Senior population requires high touch hypertension care

October 1, 2013

Remote monitoring helps plans keep tabs on member progress

Hypertension has high prevalence rates in the elderly and is linked to significant healthcare spending, driving some plans to increase their efforts to effectively prevent and manage high blood pressure in their older patient population.

One study using data from the National Health and Nutrition Examination Survey found that between 1999 and 2004, 67% of all U.S. adults over the age of 60 had high blood pressure.

Hypertension is not only prevalent in elderly adults, it can also contribute to serious and costly adverse events. According to a 2011 expert consensus document from the American College of Cardiology Foundation and the American Heart Assn., hypertension is the most important risk factor for cardiovascular disease in older Americans.

The consensus committee-which was co-chaired by Wilbert S. Aronow, MD, FACC, FAHA-also noted that approximately 69% of patients who have their first myocardial infarction had hypertension before the event, while that’s also the case for 77% of those who have their first stroke and 74% of those who experience incident heart failure.

“Seniors have a higher prevalence of hypertension, especially elderly women, and they are undertreated more than younger people,” says Dr. Aronow, professor of medicine at West Chester Medical Center/New York Medical College. “They have more comorbidities, and since hypertension is the number one contributing factor to cardiovascular disease, hypertension is a very major contributor to cardiovascular disease in the elderly.”

The Centers for Disease Control and Prevention estimates that high blood pressure costs the United States approximately $47.5 billion a year in direct medical expenses.

Managing Seniors

While many of the same recommendations to treat hypertension in younger patients-such as diet, exercise, medication and weight loss-ring true for the elderly as well, healthcare experts say there are certain factors that make this group unique and more difficult to treat. For instance, some seniors are no longer able to cook for themselves. Instead, they rely on packaged food or dining out, options that may make it more difficult to avoid sodium or maintain healthy eating habits.

“A low sodium diet is more important in the elderly than in younger people because they are more sodium-sensitive,” Dr. Aronow says.

CareMore, a WellPoint subsidiary that serves approximately 70,000 seniors in its Medicare health plans, has a chronic disease management program that works to specifically address care obstacles for seniors. Upon entering a CareMore plan, beneficiaries are given a healthy start exam that identifies any physical, social or mental health issues a patient may have.

Those patients who are identified for hypertension management services typically make up 15% to 20% of the plan’s sickest patients who have uncontrolled blood pressure.

Peggy Salazar, MSN, FNP, director of clinical programs, says education is an essential aspect of their “high touch” hypertension program, whether it’s teaching patients what signs and symptoms of high blood pressure to look for, how to take their medication or what kinds of foods will increase their blood pressure.

Experts agree that frequent and regular measurement of blood pressure-especially in the home-is also essential to effective management.

“Data from ambulatory blood pressure monitoring or data from home blood pressures more accurately correlates with cardiovascular events than blood pressure [readings] in the physician’s office,” Dr. Aronow says, adding that seniors blood pressure measurements should be taken both sitting and standing to get accurate results.

He says tracking methods don’t have to be sophisticated-a piece of paper and pencil may be all that’s necessary-but CareMore has turned to a real-time technique to monitor its patients at home.

Through their plan, patients are given a blood pressure device and trained how to take the measurements themselves at home. Data is transmitted back to CareMore where nurse practitioners are able to monitor the data on a daily basis. This data transmission is done automatically, making the technology easy to use.

“We set parameters for patients for alerts if the blood pressure goes over a certain number, and [the nurse practitioners] will call the patient,” Salazar says. “They will verify symptoms, verify blood pressure, have them re-check, check on whether they took their medications and treat.”

If a patient doesn’t measure their blood pressure for a day, a team will contact the patient directly.

“The challenges we get with some of our seniors is they are forgetful sometimes,” Salazar says. “They forget to take their medication, and sometimes they don’t have the support. They have limitations in their functional state.”

CareMore created a plan that centers around accessibility for its members.

“We have what we call care centers where we have our disease management programs, and they are located in the communities we serve,” says David Ramirez, MD, director of quality management for CareMore. “We also provide transportation to our members to get them to their medical services.”

Another challenge with seniors is that they are often on multiple medications, and Dr. Aronow says the best drug to use to combat hypertension often depends on the individual.

“You have to avoid drugs that raise blood pressure and interfere with the action of blood pressure,” he says. “For example, non-steriodal anti-inflammatory drugs, over the counter medications, increase blood pressure and they interfere with the efficacy of blood pressure lowering medications.”

Dr. Ramirez says CareMore looks at the whole patient before making medication decisions to try to avoid any drug interactions or safety concerns.

“Our clinicians are very experienced in dealing with patients who have 10 to 15 different medications,” Dr. Ramirez says. “The side effects and the dosing is a little bit different for the elderly, and that comes with the experience of taking care of a senior population.”

Curbing Costs

Healthcare experts agree that prevention and management is more cost effective than paying for later adverse events related to high blood pressure.

“Health plans could give out free medication and they would save money in the long run,” Dr. Aronow says.

One health plan has essentially done just that for its highest risk Medicare members. In 2013, Humana partnered with Walmart to offer a plan for their Medicare Part D members that offers 10 hypertension medications for a penny if the prescriptions are filled at a Walmart or Sam’s Club pharmacy.

Betsy Warren, PharmD, director of Medicare Pharmacy for Humana Pharmacy Solutions, says beneficiaries in the plan were able to purchase medication for that price regardless of whether they had met their deductible or if they were in the coverage gap.

The company chose hypertension medications for the partnership due to its high prevalence in Medicare members.

“We picked a category that had a wide variety of generic drugs available, and because of the prevalence of hypertension, we just thought it was a nice match,” Dr. Warren says.

Research has shown that reducing the patient’s financial obligation has significant impacts on adherence.

A previous 2004 study done by Dr. Aronow and his colleagues found that systemic hypertension was adequately controlled in 70% of patients who received their medications at minimal or no cost, while it was controlled in only 38% of those who had to pay for their medications.

Dr. Warren says Humana hasn’t specifically tracked whether offering the hypertension medications for a penny has effected patient adherence rates, but says the company has employed other policies as well to keep medication costs down for the patient. In addition to offering a plan with medications for a penny, Warren says all of Humana’s Part D Prescription Drug Plans and most of the Medicare Advantage Prescription Drug plans offer a zero dollar co-payment for generic drugs once a patient reaches their deductible and they use a mail order pharmacy.

Humana also has a program where they can identify members who are late in refilling their hypertension medications and can call them to try to help coordinate re-filling the drug.

Dr. Ramirez says CareMore hasn’t done a rigorous analysis to determine whether there are cost savings from its program to the health plan itself, but says he believes having more patients with controlled blood pressure likely has a significant impact.

“We really strongly believe our utilization at the hospital and the emergency room is really low, particularly given how sick a lot of our patients are, and we attribute that to controlling chronic diseases like blood pressure and diabetes,” he says.

 

Jill Sederstrom is a freelance writer based in Kansas City