Million Hearts Cardiovascular Disease Risk Reduction Model

Abstract

Cardiovascular disease (CVD) is the leading cause of death in the US 1,2 and is responsible for extensive costs to the health care system. 2 Although CVD mortality rates declined over the past several decades in the US, this decline has recently stagnated. 1,3 Additionally, population-level increases in CVD risk factors and aging of the population threaten to further undermine progress. 1,2 Key clinical guideline recommendation changes to chronic CVD treatment have been implemented over the past 10 years aiming to lower atherosclerotic CVD (ASCVD) risk in the US. 4,5 In 2013, the American College of Cardiology/ American Heart Association recommended statin use for primary prevention of CVD among adults with a 10-year predicted ASCVD risk greater than or equal to 7.5% calculated using the pooled cohort equations. 4,6 In 2017, the American College of Cardiology/American Heart Association recommended reducing the blood pressure threshold for hypertension diagnoses and treatment from 140/90 mm Hg to 130/80 mm Hg. 5 However, guideline-recommended treatment goals at the population level have not been reached, and reductions in CVD rates are lagging.Given the need for innovative strategies to reduce population-wide CVD risk, the Centers for Medicare & Medicaid Services (CMS) has increasingly focused on using payment models as tools to drive quality improvement. In this issue of JAMA, Blue and colleagues report findings from one such model, the Million Hearts CVD Risk Reduction Model (Million Hearts Model) assessed in a pragmatic, clusterrandomized health services trial among 345 US health care organizations. 7 An initiative within the CMS and Centers for Disease Control and Prevention Million Hearts program, the Million Hearts Model was designed to reduce incident myocardial infarctions and strokes by incentivizing health care organizations to assess and lower 10-year ASCVD risk among Medicare beneficiaries. In addition to clinical targets, differences in Medicare spending on CVD events were assessed between intervention and control organizations.The Million Hearts Model study was conducted from 2017 to 2021 with beneficiaries entering the model from 2017 to 2018. Organizations participated voluntarily and were randomized to either an intervention or control group. Those randomized to the intervention group agreed to use the pooled cohort equations to calculate 10-year ASCVD risk among eligible Medicare beneficiaries (aged 40-79 y without established CVD, kidney failure, or hospice use). Direct compensation was provided for risk assessments, along with a risk reduction payment per beneficiary per month. In later study years, organizations received additional compensation

Twenty years on from the introduction of the high risk strategy for stroke and cardiovascular disease prevention: a systematic scoping review

“…Although it was postulated that the benefits of CVD risk‐reducing interventions are proportional to the estimated CVD risk [25], no robust evidence has been found for medical effectiveness of targeted high CVD risk screening compared to opportunistic/conventional screening for CVD risk. Although the Million Hearts Model cluster RCT in the USA [41], which encouraged and paid for CVD risk assessment and reduction, showed reduction in first‐time strokes and myocardial infarctions, the study did not directly test efficacy of the high CVD risk prevention strategy, did not show effects on the primary outcome of CVD events or the outcome of CVD events or CVD deaths amongst high risk beneficiaries alone, and suffered from a number of significant limitations [50]. On top of the limitations already acknowledged by the authors, the internal validity of the trials was not high as a third of randomized clusters did not provide CVD risk estimates, and only about half of beneficiaries in the intervention group used the CVD screening tool.…”

Million Hearts Model Reduces Cardiovascular Events Without Increasing Care Costs

“…Karen Joynt Maddox, MD, MPH, a cardiologist and associate professor of medicine at Washington University in St. Louis and co-author of an accompanying editorial 6 about the study results, said in an interview that one of the strengths of the Million Hearts Model is its simplicity and focus on cardiovascular disease, which likely contributed to its success. She explained that many of CMS's payment models are complex, multispecialty models that may have complex scoring systems for many different quality measures that may affect how much is reimbursed for each test or service.…”