Health care costs in the United States are rising rapidly. At present they exceed $1.3 trillion per year. Part of this increase in cost relates to the proliferation of technologies that in many cases provide life‐saving information but in some cases add expense and inconvenience with little benefit in prolonging life or relieving symptoms. Thus far, control of hypertension has not involved the widespread or extensive use of procedures. We should not be adding the cost of technologies that have not been proven to improve outcome in the management of hypertension, yet this is what appears to be happening.
Numerous solutions to the health care cost problem have been advanced, specifically health maintenance organizations (HMOs) and systems to privatize the delivery of health care. Seniors are being lured into managed care and urged to give up traditional Medicare plans with the promise that health care will be delivered more effectively with less cost and with drug prescription benefits. But are the proposed solutions appropriate for the problem?
While Medicare overhead is about 3% of every dollar spent, the overhead costs of HMOs may run between 20% and 30%. The health care dollar costs are shared by administrators, stockholders, and highly paid executives, with the remainder of the cost going to the health care providers. Thus far, managed care has not been very effective in reducing costs or in moderating the use of excessive testing.
Pharmaceutical companies are being targeted because of escalating costs of medications, especially in the senior population, yet medications account for only approximately 10% of the huge budget. Curbing drug costs is an important objective, but the overuse or abuse of procedures should be more specifically targeted if significant inroads are to be made in cost reduction. This can be done without affecting the quality of care.
Much of the increase in the health care bill over the past 15 years has been attributable to increased testing. Physicians are often shortchanged for their ability, judgment, and experience while being highly compensated for performing procedures. More tests are now being done as part of the management of hypertension, as more and more emphasis is put on “new” and intriguing technologies.
Advances in technology have led to better medical care, but many physicians, as well as health care experts, agree that technology is being abused. When an ear, nose, and throat physician charges $400 for a “nasal endoscopy” (which literally involves looking into the nose with a speculum, takes a total of a minute or two, and should be part of a routine exam) for a patient who comes in with a cold or sinus infection; when an ophthalmologist charges $450 for a retinal photograph as part of a routine exam; when a gastroenterologist insists on gastroscopy when dietary changes and antacids plus a short wait might solve the problem; or when a cardiologist performs an echocardiogram routinely when a grade 1 murmur is heard or makes a referral for magnetic resonance imaging when the patient is a person with a headache who has had a recent, clear‐cut emotional upset, we must question the direction that medicine is taking. Have clinicians been completely replaced by procedures? Are these tests being done because physicians can't earn a living by just being doctors, because lawyers determine medical care practices, or because patients expect the “newest and latest“ tests that are being heralded by the media, or is it all of the above?
Health care dollars are being wasted on “procedurism“ and this must somehow be monitored more effectively; the reimbursement system must be refocused.
HOW ARE HEALTH CARE COSTS RELATED TO HYPERTENSION?
How is the explosion of testing related to the management of hypertension? When Dr. Raymond Gifford, Jr., the icon of hypertension featured in this issue of The Journal of Clinical Hypertension, was asked to list one of his major contributions, he stated that “keeping the evaluation and treatment of hypertension simple“ was one of his two most important contributions. Even though it has been kept simple, the treatment of hypertension has improved dramatically over the past 30–40 years. Many hypertension experts have resisted the temptation to make management more costly and complicated by doing more testing. This may be changing.
In 1977, when the first Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) report was published, most physicians had been advised that an intravenous pyelogram and screening for pheochromocytoma and aldosteronism were routinely necessary in the evaluation of hypertensive patients to rule out secondary causes. Studies had indicated, however, that these were not necessary. The JNC I report suggested that these procedures be performed only where clinical judgment, a physical exam, and simple laboratory tests suggest them. The six subsequent JNC reports have resisted the temptation to recommend the use of special and more expensive testing in the routine evaluation of persons with hypertension.
In recent years, with the proliferation of echocardiography laboratories, ambulatory monitor centers, and companies that are promoting the use of physiologic testing as a part of the diagnostic evaluation, great pressure has been put on practicing physicians to be “up to date.” Physicians are advised, for example, that unless ambulatory blood pressure monitoring (ABPM) is done, they would never know whether a patient was a “dipper” or “nondipper” (a blood pressure decrease of less than 10% during the night). The patient whose pressure does not decrease by at least 10% at night (a nondipper) does indeed have more of a chance than a dipper of developing chronic target organ involvement, especially left ventricular hypertrophy (LVH). Physicians are being told that it is important to diagnose white coat hypertension and that the only way to do this is to see what blood pressures are during a typical working day. ABPM has now been approved for reimbursement to determine some of these factors. Its use is beginning to increase. The JNC 7 report did not recommend this as a routine procedure. Is it necessary to add the cost and some inconvenience of this procedure to the diagnostic evaluation of a hypertensive patient? The answer is a clear no.
Studies have confirmed dippers or nondippers and research has shown that ABPM does indeed correlate somewhat better with target organ involvement. These are interesting facts; however, if we are to follow the guidelines not just in the United States but worldwide and the advice of hypertension experts throughout the world, we should be treating any patient whose blood pressure is elevated consistently in a doctor's office, even if home blood pressures are <140/90 mm Hg. This is especially true if there is evidence of diabetes, hyperlipidemia, obesity, or a history of smoking. The patient should be treated regardless of whether or not he or she is a dipper or nondipper and whether or not the ABPM outcome is within normal limits. This technology has advanced and is now reasonably accurate but it only gives a picture of one 24‐hour period. Including ABPM in the routine evaluation of even 5–10 million patients would add $1–2 billion a year to the cost of care—and there is only very limited evidence that outcome will be improved. The achievement of goal blood pressures should be the objective of treatment regardless of the results of an ABPM.
Echocardiography is useful in patients with heart failure, in those with significant valve lesions prior to surgery, and is useful in determining wall motion in people with coronary disease. Many physicians have been advised that an echocardiogram should be done routinely in patients with hypertension to detect LVH, but is it necessary or is this just another costly procedure to make the workup more complicated and expensive? None of the JNC reports, including JNC 7, suggest echocardiography as a routine procedure. Yes, it is a more sensitive indicator of LVH than an electrocardiogram, but is it necessary before treatment? A patient should be treated if his or her blood pressure remains >140/90 mm Hg whether or not LVH is present.
Some will argue that treatment will be more vigorous if LVH is demonstrated, but the goal should be to reduce blood pressure to 140/90 mm Hg or even lower in patients with diabetes or renal disease regardless of whether or not LVH is present. Some will argue that determining the presence or absence of LVH helps determine which drugs to use, but many studies have determined that blood pressure control primarily determines whether or not LVH regresses and blood pressure levels determine whether or not LVH is prevented if absent before therapy. Some studies suggest that the use of regimens based on the use of an angiotensin receptor blocker (ARB) or an angiotensin‐converting enzyme (ACE) inhibitor (usually with a diuretic) might be more effective in regressing LVH than a regimen based on a β blocker or calcium channel blocker. These data can be used by clinicians to decide on specific therapy. (All of the trials that have been done with ACE inhibitors, ARBs, and the like included the use of a diuretic in the regimen.) Thus, in a patient with or without LVH, small doses of an ACE inhibitor plus a diuretic or an ARB plus a diuretic are indicated. In patients postinfarction, a β blocker plus a diuretic are indicated.
The bottom line is that unlike many of the subspecialties in medicine, hypertension specialists have not yet yielded in large numbers to the use of expensive and often difficult‐to‐interpret technology for management, but there are pressures to do so.
Studies advocating physiologic studies and evaluation of arterial waveforms and impedance or the use of machines that regulate respiratory rates to control blood pressure are usually sponsored by the companies that make the equipment. These procedures will add to cost with no evidence that their use will improve outcome. The data generated may be of academic interest and suggest a “more scientific” approach to treatment, but at present there is no indication for their widespread use.
If we are to prevent runaway health care inflation from becoming even worse and prevent further intrusions on medical care practices, physicians must be the ultimate guardians of cost. This does not limit good medical care but encourages the use of judgment and clinical experience to justify procedures. Hypertension treatment may have to become complicated in some cases, but in most cases the diagnostic evaluation should and can be simple and treatment can be pursued effectively without the introduction of expensive technology. We should not yield to the lure of a new procedure because it is new or because it creates a picture or graph that may be of academic interest without having been shown to improve outcome.