Million Hearts Model Rewards Physicians for Prevention

Ken Terry

June 01, 2015

In an experiment that could lead to a new form of value-based reimbursement, the Center for Medicare & Medicaid Innovation (CMMI) has announced a 5-year, randomized controlled trial in which it will test the idea of paying physicians for reducing the long-term cardiovascular risk of their high-risk patients.

"Termed the Million Hearts Cardiovascular Risk Reduction Model, this model will represent the largest test of value-based prevention payment ever conducted by CMS and, if successful, could point to an innovative path forward for other kinds of preventive care," write Darshak M. Sanghavi, MD, and Patrick H. Conway, MD, both from the Centers for Medicare & Medicaid Services, Baltimore, Maryland, in a commentary published online May 28 in JAMA.

Today, most pay-for-performance programs, including the Medicare value-based modifier program, use quality metrics that measure either care processes or intermediate outcomes such as blood pressure and blood glucose levels. But it is hard to measure the long-term outcomes associated with preventive care.

"To resolve this tension, one promising alternative is to pay for reductions in long-term hard outcomes via the surrogate end point of predicted risk," Dr Sanghavi and Dr Conway write.

To test this strategy, CMMI plans to enroll 720 practices in its Million Hearts clinical trial between June and September. The trial, scheduled to begin in January 2016, will divide the practices into intervention and control cohorts of equal size. The practice specialties may include general/family practice, internal medicine, geriatric medicine, multispecialty care, nephrology, and cardiovascular care. All participating practices must use certified electronic health records, and their physicians must have met meaningful use stage 1 criteria. Altogether, the practices are expected to provide care for 300,000 Medicare beneficiaries (150,000 in each cohort).

The trial will use the predictive modeling approach of the American Heart Association/American College of Cardiology to identify patients who are at high risk of having a cardiovascular event in the future. Both control and intervention practices will use this method to select their high-risk patients and will work with those patients to reduce their risk factors. The primary outcomes of the trial will be population-wide reduction in 10-year composite risk and population-wide reduction in composite incidence of myocardial infarction and stroke.

Physicians in the intervention group will be paid extra for helping patients achieve these outcomes on a sliding scale: $10 per beneficiary for initial screening, and then $10 per beneficiary per month for an absolute risk reduction of greater than 10 percentage points, $5 per beneficiary per month for an absolute risk reduction of between two and 10 percentage points, and no bonus for a drop of less than two percentage points.

Practices in the control group will be asked to report only clinical data such as age and cholesterol level on patients at years 1, 2, 3, and 5 of the model. Practices in the control group will be given a payment of $20 per beneficiary for each reporting cycle.

If the trial results are positive, Dr Sanghavi and Dr Conway note, "The model test could be expanded as part of the Medicare purchasing program via rule making. In addition, this model program could open the door for further model tests or payment strategies geared toward value-based prevention that accelerate management of predicted risks of poor health outcomes."

The potential importance of this reimbursement experiment extends well beyond the Centers for Medicare & Medicaid Services' value-based modifier program. The Department of Health and Human Services recently announced that by 2016, it wants 85% of traditional Medicare payments to be tied to quality or value. This percentage is supposed to rise to 90% in 2018. If the Centers for Medicare & Medicaid Services meets those targets, and the Million Hearts initiative proves successful, value-based reimbursement could look very different in the 2020s than it does today.

The authors have disclosed no relevant financial relationships.

JAMA. Published online May 28, 2015. Full text

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