Science Behind the Issue
Researchers conducting a 2012 study found that reducing or eliminating copayments for generic drugs for hypertension and hyperlipidemia, combined with disease management support as part of a value-based payment program, increased patient compliance from 1.4% to 3.2% after 1 year. Two years after value-based payments were started, patient medication adherence showed an additional 2.1% gain, increasing to 5.2%. These researchers observed that adherence changes were most notable among patients who were not consistently taking their medications before a value-based system was implemented.29
A simulation study conducted by Goldman et al found that implementation of a pharmacy benefit that varies copayments for cholesterol-lowering therapy based on expected therapeutic benefit will improve patient medication compliance and reduce use of other services (e.g., hospitalizations, emergency department services). In this study, copayments for high- and medium-risk patients were eliminated but increased (from $10 to $22) for low-risk patients. This simulation revealed that, assuming 6.3 million privately insured or Medicare-insured US adults were on cholesterol-lowering therapy, varying the copayments resulted in the avoidance of 79,837 hospitalizations, 31,411 emergency department admissions, and over $1 billion in spending annually30
A systematic review of 13 studies assessing the effects of value-based insurance design programs with reduced medication copayments found a consistent association with improved adherence (average change of 3.0 % over 1 year) and lower out-of-pocket spending for medication. Findings suggest that generous coverage did not lead to significant changes in medical spending by patients and insurers. Research is needed to clarify how best to structure value-based programs to improve quality of healthcare and reduce spending.31
The Post-Myocardial Infarction Free Rx Event and Economic Evaluation, a prospective trial of a cohort of 2,387 people (41% of the trial population), assessed whether reducing patients’ out-of-pocket costs increased medication adherence among those discharged from the hospital after a heart attack. This study found that rates of medication adherence were significantly lower and rates of adverse clinical outcomes were significantly higher for nonwhite patients than for white patients. Providing full drug coverage increased medication adherence in both groups. However, the overall adherence rates remained low even when there was no cost-sharing for the medications and the patients had just suffered a myocardial infarction. Among nonwhite patients, full drug coverage contributed to lowering the rates of major vascular events or revascularization by 35% and reducing total health care spending by 70%. Providing full coverage had no effect on clinical outcomes and costs for white patients. This study concluded that lowering copayments for medications after heart attacks may reduce racial and ethnic disparities for cardiovascular disease.32
Additional research is still needed to identify and collect the key strategies that should be implemented to achieve the largest improvement in health outcomes and the most desirable reductions in healthcare spending. These strategies will likely have to be tailored to the specific population of the health plan or provider. Suggested research areas include determining the strategies needed to reduce costs for patients and insurers and whether medication costs affect adherence for primary (no heart- or stroke-related events) versus secondary (post-cardiac or stroke event) prevention. Additional research could also foster a better understanding of 1) how socioeconomic variables (e.g., race, income) and selection of pharmacy plan are integrated with claims and administrative data and 2) the effect on medication cost sharing.33
Care Coordination Within Networked Primary Care Teams
In a review of the use of team-based care to treat blood pressure, the proportion of patients with controlled blood pressure improved (median increase by 12%); systolic blood pressure decreased (median reduction by 5.4 mmHg); and diastolic blood pressure also decreased (median reduction by 1.8 mmHg). This review concluded that team-based care increased the proportion of people with controlled blood pressure and reduced systolic and diastolic blood pressure, especially when pharmacists and nurses were part of the team.34
A CDC Community Guide Task Force review found that there is strong evidence of effectiveness for interventions that engage community health workers in a team-based care model to improve blood pressure and cholesterol in patients at increased risk for heart disease. Findings suggest that the use of community health workers alongside physicians and nurses in team-based care was associated with large improvements blood pressure and cholesterol outcomes. In the studies reviewed, community health workers used more than one mode of delivery to communicate with clients, the most common combination being face-to-face sessions accompanied by telephone contact. As most of the review studies evaluated outcomes at 12 months, more evidence is needed on programs evaluated over a longer time period. It also would be useful to have research on larger-scale interventions (i.e., more than 500 patients) and how these programs can be funded and continued in ways other than public grants.35
A CDC Community Guide review examining cost estimates (31 studies; search period, January 1980–May 2012) of team-based care found most cost-effectiveness estimates below the conservative threshold of $50,000 per quality-adjusted life year (QALY) saved.36
SMBP plus clinical support was more effective than usual care in lowering blood pressure and improving control among patients with hypertension.37
Pharmacists as Part of Care Coordination Teams
In another study lasting 6 months, pharmacists provided a variety of MTM services to patients with heart disease at no cost to the patients as part of their employer’s health plan. Researchers compared clinical and economic outcomes for those who received MTM (n=63) with a matched group of patients who did not receive MTM (n=62).38 Economically, the MTM group’s total direct healthcare expenditures were significantly lower ($359/patient) and revealed a return on investment of $1.67 per $1 spent. Clinically, those who received MTM were more successful at meeting their blood pressure and body mass index goals. The specific scope of MTM service provided was adapted according to individual patient needs, and it showed that in less than 1 year, pharmacists had a positive financial and clinical impact on patients with cardiovascular disease.
A study of a pharmacist–physician collaborative approach to managing high blood pressure showed that within 18 months, nearly twice as many patients whose pharmacists helped manage their medications had control of their blood pressure than those not assisted by pharmacists.19,39
National and international organizations and agencies are promoting SMBP with clinical support as an evidence-based strategy for improving blood pressure control. By definition, SMBP is the regular measurement of a patient’s own blood pressure, often using a personal blood pressure measurement device, outside a clinical setting.41
It is important to note that the delivery of SMBP interventions requires a team-based care model to ensure the patient receives the appropriate clinical support needed to take and send accurate blood pressure measurements. A care team includes the patient, the primary care provider, and other clinical professionals such as nurses, community health workers, social workers and pharmacists.42
SMBP is defined as the regular measurement of blood pressure by the patient outside the clinical setting, either at home or elsewhere.57 A 2008 Joint Scientific Statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association encourages clinicians to increase the regular use of SMBP among the majority of their patients with known or suspected hypertension as a way to increase their engagement and ability to self-manage their condition.58 However, a 2013 study using 2009–2010 National Health and Nutrition Examination Survey data found that among people with hypertension, only 36.6% engaged in monthly or more frequent SMBP.59
A 2012 comparative effectiveness review by the Agency for Healthcare Research and Quality (AHRQ) examined the effectiveness of usual care compared with SMBP plus additional clinical support. This review found strong evidence that SMBP plus additional clinical support was more effective than usual care in lowering blood pressure and improving control among patients with hypertension.53 Based on the AHRQ comparative effectiveness review, in 2015 the Community Preventive Services Task Force conducted a systematic review evaluating the effectiveness of interventions using SMBP with additional support to manage high blood pressure and SMBP alone.60 Results of this review demonstrated strong evidence of effectiveness for interventions using SMBP plus additional support to improve high blood pressure outcomes and sufficient evidence of effectiveness for SMBP interventions used alone.61 The Task Force identified “additional support” as:
- One-on-one patient counseling on medications and health behavior changes (e.g., to improve diet and exercise).
- Educational sessions on high blood pressure and blood pressure self-management.
- Access to electronic or web-based tools (e.g., electronic requests for medication refills, text or email reminders to measure blood pressure or attend appointments, direct communications with healthcare providers via secure messaging).62
The Task Force also stated that SMBP interventions are often used with team-based care.63
The summary blood pressure improvements demonstrated by the studies evaluating SMBP plus additional support included 1) an increased proportion of patients with their blood pressure at goal, 2) a median 4.6-point reduction in systolic blood pressure during a median duration of 12 months, 3) a median 2.3-point reduction in diastolic blood pressure during a median duration of 9 months, and 4) consistent and meaningful improvements in blood pressure that were sustained at 12 months when compared with usual care.”64 These results and the findings of other core studies demonstrate the significant impact and value that SMBP can have, particularly in conjunction with additional clinical support, on reducing high blood pressure and controlling hypertension.
Additionally, the Task Force concluded that “SMBP interventions are cost-effective when used with additional patient support or within team-based care.”65 The Task Force did not find sufficient evidence to make a determination on the cost-effectiveness of SMBP when used alone, but the averted cost of medications and outpatient visits was found to exceed the intervention cost.66
One economic analysis study employing a decision–analytic model concluded that reimbursement of home monitoring of blood pressure (HBPM) is cost beneficial, from an insurer’s perspective, for diagnosing and treating hypertension. The study estimated net savings associated with the use of HBPM ranging from $33 to $166 per member in the first year and from $425 to $1364 in the long run (10 years), with return on investment ranging from $0.85 to $3.75 per dollar invested in the first year and from $7.50 to $19.34 per dollar invested in the long run.67