to be willing to work with the patients,” she says. “You don’t want to prescribe something, and then the patient doesn’t take it because they can’t afford it.”
Another challenge is that many patients don’t always make hypertension medications a priority, says Tashko. “Because hypertension is a silent condition, it’s a natural human response that if you don’t feel symptoms, maybe you don’t need the medication.”
Tashko reminds patients that medication adherence is essential because data over the last 50 years proves that lowering blood pressure reduces the likelihood of cardiovascular illness, kidney disease, heart failure, stroke and myocardial infarction. He also emphasizes that uncontrolled blood pressure increases the risk of death from heart attack or stroke.
Older patients with memory problems often struggle the most, says Tashko, so he takes the time to help these patients organize and identify their pills based on color and shape. He also encourages patients to bring a friend or family member with them to the appointment who can help keep them on track with their medication regimen.
Focus on diet and exercise
Physicians may also see a boost in their MIPS score by helping patients lose weight and eat healthily. Kahn says many of her patients have hypertension due to obesity, which is why she tries to focus not only on blood pressure self-monitoring but also on weight loss. Talking with a patient about his or her body mass index (BMI)—and what they can do to change it—often inspires change. Using BMI is helpful because it serves as an objective criterion, she says.
Be prepared to talk with patients about what foods can help lower their blood pressure—and what foods patients with hypertension should avoid, says Lewis. Another option is to refer patients to a dietician. When patients do lose weight, it’s important to praise them, Lewis says, adding, “Support them in their endeavors.”
By Lisa Eramo, MA