October 28, 2018
To Whom It May Concern:
I would like to provide the following commentary concerning CMS deliberations about expanding Medicare coverage for ambulatory blood pressure monitoring (ABPM) for the diagnosis of hypertension. I am submitting this commentary as a concerned individual, and these recommendations should not be considered to reflect the views of the University of Nevada School of Medicine, Renown Medical Center, the American Society of Hypertension, any of my colleagues, or any other institution or group.
I am moved to provide commentary based on my long history of mentorship by Dr. Thomas Pickering, now deceased, whose landmark work in the field of ABPM has led to its adoption as an essential tool in the management of hypertension. Dr. Pickering consistently advocated for increased utilization of, and reimbursement for, ABPM.
The purpose of diagnosing hypertension is to identify and treat cardiovascular risk. Based on data nicely summarized by the recent USPSTF and the ACC/AHA Blood Pressure guidelines, it is clear that there is strong evidence that ABPM predicts target organ damage and future cardiovascular risk better than traditional office readings. While home blood pressure monitoring and in office automated repeated blood pressure measurement both may also perform better than traditional office blood pressure, the evidence supporting their use is less robust. As such, ABPM remains the ‘gold standard’ for determining the presence or absence of hypertension.
Given the prevalence of elevated blood pressure, I certainly understand that there are financial implications in CMS expanding the approved indications for ABPM; however, I think it is imperative to realize the merely because it is the ‘gold standard’ does not necessarily mean that it must be used in every patient. Recently, Dr. Jan Basile and I published a potential algorithm for the diagnosis of hypertension that integrates ABPM with home blood pressure monitoring and office measurement to accurately make the diagnosis of hypertension while potentially limiting the use of ABPM to those whose home reading suggest the presence of white coat hypertension or where home readings are not necessarily available or cannot be trusted. This work is based on an algorithm originally published by Dr. Pickering over 10 years ago. The figure below represents this algorithm updated with thresholds defined by the ACC/AHA in their 2017 guidelines.
I have been employing ABPM in my clinical practice in Northern Nevada for the past 18 years; however, I feel that my patients with Medicare are often disadvantaged as compared to those with commercial insurance since I cannot always obtain coverage for ABPM for these patients. Having a CMS coverage decision that is inconsistent with USPSTF and ACC/AHA recommendations seems inappropriate from a public health and policy prospective.
Based on the scientific evidence, my own clinical practice, and the public health impact of incorrect hypertension diagnosis, I strongly support expanding Medicare coverage for ABPM for the diagnosis of hypertension.
Michael J Bloch, MD, FAHA, FACP, FASH, FVM, FNLA
Associate Professor, University of Nevada School of Medicine/Reno
Medical Director, Renown Institute for Heart and Vascular Health
President, Blue Spruce Medical Consultants, PC
Vice President, American Society of Hypertension
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