CMS risk reduction program lowered first-time heart attacks, strokes without raising costs
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Key takeaways:
- CMS’ Million Hearts Model reduced the probability of a first-time CV event or CV death over 5 years.
- Researchers noted small risk differences can translate to meaningful effects at the population level.
Data show CMS’ Million Hearts CVD Risk Reduction Model, which provided payments for CVD risk assessment and reduction, reduced incidence of first-time MIs and strokes over 5 years without significant changes in Medicare spending.
“The results support clinical guidelines for CVD preventive care,” G. Greg Peterson, PhD, MPA, a principal researcher with Mathmatica, told Healio. “Current guidelines in the U.S., similar to those in other countries, recommend that health care practitioners calculate CVD risk scores and use the scores to engage patients in discussions about CVD prevention. Although previous studies of CVD risk scoring interventions have shown improvement in CVD risk factor control, this is the first study of a CVD risk score-focused intervention to demonstrate declines in CVD events.”
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CMS launched the Million Hearts Model in 2017. It paid participating health care organizations to assess and reduce CVD risk among Medicare fee-for-service beneficiaries aged 40 to 79 years. The participating organizations agreed to follow guideline-concordant care processes for the primary prevention of CVD.
“The model was unique in paying for overall CVD risk reduction, measured by a novel, longitudinal risk calculator, rather than tying performance-based payments to control of individual risk factors,” the researchers wrote.
Benefits of routine risk assessment
In a cluster-randomized trial, Blue and colleagues analyzed data from organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 U.S.-based primary care and specialty practices, health centers and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population. Patients had no previous MI or stroke and high or medium CVD risk, defined as a 10-year predicted probability of MI or stroke of 15% or greater in 2017-2018.
The organizations agreed to perform guideline-concordant care, which included routine CVD risk assessment and CV care management for high-risk patients. CMS paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries and rewarded organizations for reducing risk among high-risk beneficiaries.
Outcomes included first-time MIs, strokes and transient ischemic attacks identified in Medicare claims, combined first-time CVD events from claims and CV deaths, measured through 2021.
Researchers found that high- and medium-risk model intervention beneficiaries (n = 130,578) and standard care control beneficiaries (n = 88,286) were similar in age (median age, 72 to 73 years), sex (58% to 59% men), race (7% to 8% Black), and baseline CVD risk score (median, 24%).
At 5 years, the probability of a first-time CV event was 0.3 percentage points lower for the intervention group vs. the control group (3.3% relative effect; adjusted HR = 0.97; 90% CI, 0.93-1; P = .09).
Also at 5 years, the probability of combined first-time CV events and CV deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR = 0.96; 90% CI, 0.93-0.99; P = .02). Medicare spending for CV events was similar between the groups, with an effect estimate of –$1.83 per beneficiary per month (90% CI, –3.97 to –0.3; P = .16), as was overall Medicare spending including model payments, with an effect estimate of $2.11 per beneficiary per month (90% CI, –$16.66 to $20.89; P = .85).
Identifying ‘overlooked’ beneficiaries
“This study did not test risk scoring or other CVD preventive care directly but tested a policy to incentivize CVD preventive care,” Peterson told Healio. “Still, results of the study suggest that CVD risk assessment and resulting care were more important than other activities incentivized under the model, which were specific to high-risk beneficiaries. In particular, we observed effects were generally larger for medium-risk beneficiaries than high-risk beneficiaries. The model increased the use of CVD risk assessment and subsequent improvements in both CVD medication use and CVD risk factor control.”
Peterson said risk scores might be especially useful for identifying medium-risk beneficiaries, whose risk might otherwise be overlooked.
“The findings thus bolster the case for current guideline recommendations advocating CVD risk score use, even though we cannot entirely disentangle effects of risk assessment from organizations’ other CVD efforts,” Peterson said.
The researchers noted that organizations volunteered for random assignment into the model, which limits the generalizability of the findings.
“Intervention organizations were likely motivated to implement the model,” the researchers wrote. “Other practitioners might not respond equally to model incentives and supports offered from 2017 to 2021. It is unclear how findings would generalize to an older, younger, or sicker population; to secondary prevention of CVD; or to settings outside the U.S.”
Reference:
- CMS. Million Hearts Cardiovascular Disease Risk Reduction Model. Available at: https://www.cms.gov/priorities/innovation/innovation-models/million-hearts-cvdrrm. Accessed Oct. 16, 2023.
For more information:
G. Greg Peterson, PhD, MPA, can be reached at gpeterson@mathematica-mpr.com; X (Twitter) @MathmaticaNow.
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