New Research Shows Hypertension Guidelines Reflect Best Practice

Aug 12, 2014
Revised treatment guidelines could penalize plans measured under current star ratings system.
  • Medicare
  • High Blood Pressure/Heart Disease
  • Diabetes
  • Seniors
  • Adults

Last December, the Joint National Committee published the JNC8, offering strikingly different recommendations for the way physicians treat patients with hypertension (high blood pressure).

While there’s been much debate about the new guidelines even within the medical community, new research from Express Scripts shows these guidelines are consistent with the way doctors are already treating patients. However, Centers for Medicare and Medicaid Services (CMS) technical specifications still refer to previous treatment guidelines when rating Medicare Part C and Part D plan performance on hypertension adherence and management.

Due to this inconsistency, we risk confusion among all parties involved in a Medicare patient’s care – physicians, caregivers and the health plan – regarding appropriate treatment goals. This inconsistency also may have a negative impact on a plan’s overall CMS Star Ratings.

Guidelines Support Current Prescriber Practice

The new guidelines advocate tightly managing high blood pressure in patients younger than 60, but ease the blood pressure goals for patients ages 70 and older, stating that a systolic blood pressure of 150 and a diastolic blood pressure of 90 (150/90) is an appropriate treatment goal versus the previous treatment goal of 140/90.

The guidelines also recommend use of diuretics, beta blockers or calcium channel blockers (CCBs) to maintain blood pressure in older patients and those of African descent who do not have chronic kidney disease instead of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). ACE and ARB therapy can be risky for these patients, particularly patients over age 75 with impaired kidney function, due to the risk of high potassium levels, increased creatinine and further renal impairment. The side effects of ACE and ARB therapy (severe chronic cough, dizziness) also can be an obstacle to medication adherence for patients.

New, exclusive research from Express Scripts that looked at pharmacy claims for nearly 2.4 million Medicare patients in 2013, shows these guideline changes are consistent with how physicians are treating older patients across the country: The percentage of Medicare members in 2013 using an ACE inhibitor or an ARB declined with age, while use of CCBs and beta blockers increased.

Among Express Scripts members in a Medicare Advantage Plan (MA-PD), 75% of patients ages 65 to 70 used an ACE inhibitor or an ARB, compared to 68% of those 75 and older. Meanwhile, 33% of patients ages 65 to 70 used a CCB compared to 41% ages 75 and older.

Pharmacy Claims Among Express Scripts Members in a Medicare Advantage Plan

Pharmacy Claims Among Express Scripts Members in a Medicare Prescription Drug Plan 

Why CMS Wants Tighter Controls

CMS pays sharp attention to the treatment of hypertension, particularly in Medicare patients with diabetes, with an eye toward preventing end-stage renal disease. To that end, CMS Star measures put high value on more tightly managing hypertension, and the use of ACE and ARB therapy, because of their renal protection properties.

In Medicare Part D, CMS rewards plans that have their members with diabetes following CMS’ recommended hypertension therapy guidelines for ACE inhibitor and ARBs (rating D12 for diabetes treatment). The current industry average performance on D12 is less than 3 stars, likely due to the decreasing trend in use of ACE inhibitors and ARB therapy as the Medicare population ages, as seen in our data.

CMS also rewards Medicare Part D plans that have a higher proportion of patients who are adherent to their hypertension medication in rating D14. Patients are considered adherent when the percentage of days the patients have their prescribed hypertension medication on hand (proportion of days covered, or PDC) is 80% or greater. Yet as mentioned earlier, side effects of ACE and ARB therapy can actually become an obstacle to patient adherence to medication.

CMS also measures Medicare Advantage plans in the controlling blood pressure measure (C19), which rewards plans based on the percentage of patients with hypertension who maintain a blood pressure under 140/90 – the previous treatment guideline.

What Can Plans Do?

Up until now, plans had no clinical evidence to support what they may have known to be true. Our research now confirms that prescribers are already treating patients in accordance with clinical best practices, so it’s important for plans to monitor their physician prescribing and potential treatment changes as a result of these guidelines.

Hopefully with the combination of these new and already seemingly accepted clinical guidelines, and fresh insights from Express Scripts’ vast national bank of Medicare data, we can partner with our health plan clients and as an industry encourage an adjustment in the 2016 Technical Specifications on the measures impacted by these new guidelines.

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