Stepping Through a Patient’s Experience with Hypertension: Setting Rates and Negotiating Benefits

This is fourth of a multi-part series on a patient’s experience managing a chronic condition, in this case hypertension. A diagnosis has been made, and our patient has hopefully followed up and has hopefully been maintained on appropriate therapy (there is a 1 in 3 chance that this is happening). Now it is time for our patient’s health care sponsor (such as his employer) to review the health care benefit.

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Patient Story (Frydman)

There is no patient story in this phase. At some point during the year, our patient’s employer will discuss provided health care coverage with a health plan or plan(s) who have set rates for coverage in the coming year. On the diagram, there’s no red dot indicating the presence of data because in many (most?) cases there is not a lot of data to guide this conversation. Many health plans have claims data, to show how many services and what types have been paid for throughout the year. They may not have data about the effectiveness of those services. For example, they may not know what percent of office visits for high blood pressure showed effective control. On the employers’ part, they may not have much data, either. If they are self-insured, they may have similar levels of claims data, but not measures of performance.

Even in health care organizations with advanced electronic medical records, the determination of “% patients with appropriate blood pressure control” may not be done in an automated fashion – a random selection of charts may be used to come up with this percentage. The electronic health record may facilitate the selection and review of charts, but nothing more. This is dependent on the health care environment being studied.

(If there are health plan and providers who would like to inform this part of the story, comments are open)

Clinical and Public Health pearls (Houston-Miller and Eytan)

  • High blood pressure is one of the most costly conditions for employers, more than cancer, diabetes, heart disease, and behavioral health conditions. This does not take into account that hypertension is responsible for a significant amount of morbidity among patients with heart disease and diabetes. This post shows the costs of each. The first graph shows the cost per person with the condition. When you average the costs across an entire employed population, the large numbers of patients with hypertension escalates the cost of this condition above all others. For those people interested in the cost profile of chronic conditions to employers, The Center for Studying Health System Change hosted a forum where expert Ron Goetzel, Ph.D. provided an updated look at the data. It is compelling.
  • Fewer than 10% of the cases of undetected or uncontrolled hypertension could be associated with lack of health care use. In other words, health plans and employers are already paying for this current state. It does not exist because patients are not getting enough health care.

Comment

Where is the data? and What’s Missing? In this case, there isn’t much data in the conversation. The conversation is around use of services, and in that setting, an assumption is typically made that more services is better. The result is that these stakeholders cannot engage at their potential to ensure that services are as effective as possible.

It is possible that a patient or provider may share data about the effectiveness of their blood pressure control services which are being purchased and paid for by employer and health plan respectively. Blood pressure control is already a HEDIS measure, and is a development Pay for Performance measure in California in 2009.

Next post, the yearly checkback, completing the cycle. Comments welcomed, of course

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