The US health care system often fails to deliver value (ie, outcomes relative to spending) or equity (ie, ensuring fairness in process or outcomes by race, ethnicity, social class, etc). A central question confronting the Biden-Harris administration is: Which policy and payment reforms will improve health care value and equity? In this Viewpoint, we propose starting with hypertension control and blood pressure (BP) equity as a national vital sign for unifying policy and payment reforms to accomplish these aims.
Health Care Value and Equity Requires Improving National Vital Signs
National vital signs are core, modifiable factors that profoundly influence population health and health care spending, and monitoring national vital signs can reduce health disparities.1,2 Notable examples include BP, obesity, physical activity, smoking, patient engagement/self-management, and well-being.1 Addressing health care value and equity requires aligning policies and payment to improve national vital signs.
Blood pressure control represents a natural starting point because it is a widely used clinical measure. It is the single most important risk factor for cardiovascular disease and a critical determinant of racial disparities in cardiovascular disease.3 National BP control rates have regressed in recent years,4 signaling the need for coordinated, integrated action.
Integrating Policy Reforms That Support Improving BP Control and Equity
Substantive improvement in national BP control requires alignment in policies across sectors. Health in all policies influence health by promoting equitable access to social resources, including housing and the built environment, food, education, employment, health care, and criminal justice.5 Adoption of “health equity across all policies” by government, the private sector, and nonprofit organizations could accelerate progress in improving BP control, promoting BP equity, and reducing cardiovascular disparities. Public health policies and regulations are associated with BP by affecting people’s diet, physical activity, sleep, alcohol consumption, exposure to secondhand smoke, and stress. Critically, health care payment and policies (Table) must align with the goal of improving BP control and equity, including support for organized systems of care through the Chronic Care Model (CCM).
Extending the well-established CCM that became the foundation for the patient-centered medical home,6 we propose a “BP-CCM” that specifies the core elements of organized systems of care required to create prepared, proactive teams and informed, activated patients. The core patient-centered medical home elements include team-based care, community partnerships, patient self-management support, clinician decision support, and effective and efficient health information systems.6 Each of these elements is relevant to the creation of organized systems that support teams and patients for improving BP control. For example, effective implementation of home BP monitoring for the diagnosis and management of hypertension requires trained clinical teams, electronic infrastructure, and processes for training patients in self-measurement and transmission of data, as well as clinicians’ review of home BP logs with follow-up medication adjustments and timely e-prescribing with appropriate adherence support from pharmacists. Patient self-management skills for managing BP are relevant to improving other national vital signs, such as diet, physical activity, and safe alcohol consumption, and to promoting patient engagement more broadly.
When effectively operationalized, the BP-CCM can improve BP control and BP equity.7,8 It also promotes clinical teams’ capacity to ensure continuous, comprehensive, coordinated, person-centered care. Establishment of effective teams offers the possibility for improving the patient experience as well as clinician and staff well-being, all of which align with the quadruple aim.9
Payment reform is critical to aligning health care system resources and incentives with improving BP control and equity. Payment reform can ensure that primary care teams have adequate time to meet, review data, reflect, strategize, and address practice BP control rates and disparities among patients in the practice. It also financially supports an infrastructure for ensuring that all patients have the self-management skills relevant to their BP and their health more broadly. First, adequate, prospective per-member-per-month payment ensures the resources necessary to establish and sustain the BP-CCM. Second, payments that are adjusted to account for social risk help align resources with the needs of patients who confront critical barriers to improving BP. For example, community health workers can assist patients with self-monitoring and connect patients to community resources. Third, pay-for-performance that addresses not only absolute BP control but also progress toward control and equity can avoid penalizing practices that serve patients who confront more barriers. Last, adequate payments are needed to motivate practice and organizational changes to support the BP-CCM, such as broader use of telehealth and other electronic communication. Unintended consequences that may arise from diverting resources from other services (eg, cancer screening) can be mitigated by ongoing monitoring of other core quality metrics.
A Path Forward
The US Department of Health and Human Services can lead by supporting all payers in adopting consistent, supportive policies (Table). It can issue regulations for federal programs, such as Medicare and Medicaid, and obtain public commitments from major payers and professional organizations to support the BP-CCM. The Centers for Medicare & Medicaid Services (CMS) has issued Medicare billing codes for remote monitoring and chronic disease management and policies permitting clinical pharmacists to bill under the physician’s billing number. It also permits billing for group medical visits that can be used to support group training of patients. Furthermore, CMS can use its leverage to promote adoption of key Medicare and Medicaid policies and payments to support the BP-CCM.
Long-term Investment in Primary Care
The Biden-Harris administration has a window of opportunity to fundamentally align policies and payments that support primary care and thereby improve the health care system.10 The BP-CCM can provide effective integration of health promotion and chronic care management into primary care. This model combines substantive policy and payment reforms with meaningful accountability for accountable care organizations, health care systems, health plans, and primary care. Major improvements in hypertension control and BP equity will require implementation of high-quality primary care, including funding comparable to other developed countries as a proportion of total health care spending.10 Rather than seeking immediate, short-term, annual savings, CMS and other payers can make long-term investments in primary care, starting with the BP-CCM, to reap substantial returns in population health outcomes and health equity.
Published: October 1, 2021. doi:10.1001/jamahealthforum.2021.2965
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Fiscella K et al. JAMA Health Forum.
Corresponding Author: Kevin Fiscella, MD, MPH, Highland Family Medicine Research, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620 (email@example.com).
Conflict of Interest Disclosures: Dr Fiscella reported receiving grants from the National Heart, Lung, and Blood Institute during the submitted work. Dr Tobin reported receiving grants from the National Heart, Lung, and Blood Institute and the US Department of Health and Human Services Administration for Community Living during the submitted work. No other disclosures were reported.
Funding/Support: This work was supported by the National Heart, Lung, and Blood Institute (U01 HL142107, R18 HL117801, and R61 HL157643-01).
Role of the Funder/Sponsor: The funder had no role in the preparation, review, or approval of the manuscript and decision to submit the manuscript for publication.
Additional Contributions: We thank Kathleen Silver, BA, for assistance in editing and submitting this Viewpoint. This work was performed as part of her employment by the Department of Family Medicine, Highland Hospital/University of Rochester Medical Center; she did not receive separate compensation for this contribution.
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Fiscella K, Tobin JN, Ogedegbe G. Aligning Payment and Policies With Health Care Value and Equity: Blood Pressure as a National Vital Sign. JAMA Health Forum. 2021;2(10):e212965. doi:10.1001/jamahealthforum.2021.2965