According to the CDC,(www.cdc.gov) about 610,000 people die of heart disease in the United States every year -- accounting for one in every four deaths. Coronary heart disease alone accounts for $108.9 billion each year; costs for heart disease and stroke combined top out at an estimated $315.4 billion annually.
To help physicians combat the nation's cardiovascular disease (CVD) dilemma and the economic burden it poses, HHS Secretary Sylvia Burwell introduced the Million Hearts CVD Risk Reduction Model(innovation.cms.gov) on May 28. The program will use a data-driven, widely accepted predictive modeling approach to generate personalized CVD risk scores and modification plans for Medicare beneficiaries.
"The Million Hearts(millionhearts.hhs.gov) initiative is a part of our efforts to promote better care and smarter practices in our health care system," Burwell said in a news release.(www.hhs.gov) "It recognizes that giving doctors more one-on-one time with their patients to prevent illness leads to better outcomes and that greater access to health information helps empower patients to be active participants in their care."
The new risk-reduction model was created to help prevent CVD, improve health outcomes, and reduce health care costs by implementing risk calculation and stratification at the practice level. CMS is recruiting about 720 practices to test the model. Practices chosen to participate will be randomized into an intervention group or a control group.
- HHS Secretary Sylvia Burwell has introduced the Million Hearts Cardiovascular Disease Risk Reduction Model, which will use predictive modeling to generate personalized risk scores and modification plans for Medicare patients.
- CMS is recruiting about 720 practices to test the model, which will use the American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease 10-year pooled cohort risk calculator to risk-stratify Medicare fee-for-service beneficiaries.
- Practices interested in participating in the model should submit a letter of intent electronically between now and Sept. 4.
For those in the intervention arm, the model will offer incentives to calculate CVD risk for all eligible Medicare beneficiaries using the American College of Cardiology/American Heart Association (ACC/AHA) Atherosclerotic Cardiovascular Disease (ASCVD) 10-year pooled cohort risk calculator and to develop risk-modification plans based on beneficiaries' risk profiles.
Practices assigned to the control group will be asked simply to submit patient clinical data (e.g., age, cholesterol levels, blood pressure readings, etc.) on all of their Medicare patients for CMS to monitor as part of the trial.
After determining each individual's risk for a heart attack or stroke in the next 10 years, practices in the intervention group will then work with patients identified as being at high risk (i.e., those with a more than 30 percent risk for heart attack or stroke during the course of 10 years) to determine the best approach to reduce their individual risk -- for example, stopping smoking, reducing blood pressure, or taking cholesterol-lowering drugs or aspirin. Each high-risk patient will receive a personalized risk-modification plan that targets their specific risk factors. Practices will then be paid for reducing the absolute risk for heart disease or stroke among their high-risk patients.
Intervention practices will be paid a one-time $10 per-beneficiary fee to calculate each Medicare patient's ASCVD risk score and to engage patients in shared decision-making. After identifying their high-risk beneficiaries, those practices then will be paid a monthly $10 CVD care management fee for each of those high-risk patients.
Control group practices, meanwhile, will receive a $20 fee for reporting clinical data for all of their Medicare patients during years one, two, three and five of the project.
CMS Lays Out Rationale
Darshak Sanghavi, M.D., director of CMS' Preventive and Population Health Care Models Group at the Center for Medicare and Medicaid Innovation, told AAFP News that the Million Hearts model is the first to look at specific predicted outcomes while incentivizing risk-reduction across the board.
The model does this by examining each risk-reduction intervention and calculating how much each affects the patient's health, said Sanghavi. For example, one intervention might reduce the risk of heart attack or stroke from 35 percent to 22 percent but another might only reduce risk by 2 percent. Thus, he said, the first option might take priority as a result of the model calculation.
"The model empowers both the patient and the physician to understand the risk and then take action to manage that risk," said Sanghavi. "It gives patients and physicians a much more concrete sense of how their interventions are affecting their health."
He also pointed out that this model doesn't reward practices for reducing a single patient's risk but instead looks at aggregate risk of the practice's entire panel of high-risk Medicare patients. If overall risk is reduced, the practice is rewarded for that.
The goal of the model is pretty straightforward, said Sanghavi: "We're hoping to see a statistically significant reduction in heart attacks and strokes."
He added that CMS will offer participants a variety of options to report their data, including via electronic health record systems. If this isn't an option in an office, CMS will provide access to a free online tool to record information and support decisions.
Family Physicians Wanted
CMS is looking for a diverse group of practices that treat Medicare patients to participate in the model, so family medicine offices are prime targets. The initiative aims to include practices of varying sizes, patient case mixes and other patient demographic factors, as well as private practices, community health centers and hospital-owned physician practices.
Family physicians, by their very nature, focus on the whole patient and have an intuitive understanding that no problem occurs in isolation, Sanghavi acknowledged. But when treating a patient to reduce the risk of heart attack and stroke, risk factors are often treated in isolation, such as by asking a patient to get their blood pressure below 140 or hit a specific cholesterol target.
The Million Hearts model moves away from looking at individual clinical targets and toward measuring long-term heart health, Sanghavi said. "That's the fundamental shift we want to make when we're talking about paying for and incentivizing prevention," he added.
Practices interested in participating in the model must submit a letter of intent(innovationgov.force.com) electronically by Sept. 4. Applications are scheduled to be available online starting July 6, and they also will be due to CMS by Sept. 4.
Applicants are strongly encouraged to use the review criteria information provided in the "Application Scoring and Selection" section of the Request for Applications (RFA).(innovation.cms.gov) It's important to note that CMS won't consider applications from organizations that do not submit a letter of intent.
"Participating in these models is a really exciting opportunity to help bring attention to how Medicare could do a better job in paying for long-term health," Sanghavi said. "This is one of the first steps in that direction that we're taking.
"We believe participants will be doing a service for their patients but also helping us to design a payment system that is better for all physicians."
Related AAFP News Coverage
HHS Awards Aim to Help Primary Care Practices Promote Heart Health
Journal of the American Medical Association: Paying for Prevention: A Novel Test of Medicare Value-based Payment for Cardiovascular Risk Reduction(jama.jamanetwork.com)