Care Model Eligibility – Million Hearts Cardiovascular Disease Risk Reduction Model

Patients aged 40 – 79 who have not had previous heart attack, stroke, or transient ischemic attack. They cannot be in hospice or have End Stage Renal Disease (ESRD).

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Patient Segment Eligibility Description Data Source
All patients aged 40 – 79 Patients must meet the following requirements:

  • No previous heart attack, stroke, or transient ischemic attack
  • Not in hospice
  • Not have End Stage Renal Disease (ESRD)
  • Not have Medicare Advantage or other health plan coverage as primary payer
 EHR:

  • Determine if patient has had heart attach, stroke, or transient ischemic attach

Claims:

  • Determine if patient is receiving hospice care or is ESRD patient

Care Model Implementation – Million Hearts Cardiovascular Disease Risk Reduction Model

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Time Frame Action
Trigger event Medicare FFS beneficiary is assigned to intervention group
Each year for 5 years, following trigger event Conduct three annual patient encounters:

  • Conduct at least one face-to-face annual reassessment of the American College of Cardiology/American Heart Association ASCVD ten-year pooled risk calculator to develop risk modification plans based on beneficiary risk profiles
  • Conduct two follow-up beneficiary encounters, either face-to-face or remotely, to discuss the beneficiary’s progress in risk reduction, modify their risk reduction plan, and/or engage in shared decision making to determine the next best course of action for continuing to reduce or maintain their reduced risk.

Report continuous risk calculator variables and ASCVD 10-year risk score through a Data Registry (QCDR) provided as part of the model test.

Care Model Compliance – Million Hearts Cardiovascular Disease Risk Reduction Model

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Intervention Intervention Description Data Source
Enroll beneficiary into the control/intervention group Depending on if the practice has been assigned as a control or intervention, the intervention will differ. For a practice in the control group, clinical indicators are submitted in years 1, 2, 3, and 5.

For practices in the intervention group, the risk calculator must be used – see additional information on the previous slide for “Care Model: Cardiovascular Disease Risk Reduction – Intervention”

 ACOs must provide an export from the data registry tool used to submit results to CMS in order to determine the beneficiaries participating as well as their change in absolute risk reduction.