Effects of the Million Hearts Model on Myocardial Infarctions, Strokes, and Medicare Spending

Effects of the Million Hearts Model on Myocardial Infarctions, Strokes, and Medicare Spending

A Randomized Clinical Trial
Published: Oct 17, 2023
Publisher: JAMA, vol. 330, issue 15
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Associated Project

Million Hearts Cardiovascular Disease (CVD) Risk-Reduction Model

Time frame: 2017–2023

Prepared for:

U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services

Authors

Amanda Markovitz

Rhea E. Powell

Malcolm V. Williams

David J. Magid

Allison Steiner

Kate A. Stewart

Julia M. Rollison

Patricia Markovich

Key Findings

Question

Did the Million Hearts Model, which encouraged and paid for cardiovascular risk assessment and reduction, reduce the incidence of first-time myocardial infarctions and strokes or Medicare spending among Medicare beneficiaries aged 40 to 79 years?

Findings

The model reduced the probability of a first-time myocardial infarction or stroke over 5 years by 0.3 percentage points among people at high or medium risk for these events, without statistically significant changes in Medicare spending.

Meaning

The commitment of health care organizations to cardiovascular risk assessment and follow-up, coupled with payments for risk assessment and reduction, reduced myocardial infarction and stroke rates. Results support guideline recommendations for cardiovascular risk assessment.

Importance

The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown.

Objective

To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years.

Design, Setting, and Participants

This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-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, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018.

Intervention

Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%).

Main Outcomes and Measures

Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021.

Results

High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD 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 CVD events was similar between the groups (effect estimate, −$1.83 per beneficiary per month [90% CI, −$3.97 to −$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, −$16.66 to $20.89]; P = .85).

Conclusions and Relevance

The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention.

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