Pay (Adequately) For What Works: The Economic Undervaluation of Office and Ambulatory Blood Pressure Recordings

Abstract

When they tell you it's not about the money—it's about the money.—H.L. Mencken (not verified)

A recent editorial in Scientific American entitled “Pay for What Works” suggests that one way to reduce the cost of health care in the United States is to “pay for what works.” ¹ They even raise the prospects of rejuvenating the Agency for Healthcare Research and Quality to compare the benefits and risks of drugs, procedures, and medical devices and then performing a cost/benefit analysis. Everyone has items to include on a list of things that produce little benefit and cost a great deal; however, the editorial does not address the issue of underpaying for things that produce benefit.

Office recording of blood pressure is a classic example of an undervalued service. A properly recorded office blood pressure is a major requirement for assessing cardiovascular risk and the diagnosis of hypertension and other medical conditions. The focus here is on the office recording because data obtained from other venues, eg, emergency room, critical care units, serve a different purpose (perhaps the manner in which blood pressure assessments are performed in other venues contributes to the inadequate manner in which blood pressure is often recorded in the office). Of equal importance is that an improperly recorded blood pressure may lead to misdiagnosis with all of the consequences of failure to treat, treating unnecessarily with ramifications for employment and insurance, and creating emotional distress when a label is inappropriately affixed to the individual.

SO, WHAT IS THE TIME AND EFFORT REQUIRED TO PERFORM AN ADEQUATE BLOOD PRESSURE RECORDING IN THE OFFICE?

We asked Clarence Grim, MD, a recognized expert in blood pressure recording techniques to provide us with a time analysis for performing an adequate blood pressure recording (written communication, February 2008) (Table).

Table.

Time Analysis for Performance of an Adequate Blood Pressure Recording in the Office

Step	Time (min)
1. Usher into room, have stand, and remove clothes over upper arms. If first visit, both arms	1
2. Measure arm circumference (record)	0.5
3. Ask to sit down	0.5
4. Select cuff, palpate brachial artery on the inner arm and apply cuff	0.25
5. Adjust seat/table so center of cuff is at heart level, feet flat on the floor	0.25
6. Inquire about recent coffee, smoking, etc. If yes, send out of room for 30 minute	0.25
7. Explain procedure and stress that there will be no talking until measurement is completed	0.25
8. Palpate for systolic blood pressure to attain maximum inflation level	0.25
9. Palpate for brachial artery location and mark	0.25
10. Start 5 minutes rest	5
11. Record pressure	1.5
12. Record pressure 2	1.5
13. Record pressure 3	1.5
14. Give patient average of last 2 recordings	0.5
15. Remove cuff from arm and escort from room	0.5
Total time first visit ≈21 minutes. Total time repeat visit ≈14.5 minutes

Obviously, if recordings are made in several positions, eg, lying down or standing, additional time will be required. Since the blood pressure recording will usually be performed by a nurse or technician, the time that the physician would spend seeing the patient is not included.

One may quibble with the exact times; however, many physicians underestimate the time required to perform a proper blood pressure recording. One of my colleagues, a hypertension specialist no less, told me that “it should take about 5 minutes.” This is the amount of time that the patient is supposed to rest!

The cost of a proper blood pressure recording is approximately $6–7 per 15 minute increment of time (based on the service provided by licensed practical nurse whose salary is approximately $32,000–40,000 per year and a 60% overhead (information derived from Practice Support Resources, Inc). This cost is usually bundled into a level 1 to 2 patient encounter that is reimbursed $30–$50, leaving $23–$43 to pay for everything else, including the physician's time.

PATIENTS DO NOT UNDERSTAND THE VALUE OF A PROPERLY RECORDED BLOOD PRESSURE

Despite the acknowledged value of a properly recorded blood pressure by the medical profession, patients are unaware of the value. For example, a properly recorded blood pressure could be billed under CPT 99211 (a level 1 visit) and would bring a Medicare reimbursement of ≈$19.41 in our area (80% reimbursement for the region is approximately $16–$17). The cost incurred by the provider for such a service would be ≈$6–$7; however, this is rarely done because the patient does not want to be charged a co‐pay of $4 because the value of the service is not recognized. Moreover, this approach may run the risk of being accused of “unbundling” of charges.

WHAT ABOUT AMBULATORY BLOOD PRESSURE MONITORING?

Ambulatory blood pressure monitoring (ABPM) provides even more information than recordings of blood pressure in the office. When one considers the magnitude of the problems related to hypertension, one would think that a high reimbursement value would be attached to recording this information; however, the only ICD‐9 code covered by Medicare is 796.2 which is elevated blood pressure reading without diagnosis of hypertension.(At least the ICD folks recognize the difference between the disease, hypertension, and the biomarker, blood pressure.) The current CPT code for ABPM recording, scanning analysis, interpretation, and report is 93784; however, one may use 93786 for recording only, 93788 for scanning analysis with report, and 93790 for physician review with interpretation and report. Reimbursement for 93784 varies among private providers from $55 to $300 per procedure.

THE IMPORTANCE OF CERTIFICATION

Providers of services included in the cardiovascular risk assessment need to be certified. This includes the measurement of blood pressure in the office, ABPM, electrocardiography, echocardiography, measurement of blood lipids, urine analysis, etc. Those providing the interpretation and analysis of these services also need to be certified. Such certification is already provided in a piecemeal fashion, eg, echocardiography and electrocardiographic recording; however, certification for blood pressure measurement is almost never done once initial training is completed, either in nursing or medical school (the American Heart Association recommends certification every year).

PROPER BLOOD PRESSURE RECORDINGS COULD SAVE MONEY

By eliminating unnecessary testing and treatment, appropriate cardiovascular risk assessment, including blood pressure recording, could save money. Moreover, reassuring patients when they do not have a disease is also rewarding both from humane and economic considerations.

WHAT NEXT?

We believe that most of us want patients and third party payers to “pay for what works.” We also recognize that there are powerful financial incentives for a desire often to “pay for what may work;” however, a great debate is going to take place in the United States regarding provision of universal health care. Until now, most politicians are not talking about ways to reduce the cost. Since we are usually dealing with a finite budget figure, paying adequately for some undervalued services will require a decrease in reimbursement for some services that are less proven.

It is time to educate and inform those who make policy decisions regarding reimbursement about the need to provide adequate reimbursement for proven cognitive and non‐cognitive services and that are currently undervalued, eg, the recording of blood pressure. The current situation will only perpetuate the practice of obtaining inaccurate data with consequences for the public and individual patients of suboptimal medical care.