Staging of Hypertension and Potential Means for Estimating Disease Outcomes and Reimbursement

In this issue of Hypertension, we publish two articles concerned with the classification of hypertension according to disease severity. The first article, by Black and Yi, presents a new classification for hypertension based on relative and absolute risks with implications for treatment and reimbursement. In the second, Pogue et al evaluate the effect of the Fifth Joint National Committee's report on the assessment of the severity and treatment of hypertension.¹ The editors and referees of Hypertension feel that both are important articles that have the potential of providing a means for thinking about disease outcomes in hypertension as well as for providing a new way of assessing the implications of the severity of hypertension for reimbursement of providers for their management of hypertensive patients.

In this respect, some background information is necessary relating to the new classification of hypertension published in the Joint National Committee's Fifth Report in 1992 (JNC V)¹ as it deals with hypertension severity. This classification had several goals in mind. First, it underscored the fact that all patients with elevated arterial pressure (no matter how high the systolic or diastolic pressures) are at increased risk for premature cardiovascular morbidity and mortality. Second, it emphasized that point by stating that no form of essential hypertension is truly “mild” or, in fact, is without concern. Thus, Pogue et al took particular care to classify 1158 patients with essential hypertension according to the classifications suggested in both JNC IV and JNC V. With respect to the JNC V classification, 321 (28%) patients remained in the same category (that would be made by using JNC IV criteria), but a remarkable number of patients (ie, 837 or 72%) had an increase in the staging of the hypertension severity. The more severe staging, for more than 600 of these patients, reflected the new cut points of diastolic pressure in JNC V. A lesser number (275) were upstaged because of systolic readings. Of note, hypertension severity based on systolic pressure was not made by JNC IV. Thus, with JNC V, both systolic and diastolic pressures were utilized for grading hypertension severity; the higher severity scoring for either pressure confers the overall severity score. It is important to appreciate this latter major difference provided by JNC V. This increased severity of staging with JNC V, while it was defined according to systolic and diastolic pressure levels, actually also reflected structural and functional manifestations of hypertensive disease involvement of target-organ damage. Thus, the conclusion of Pogue et al indicated that the newer (JNC V) classification did reflect target-organ disease not only of the heart and brain but also of the kidney.

The article by Black and Yi is of particular interest because it was Dr Black who originally suggested the JNC V classification to the drafting group after long consideration of the risk imparted by the severity of both diastolic and systolic pressure elevation. Accordingly, Drs Black and Yi now propose, in their article in this issue of Hypertension, that the stages of hypertension used in JNC V (and also by the World Health Organization/International Society of Hypertension classification) take into consideration both of the risk factors related to the height of arterial pressure, but they offer some modifications. In addition, they propose that data concerning patients' medical history, physical examination, and the fundamental laboratory studies that are currently recommended in JNC V for the minimal evaluation of every patient with hypertension be applied to the professional determination of risk. Accordingly, they propose that compensation by third-party insurance carriers for healthcare providers should be greater when one provides service to patients with more severe and more complicated hypertension than when one treats those patients with less abnormal clinical indexes.

The thinking presented in both articles, therefore, provides an important basis for implementation by those entities that are concerned with reimbursement, healthcare analysis, and outcome data. As we all know, it is extremely difficult to develop a practical means for reimbursement with respect to services involved when one is evaluating and managing patients who require more time expenditure. Hence, the greater time and effort expended should reasonably generate greater charges. This concept has already made inroads with respect to reimbursement for care of patients with diabetes mellitus and other chronic diseases. To this end, the efforts of Drs Black and Yi are extremely important because the information that they provide takes the first step toward the development of a practical strategy for eventual reimbursement purposes for the time and effort necessary to care for the patient with more severe hypertension. Moreover, these reports provide the impetus for the development of the analytical means necessary to evaluate disease severity and to treat patients with more complicated involvement of target organs from hypertension. As a result, these classification tools could provide a potential means for determination of the level of professional reimbursement for services that vary in intensity as well as complexity. We look forward to additional reports on healthcare analysis research dealing with hypertensive patients.