Reimbursement of ambulatory blood pressure monitoring in the US commercial insurance marketplace

Abstract

Ambulatory blood pressure monitoring (ABPM) is increasingly recommended for confirming hypertension diagnosis and ongoing hypertension monitoring. However, reimbursement in the United States is variable and low compared with other advanced health care systems. We examined the reimbursement of ABPM and factors associated with successful reimbursement. A retrospective analysis of IBM MarketScan® commercial claims database was conducted for patients ≥18 years with ≥1 ABPM claim from January 2012 to December 2016. The date of first the ABPM claim was used as the index date. Per‐beneficiary ABPM episode reimbursements were calculated by aggregating all ABPM‐related reimbursements within a 30‐day post‐index window, considered as an ABPM episode. Multivariable logistic regression was used to identify predictors of successful reimbursement. Of 20 875 beneficiaries with ABPM claims, 16 920 (81.0%) were reimbursed. The median reimbursement per beneficiary for an ABPM episode was $89 (Inter Quartile Range [IQR], $62, $132), driven primarily by reimbursement for the full procedure (median, $86; IQR, $66, $110). Comparing benefit plan types, consumer‐directed health plans provided the highest median reimbursement ($96; IQR, $61, $175). Successful reimbursement was associated with female patient sex (adjusted OR [aOR], 1.20; 95% CI, 1.11‐1.28), having a health maintenance organization (aOR 2.11; 95% CI, 1.82‐2.43) or point of service (aOR 2.08; 95% CI, 1.74‐2.49) as benefit plan types, claim filing by a specialist (aOR 1.26; 95% CI, 1.14‐1.40) and services provided at an outpatient hospital (aOR 1.17; 95% CI, 1.01‐1.35). Among commercially insured Americans, our data suggest significant variability in successful reimbursement. Accordingly, more uniform criteria for ABPM reimbursement may facilitate greater use of guideline‐recommended monitoring.

Trends in ambulatory blood pressure monitoring use for confirmation or monitoring of hypertension and resistant hypertension among the commercially insured in the U.S., 2008–2017

“…Secondly, reimbursement rates are often perceived as insufficient to justify the cost of performing ABPM routinely. Our prior research suggests that median reimbursement rates for ABPM range from approximately $86 to $96, depending on commercial plan type, although nearly 20% of submitted ABPM claims are not reimbursed at all [ 10 ]. Relatedly, patients often incur out-of-pocket expenses for ABPM, which may be cost-prohibitive.…”

“…The high proportion of ABPM use is likely more indicative of well-known inequities in prevalence and control of cardiovascular risk factors, including hypertension, in this “stroke belt” region [ 12 ]. Interestingly, our prior work found that claims from the Southeastern U.S. are less likely to be reimbursed than claims from the Northeast [ 10 ]. Taken together, these data suggest a greater need for ABPM in this region, as indicated by the number of claims filed, but lower likelihood of successful reimbursement in the most racially and socioeconomically diverse region in the U.S.…”

Out-of-Pocket Payment for Ambulatory Blood Pressure Monitoring Among Commercially Insured in the United States

“…For example, we previously showed that ABPM claim submissions decreased from 2008 to 2017 and fewer than 0.5% of commercially insured patients with hypertension have had ABPM claims billed to their commercial insurance. 4,7 We hypothesized that one possible explanation for these findings could be low patient acceptance, either because ABPM is cumbersome or because of OPP burden. Our present findings suggest the latter may not be the primary barrier for most individuals with coverage, particularly when excluding deductibles from OPP calculation.…”

“…6 Among commercial insurers in the United States, the median reimbursement to providers for each ABPM episode is $89. 7 However, to date, out-of-pocket payment (OPP) for ABPM in the commercial insurance marketplace has not been studied. Given that high OPP may be a significant barrier to patient acceptance of ABPM, we sought to characterize ABPM OPPs in a nationally representative US cohort of patients with commercial insurance.…”

How a cloud based platform can make ambulatory blood pressure monitoring more efficient, accessible, and evidence based

“…In the US, ABPM testing is reimbursed by Medicare, a national health insurance program covering approximately 55 million Americans. In an analysis of 1970 Medicare beneficiaries, for whom white coat hypertension was the chief indication for reimbursement, the median reimbursement rate was $52 USD (range $33-65) [19] . To qualify, documentation of masked or white coat hypertension using office and home BP measurements is required, and these additional bureaucratic requirements likely further constrain use.…”