Anthony Brown starts his morning with a prized possession: his blood pressure cuff. The 63-year-old Cape Cod resident has high blood pressure, high cholesterol and has had two strokes. He’s determined to avoid a third.
So Brown straps on the cuff every morning before he heads to work, running the fry station at a seafood restaurant in Orleans, and again every evening. The cuffconnects to a remote monitoring device. Each reading goes right to staff at the community health center where he’s a patient.
“You don’t have to worry about nothing, because they see it,” said Brown. “If it's high, they follow up.”
Brown’s routine is a potentially life-saving change from the years when he would get blood pressure checks only during medical office visits a few times a year. Black men like him have a 50% greater chance of stroke as compared to white men and are 70% more likely to die.
Those statistics are part of the reason MassHealth, the state’s Medicaid program, is now picking up some of the costs of remote blood pressure monitoring for patients like Brown. It’s a strategy to detect warning signs and prevent complications in high-risk patients.
Brown received his remote monitoring kit this fall. On a morning in late October, he pulled out his phone for a video chat with his primary care provider, Gretchen Eckel.
She was concerned because his morning numbers had been creeping up. It might’ve been the one cup of coffee he didn’t want to give up, the extra cigarette he smoked, or anxiety about a busy day of fish-and-chip orders. But whatever the reason, she wanted to address it.
“His cardiovascular risk is high,” said Eckel, a family medicine physician assistant at Outer Cape Health Services. “If we don’t optimize his blood pressure, a third or final stroke is inevitable.”
During the virtual appointment, Eckel asked about Brown’s diet, his smoking and his medications. Brown told Eckel he’d stopped drinking Gatorade to cut back on salt and was checking the sodium content of food he buys. After some nudging, Brown agreed to try chewing nicotine gum occasionally, instead of lighting a cigarette during work breaks.
“Maybe I’ll just stay in the kitchen and not go outside,” he said, sounding defeated.
Even with these changes, Eckel told Brown it would be wise to try a new medication. She described two options. The first would likely cause Brown to urinate more often. So he opted for Eckel’s second recommendation, even though it can cause dizziness in rare cases, and swelling.
“If it’s not tolerable, if your feet are so fat you can’t fit them into your shoes, we’ll consider other medication options,” Eckel said. She said the health center would mail him the new pills.
The visit lasted 17 minutes. In person, it would have taken several hours of Brown’s day, because he doesn’t have a car.
“The bus is like an hour and a half one way because it stops at all the supermarkets,” Brown said. “But I have no choice, because I don’t have a ride.”
Two months later, the new approach seemed to be helping. Brown had triggered just one high blood pressure alert since Eckel adjusted his medications.
“We’ve been able to get his blood pressure under control without having Anthony return to the office once yet,” said Eckel. “To put our money, time and resources into remote monitoring for patients like Anthony is critical.”
Eckel and other clinicians at Outer Cape Health Services have enrolled 102 patients in their remote blood pressure monitoring program. But other community health centers in Massachusetts are finding it difficult to add or reorganize staff to make similar programs work. Dr. Monica Vhora, chief medical officer at DotHouse Health in Dorchester, said her team will find a way because she’s convinced remote monitoring is good for patients.
Vhora said blood pressure numbers collected at home are often more accurate than those she sees in the clinic where patients get nervous and show higher numbers — what’s known as “the white coat effect.”
“Remote readings keep us from overmedicating people,” said Vhora, “so it really affects how we manage their blood pressure.”
MassHealth began covering a range of remote monitoring devices and care in August for patients with asthma, congestive heart failure, chronic obstructive pulmonary disease, diabetes, hypertension and those who are pregnant or who have recently given birth. It’s a model already used by Medicare, the government insurance program for older Americans. It’s limited to patients who have been to a hospital within the last two years or are at risk of needing hospital-level care.
Before MassHealth started paying for remote monitoring, some hospitals and health centers were already doing this, relying on funding from grants or other resources.
Over the past few years, Boston Medical Center has enrolled nearly 3,000 patients in a program that monitors patients during and after pregnancy. The program, anchored by a pair of watchful nurses, is intended to prevent complications such as stroke and organ failure.
“We’ve seen from our patients and heard from our patients how valuable it’s been to their pregnancy and to their birth experience,” said Dr. Naima Joseph, a maternal-fetal medicine specialist at Boston Medical Center.
Beyond satisfying patients, Joseph and her colleagues are looking at the impact of remote monitoring on the numbers of pregnant patients who are induced, have a C-section or deliver prematurely.
Studies suggest at-home monitoring programs may be cost-effective. Dr. Clara Filice, deputy chief medical officer at MassHealth, said it’s too soon to know for sure.
One reason MassHealth is paying for remote monitoring is because high blood pressure — and other chronic conditions — affect certain racial and ethnic groups more than others. Filice said remote care is one part of a broader effort by state health officials to reduce racism and bias in health care.
“Will this solve disparities in Massachusetts for our members? No, not this alone,” Filice said. “But we think together, with everything else, we have a real opportunity to begin chipping away at these decades-long entrenched disparities in chronic disease care.”
Research shows that experiencing racism in everyday life, well beyond the health care system, can affect people’s health, including their blood pressure.
Anthony Brown, the patient on Cape Cod, has heard about that research but said he doesn’t think racism contributes to his high blood pressure. He said he’s gotten used to daily insults, like having a supermarket employee trail him while he shops. Sometimes, though, he gets fed up.
“One day, I stop, I say ‘hey, why you following me around? I don’t come here to steal, I come here to buy. I’m spending my money,’ ” Brown remembered telling the employee.
Brown said he can’t control the way other people treat him. So he focuses on what he can change — taking better care of himself.
