What Are Some Needed Changes in Heart Failure Managment Peer Review

Heart failure (HF) is a leading cause of hospitalizations and readmissions, specially among the elderly,¹ and its costs are projected to reach $seventy billion by 2030.ⁱⁱ The prevalence of HF is expected to continue to rise equally the population ages.² Despite tremendous progress in improving HF intendance and examples of impactful innovations in care redesign, the quality of HF care varies greatly. Ensuring all patients with HF receive high-quality intendance is, therefore, a clinical and public health priority.

The current payment organization for HF intendance, largely based on fee-for-service (FFS) reimbursement, leads to fragmented, depression-quality HF care.^three–6 Showtime, FFS pays for illness rather than wellness,⁷ and thus provides few resources for preventing HF or managing it longitudinally using tools like nutrition and lifestyle coaching, or addressing social determinants of wellness. Second, many of these direction techniques could and should exist done by a nonphysician clinician, such equally an HF nurse, but FFS is less likely to reimburse the services of such clinicians.^viii Third, FFS tends to divide primary and specialty care, which impedes care coordination needed for chronic management of patients with HF.⁹ Fourth, for later-phase patients, FFS encourages invasive and intensive treatments,^seven such every bit left ventricular assist devices, heart transplantation, and implantable defibrillators, merely may non cover shared determination making almost handling options or palliative intendance. The challenges associated with FFS thus have a major impact on patients with HF beyond the care continuum, and the clinicians who care for them.

Still, the payment landscape is irresolute. An increasing proportion of all healthcare dollars are moving abroad from FFS toward value-based payment (VBP) models. For the healthcare organisation as a whole, VBP models constituted 36% of all healthcare spending in 2018, upwards from roughly 25% three years prior.¹⁰ VBP models exist in unlike forms (eg, bundled payments, accountable care models) merely typically include some level of clinician responsibility for total costs of care and quality metrics. Such payment models encourage care redesign in ways that would particularly benefit HF care through more flexible reimbursement of services, such every bit care coordination, team-based care, remote monitoring, behavioral tools, and social and community interventions. There is evidence that several of these models take been associated with reduced costs and improved quality of care,^11–13 although the evidence base of operations is still developing^fourteen and results have varied based on the model and the conditions it covers.¹⁵

Thus far, the majority of VBP and alternative payment models have focused on population wellness and primary care. None of the models that involve fiscal risk and bigger care redesign changes (eg, answerable intendance organizations)—the models with more promising results—have focused on HF.¹⁶ Fifty-fifty in the context of recent growth in specialty care VBP models (such equally models for cancer care, kidney intendance, and joint replacements), there has been less activity focused on cardiovascular weather. The few cardiovascular-focused payment models in use have been episode-based, focused on astute events or procedures, and non prospective in nature.^9,16 A physician-led model that addresses a patient'south longitudinal needs for HF and is designed to exist compatible with prevalent payment models and reforms being implemented today would utilize to a larger proportion of Americans and be more preventive in nature.

This article describes a proposal to accost this gap by the Value-Based Models Learning Collaborative of The Value in Healthcare Initiative,¹⁷ a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Wellness Policy at Duke University. The Learning Collaborative contains a diverse representation of stakeholders with expertise and perspectives on this topic representing patients, clinicians (including cardiologists), academia, authorities, health systems, payers, professional person associations, and others. The Learning Collaborative reviewed existing literature (both peer-reviewed and gray literature) to highlight areas for improvement in HF care and gaps in current VBP models. Through a serial of calls and in-person meetings, the group designed a framework for a longitudinally focused, HF VBP model, identified barriers to success and strategies for implementation, and set forth potential next steps.

Current Value-Based Models Related to Cardiovascular Disease

Existing VBP models for cardiovascular care by and large fall into 1 of 3 categories. Table i highlights prominent examples for each category; details on their payment and risk-sharing approach; and how they address HF.^nine The 3 categories are as follows:

**Tabular array one.** Examples of Different Cardiovascular Disease Alternative Payment Models
Payment Approach Category	Example Alternative Payment Model	Focus (Process, Condition, Population)	Years of Beingness	Payment Approach
Episodic models
	Medicare Acute Care Episode¹⁹	Valve surgery, defibrillator implants, CABG, pacemakers, PCI	Sit-in (2009–2012)	Prospective payment with 2-sided risk
	Cleveland Dispensary and Boeing/Lowe'due south/Walmart²⁰	Valve surgery	Private sector partnership started betwixt 2010 and 2012	Prospective payment with 2-sided chance
	Integrated Healthcare Association²¹	Cardiac catheterization	Pilot launch in 2012	Prospective payment with two-sided risk
	Medicare BPCI initiative²²	Examples: PCI, pacemaker, ICD, valve surgery, CABG, HF hospitalization and recovery	Demonstration between 2013 and 2016; BPCI-Advanced in progress now¹⁸	Mix of retrospective and prospective payment and 1- and ii-sided take a chance
	Arkansas Healthcare Payment Improvement Initiative²³	Middle failure hospitalization and recovery	Pilot beginning 2012, finalized design in 2019²⁴	Retrospective payment with incentive payment or 2-sided risk
Master care-focused longitudinal models	Medicare Shared Savings Programme²⁵	General Medicare population (contains HF quality measures)	Plan (2012–current)	Shared savings/losses
Master care-focused longitudinal models	Meg Hearts: Cardiovascular Disease Risk Reduction Model²⁶	Medicare population without previous heart attack, stroke, or transient ischemic attack	CMMI model 2017–2022	Per-beneficiary payment for hazard stratification and performance payment based on take chances reduction
Specialized care-focused longitudinal models	Atlanta Value-Based Health Care Pilot²⁷ (under evolution)	Late-stage HF patients at adventure of readmission who may do good from palliative care	Details not yet appear (currently nether development)	Details not all the same announced (currently under development)

episode-based models for acute procedures and events,
primary intendance-focused longitudinal models, and
specialty care-focused models that include longitudinal intendance and disease management.

The get-go category, episode-based models, consists of public and individual bundled payments based around cardiovascular episodes of care. Most of these models are triggered by a hospitalization, either associated with an event or major process, and consist of the hospitalization plus 30, 60, or 90 days of follow-upwards care. A notable instance is the Centers for Medicare and Medicaid Services' (CMS) Arranged Payment for Intendance Improvement (BPCI) plan and its closely related successor, BPCI-Advanced.¹⁸ BPCI and BPCI-Advanced are voluntary programs in which participants (hospitals and physician grouping practices) are responsible for total costs of care arising from a triggering hospitalization.²² Participants can select from a number of clinical conditions, including a handful of cardiovascular episodes; in both BPCI and BPCI-Advanced, HF was among the well-nigh commonly selected bundles. BPCI-Advanced improves upon the benchmark adventure aligning methodology of BPCI and requires reporting of some quality metrics.^28–31

The 2d category of value-based models is primary care-focused models that are tied to population-level cost benchmarks and quality functioning metrics, with an accent on longitudinal care, care coordination, and risk factor identification and modification. These models oft include cardiovascular quality measures.^25,26 They are distinct from patient-focused commitment reform models like the patient-centered medical home model (which has neither accountability around full costs and utilization nor quality measures beyond those related to chief care).

There is one prospective principal care-focused payment model that targets atherosclerotic cardiovascular take chances reduction—Medicare's Million Hearts initiative²⁶—which has enrolled roughly 300 000 Medicare beneficiaries. This model focuses on primary prevention of cardiovascular events. However, this program is not far removed from FFS, every bit it provides bonuses for risk stratification and reduction simply non accountability for total toll and utilization. Information technology is still existence piloted, and its impact is not yet known.

A model in this category that is further removed from FFS is the Accountable Care Organization (ACO) model. ACOs take on varying levels of financial take chances for their population's overall quality and total costs of care. Roughly 44 1000000 lives are covered past ACOs across Medicare, commercial payers, and Medicaid programs.³² A prominent example is the Medicare Shared Savings Programme (MSSP), which covers about 13 meg Americans.^25,32 The MSSP evaluates participants on their performance for attributed populations broadly but does include 3 quality metrics that are HF-related (ambulatory care-sensitive HF admissions, β-blocker therapy for left ventricular systolic dysfunction, and all-cause admissions for patients with HF).³³

The third category of payment models includes longitudinal models focused on specialized care for cardiovascular weather condition. Although at that place are examples of such specialized models in the areas of kidney disease, cancer, and osteoarthritis, in that location has been less progress for cardiovascular care. One example is potentially emerging within this category targeting high-gamble, late-stage HF patients at take a chance of hospital readmissions who may benefit from palliative intendance,²⁷ but is currently limited to a pilot.

Gaps in Current Payment Model Designs

Current alternative payment models that specifically focus on cardiovascular conditions have impacted only pocket-size populations and have had pocket-size results. This department illustrates the gaps in current models, which shows where time to come models need to focus.

One major gap is that current cardiovascular models center on narrowly defined cardiovascular events, like astute myocardial infarction, or a specific intervention, like coronary avenue featherbed surgery, for short windows of fourth dimension (often 90 days or less). This may better the efficiency of a given episode only does non foreclose chronic disease from progressing to afterwards stages or prevent that intervention in the showtime identify. Further, CMS' BPCI HF bundle was non associated with significant changes in cost, quality, or outcomes.^34,35 One hypothesized reason for the lack of event was that participating hospitals were poorly equipped to influence intendance provided by post-astute intendance settings (like skilled nursing facilities, long-term intendance hospitals, inpatient rehabilitation facilities, or home health agencies).³⁴ Others take also pointed to BPCI not properly bookkeeping for patient heterogeneity,³⁵ not requiring new intendance delivery models, and non requiring systematic quality reporting,³⁶ which could besides affect success. It is worth noting that BPCI-Advanced does require quality reporting and improves upon benchmark risk adjusting, thus results of this program should be monitored as they become available.

A second gap is that there are no payment models focused on addressing patients' longitudinal chronic illness needs for HF. Medicare's Million Hearts initiative²⁶ mentioned above addresses atherosclerotic cardiovascular risk reduction, just non HF. The American Centre Clan has a Heart Failure Centers of Excellence accreditation program where hospitals that come across certain standards for treating complex heart disease receive enhanced marketing and exposure, with the goal of increasing the number of payers/patients who choose to use the hospital,³⁷ but this is not a payment model.

In that location is one advanced HF payment model airplane pilot under development,²⁷ but it will focus generally on specialty intendance for late-phase HF readmissions and will take limited HF prevention and management capacity. By comparison, CMS' Medicare Shared Savings Program ACOs have reduced spending and improved quality relative to FFS Medicare^12,32,38 and improved HF access rates and all-cause unplanned admissions for patients with HF over time.³⁹ Further, recent evidence institute that when cardiologists were part of an MSSP ACO, spending on beneficiaries with cardiovascular disease was $200 per beneficiary per twelvemonth lower than when no cardiologists participated in the ACO while achieving similar HF quality measure scores.^xl This suggests in that location may be incremental value in cardiologists' engagement in longitudinal primary care-focused payment models to improve the care of those with HF.

A final gap is that electric current VBP models oft fail to capture the patient vocalisation and feel. Quality of life is important to patients with HF, every bit HF can bear upon one's ability to have place in physical and social activities, i'south happiness, and 1's relationships.⁴¹ At that place is a need for measures that are meaningful to patients, such every bit quality of life and patient-reported measures that capture these domains,⁴¹ peculiarly since patients with HF can now alive relatively long lives but oft with low reported quality of life. Further, most models examined that do relate to cardiovascular disease do non include cost and quality accountability at the patient/person level, and thus do non marshal with existing and widespread reforms in place.

Building a VBP Model for HF

Given these challenges, the Learning Collaborative sought to develop a framework for an HF model with a longitudinal focus on disease management and prevention that could be compatible with prevalent existing payment models. This proposed HF-specific VBP model is summarized in the Effigy and could be further developed into a airplane pilot. The key elements of this model are that it focuses on longitudinal intendance, supports the integration of specialty intendance into a VBP arrangement, and promotes innovative, team-based intendance delivery.

**Figure.** **Conceptual model of the center failure value-based payment model in action.** This is for the phase C (principal) model preventing stage D. A similar model would exist for the phase B preheart failure parallel track preventing stage C. CAHPS indicates Consumer Assessment of Healthcare Providers and Systems.

General Payment Approach

The ideal payment structure would consist of a population wellness approach. This could take one of 2 forms. The get-go is similar to electric current shared savings programs, in which clinicians continue to be reimbursed through FFS merely take a payment component in which spending and functioning are reconciled against targets at the end of a predetermined flow of time (typically annually). Alternatively, payment could be shifted more than substantially to a per-member per-calendar month intendance management payment, which would be more disruptive but would provide greater flexibility for participating clinicians to introduce. Either approach would agree clinicians financially at take chances for certain outcomes directly or indirectly related to HF. Such a model would emphasize providing high-value, guideline-based HF care every bit well every bit eliminating depression-value care by including both quality measures and cost targets. The advantage of this payment approach is that it would support specialized care of the longitudinal course of HF, encouraging long-term management.^forty

Patient Population

Constructive payment models have to residual being narrow enough to be actionable while being wide enough to have population impact. The Learning Collaborative sought to remainder these with a model that focuses on people with stage C HF, with a secondary focus on people with stage B high-run a risk pre-HF. See Appendix I in the Information Supplement for an overview of HF stages and types.

While HF has already occurred in this population, at that place is opportunity for interventions to prevent clinical decompensation leading to admissions, readmissions, and the occurrence of stage D HF. Patients would leave the model when their HF has progressed to stage D, such as those with ventricular help devices, transplants, abode inotropic therapy, and hospice use, every bit this population requires a different standard of care and has less opportunity for prevention and management.

A secondary population (maybe in an optional or parallel track of the model) could include people on the higher-risk end of stage B pre-HF. Such a model could focus on those with structural centre disease and at the highest hazard of HF (ie, those with multiple risk factors or medication usage indicating they may be at loftier take chances of HF) just still with no HF symptoms. Payers could consider how narrow they desire the loftier-risk phase B population to be, merely major buckets of risk factors include combinations of prior cardiovascular history, use of certain medications that would imply high risk of (or potentially undiagnosed) HF, namely a daily loop diuretic, traditional medical HF gamble factors⁴²; and traditional behavioral HF adventure factors, such every bit smoking, poor diet, and physical inactivity.⁴²

Triggers to Enter the Model

The model would trigger with a clinical effect related to HF, such every bit a hospitalization with a primary diagnosis of HF. Every bit HF can exist difficult to distinguish from other diseases, the HF diagnosis should exist confirmed within one yr of a triggering inpatient access. This would capture recent phase C diagnoses in claims data. The intent of this model, however, is to include all phase C patients (non just patients with recent utilization). To achieve this, an additional trigger would be dr. referral into the model confirmed by outpatient, inpatient, or pharmacy claims related to HF. A similar referral arroyo could be used to generate triggers into the optional or parallel track of patients on the college-risk end of stage B pre-HF. Clinicians could refer patients with structural heart illness and multiple risk factors for HF to this model.

Triggers to enter the payment model should exist algorithmic and criteria-based to avert strategic inclusion or exclusion of patients. A 2-step process could be considered to ensure mutual agreement on eligibility (ie, the patient is proposed by the payer and confirmed by the clinician, or vice-versa). Steps would need to be taken to automate this process and not create a burdensome process similar to prior authorization.

On the payer side, potentially eligible patients could be identified in two ways. Offset, International Classification of Diseases, Tenth Revision codes could be automatically monitored to flag potentially eligible patients in a consistent manner. Using existing code lists would also let for interoperability with other programs such as the Get With The Guidelines quality registry. Second, payers could develop additional criteria that flag patients based on other aspects of care that are consistent with HF such as a claim for specific medications (eg, sacubitril/valsartan, diuretics) or coverage for investigations (eg, B-blazon natriuretic peptide elevation, echocardiography, etc). These patients could then be flagged to their clinicians as existence potentially eligible for the payment model.

On the clinician side, patients could be recruited in a similar fashion to how they are recruited for a clinical trial. For example, clinicians could refer eligible patients by providing supporting show of (i) HF symptoms, (two) a history of hospital admission with an HF diagnosis, and (three) a confirmatory diagnostic test such as an echocardiogram or B-type natriuretic peptide acme.

Given that there is an ongoing pilot of a payment model for avant-garde HF,²⁷ the VBP model proposed in this article should as well consider how patients transition to payment models for stage D HF. The length of the model should consider the amount of time needed to generate intendance improvements and fiscal sustainability as longer models may be more difficult to sustain long-term. In one case patients practice exit the model (either due to a trigger or completing the duration of the model) consideration should be given to next steps, such as whether the patient will re-enter the full general healthcare system or continue some level of connection with the HF model.

Care Delivery Model

The courage of the care commitment model would focus on show-based, high-quality guideline implementation that supports longitudinal follow-upwards. A significant opportunity exists to take existing Get With The Guidelines–Heart Failure recommendations⁴³ and adapt them to be uniform with outpatient intendance for HF prevention and direction.

We admit that many of import HF chance factors require social and behavioral interventions, but recognize that the evidence base for these interventions is still developing.⁴⁴ Futurity research should proceed to evaluate social and behavioral interventions exterior of the clinical guidelines. While the main focus here is on the known prove-based clinical guidelines, the recommendations nosotros make beneath regarding the care delivery model will help the clinical squad to place social and behavioral challenges for individual patients. This will help integrate the clinical model and care commitment model.

The intendance team should be co-led between main intendance and full general cardiology, with consulting roles for specialty HF-focused cardiologists for circuitous questions. The exact limerick of the care team should be immune to vary somewhat (although would always require some cardiologist involvement), as the availability and use of dissimilar clinicians volition vary based on geography and other factors. Importantly, the model should use nonphysician clinicians to the maximum extent possible, such as doctor assistants, nurse practitioners, pharmacists, community health workers, social workers, medical assistants, intendance navigators and coordinators, and others. This strategy would allow for more targeted use of physicians and would be more cost-efficient and maximize patient outreach, engagement, and customs knowledge.^45–47

The model should facilitate the provision of home or community-based care—potentially bolstered by telehealth and remote monitoring; keeping as much intendance in the habitation or the community as possible would exist beneficial to all and patient-preferred.^48–l Expanding the apply of patient-facing applied science, such every bit through the use of online patient portals that allow for communication with clinicians, would likely be needed to expand access outside of clinic visits.

We admit that the evidence for affliction direction programs' furnishings on clinical outcomes and spending in HF is mixed, with a number of high-profile trials demonstrating limited efficacy.^51,52 However, there have also been a number of successful trials in this space. A 2009 pooled assay of randomized controlled trials showed that multidisciplinary team-based care and in-person communication reduced readmission days per month by half-dozen.4% and 5.seven%, respectively.⁵³ A number of trials demonstrating both efficacy and cost-effectiveness of such interventions, as well as with remote monitoring, have been reported in the years since.^54–56 However, these programs have not been widely implemented, in part, due to a lack of sustainable funding models. In fact, a study surveying primary authors of published randomized controlled trials on outpatient HF management showed that, although 81% of United states studies included in the analysis showed a do good from plan implementation, 83% were discontinued after completion of the trial due to a lack of a sustainable reimbursement model.⁵⁷ Therefore, a payment model that provides funding for effective disease management strategies may hold hope for bridging the gap between theory and implementation.

Quality Measurement and Evaluation

Quality measures serve several purposes in VBP models such as providing guardrails to ensure that costs are not reduced by limiting needed care, providing requirements for meeting certain quality of care thresholds, and rewarding clinicians for further improvements in quality of intendance. The quality measures for the proposed model would appraise evidence-based guideline adherence; prevention of HF hospital admissions, readmissions, and mortality; and patient-reported outcomes for quality of life and shared decision making. Performance on quality measures would impact reimbursement in the model (eg, bonuses for improving them over time), including on patient-reported outcomes and keeping patients well.

Measures should align with already-existing measures in other programs whenever possible. This could include MSSP ACO quality measures on HF admission rates, all-crusade unplanned admissions for patients with HF, and β-blocker therapy for HF with reduced ejection fraction.³⁹ Similarly, measures of clinical guideline adherence and other HF quality measures should exist harmonized with Get With The Guidelines Middle Failure, which is used in hospitals nationwide. Patient-reported outcomes could exist collected through one of the validated instruments designed to collect HF patient-reported outcomes, such as the Kansas City Cardiomyopathy Questionnaire and the Minnesota Living with Heart Failure Questionnaire.⁵⁸ These instruments contain a diversity of questions that could exist adapted to this VBP model that assesses HF-related physical office, social role, emotional wellness, symptoms, knowledge and self-efficacy, and quality of life.

Rigorous evaluations of the model should be conducted to ensure the model is achieving its goals of improving outcomes (and lowering costs), besides equally meeting the expectations of clinicians and patients. There should be explicit monitoring for unintended consequences, such as inappropriate reductions in care, or cherry-picking patients for enrollment. Ideally, the model should allow for iterative improvements, using insights from the early on experiences of patients and clinicians, like to how the Centre for Medicare and Medicaid Innovations' approach to testing payment models involves iterative scaling and aligning.

Data Sources

To back up the model as outlined in a higher place, multiple information sources will be needed to define and identify the patient population, deliver care, adjust for the different risk factors of different patient populations, and evaluate the model. The information structures that wellness systems, clinicians, or payers may demand to access could include:

Get With The Guidelines Eye Failure;
Claims data;
Electronic Health Record data (potentially including from wellness information exchanges, if available);
Consumer Cess of Healthcare Providers and Systems;
Patient-reported data; and
Social determinants of wellness (noting that this can be hard to capture).

The platonic data system would be interoperable with other data sources to capture as much patient data equally possible. Standard data usage in the MSSP ACO model, for example, allows for coordinated approaches to care, and comparable assessment of payment model program performance over time to generate learnings. For the HF VBP model, the already existing and widely implemented Get With The Guidelines Heart Failure program registry would exist a cardinal data source.⁴³ Significant opportunity exists to conform this registry to outpatient care settings for heart failure prevention and direction.

Information technology may also be possible to design software features (often called a computable phenotype) to automatically flag patients who are likely eligible for model participation based on their electronic health record and claims data. There are successful automobile learning examples of this specific to HF.⁵⁹ Whenever possible, the data system should operate electronically, with limited use of transmission data entry. A completely electronic, coordinated, and integrated data organisation could also facilitate real-fourth dimension learning around total costs of care. This would permit clinicians (and health systems) to examine their own toll patterns and lower overall costs.

There are a number of details across the scope of this framework that payers in coordination with clinicians, regulators, and other expert stakeholders would need to mankind out to apply this model in practice. Outset, payers will need to determine the level of financial risk and the glide path to chance. Lessons from the MSSP ACO plan suggest that clinicians may demand to start in upside-only contracts (ie, potential for financial gain, but no potential for loss) and transition to downside adventure subsequently having time to build organizational competencies for the model.^threescore Second, payers will need to determine how to coordinate savings and risk in the model, as intendance will likely exist delivered by multiple clinician groups. Third, they will need to decide the specific services that are included in the payment (eg, perhaps excluding other specialty conditions similar those related to cancer). 4th, payers would need to determine the appropriate method for bookkeeping for the differing characteristics of the patient population and risk adjusting accordingly. This is especially important in light of recent mixed prove around hot-spotting circuitous populations⁵¹ and is part of our rationale to apply registry data and other information sources instead of merely claims information. Finally, they will need to determine how this model interacts with and nests within other developing population health-focused models, such as CMS' primary intendance first, that may support care management for HF. Other payment models like the oncology care model involve interaction of specialty intendance models with broader, primary care-focused models and could offer important lessons.

Implementing the Payment Model in Practice: Barriers to Success and Competency Building

Payment reform alone is not plenty to drive changes in care delivery and improve the quality of care for patients with HF. Designing a payment model is an important first stride—only effective and well-designed payment reforms depend on irresolute care delivery, leveraging existing infrastructure as well as edifice new value-based competencies and infrastructures, and overcoming multiple implementation barriers. Organizations face both external and internal barriers to successfully participating in VBP models broadly and for cardiovascular weather. These barriers and strategies to overcome barriers are summarized in Table two.

**Table 2.** Implementation Considerations for a Centre Failure Specific Value-Based Model
Barriers/Considerations for Implementation	Strategies to Overcome Barriers, Examples
Building an appropriate workface and gaining physician buy-in	Allowing flexibility on clinician coordination and care team composition tin can arrange differing intendance team mixes and let for innovative care pathways
	A multi-level, coordinated strategy to enact culture change is needed to implement a major VBP model
Implementation in low resources settings	Telehealth could allow for remote consultations to address workforce shortages
Implementation in low resources settings	Providing upfront capital and technical help to smaller, more fragmented, and rural organizations could help facilitate their success
Using implementation science	Wait to previous examples of success in implementing payment reform
Using implementation science	Consider an implementation science approach to program testing and rollout
Managing model overlap and model development	Marshal with preexisting models, partner with innovative plans, clinicians, and value-based help organizations to reduce provider brunt
Managing model overlap and model development	Offset with a express number of steps and expand over fourth dimension

Supporting the Electric current Workforce and Getting Their Buy-In

One consideration is whether there is an appropriate workforce to implement the care model supported past the payment arroyo. This may include physicians, pharmacists (specially for medication titration in the community), nurses, community health workers, and others. Furthermore, there will be additional challenges in providing new models of care in rural settings, which may not have general cardiologists or specialized HF physicians. This VBP model should be inclusive of vulnerable populations and implemented in a diversity of settings and geographies, including in resources-deprived organizations and areas. The model must be conscientious to non create or worsen any health inequities, which already exist in cardiovascular care. Looking to the futurity, this (and other) VBP models could be adapted to provide additional supports for accountable intendance for the most disadvantaged patients, as a style to reduce health inequities and intendance asymmetries.

Telehealth technologies could allow for remote consultations that would assistance address local workforce shortages while too allowing the patient to be treated in their community or at home. Recently, CMS expanded the availability of telehealth payment in its MSSP ACO model,⁶¹ which could offering opportunities for rural wellness implementation.⁶² Moreover, beginning in 2020, CMS is piloting an expansion of telehealth to Medicare Reward.⁶³ While particularly useful in rural and underserved areas, greater utilize of telehealth can be incorporated in all environments to promote greater accessibility and convenience for patients.

Even with a sufficient workforce, organizations may struggle with achieving the necessary participation and engagement. While it is of import to get buy-in from executive leadership, buy-in from front-line clinicians is critical as they will be driving the change. There needs to be a coordinated strategy at all levels of an organization to implement the culture alter for a major VBP model to succeed. These strategies for achieving modify in payment and delivery reform models are discussed in prior literature, including how to effectively communicate payment and delivery reform changes to a variety of clinicians, how to effectively employ organisation resources and workflow in ways that back up new models, and how to create a team-based and care coordination oriented organizational environment.⁶⁴

Longitudinal, HF-specific models volition need coordination between chief care clinicians and specialist clinicians. Many patients with HF (especially advanced HF patients) will need a cardiologist for specialized care and a primary intendance doctor for chronic management. A longitudinal model needs to let for flexibility as to how primary intendance clinicians and specialists coordinate. This coordination volition likely vary depending on local workforce and how the model attributes patients to clinicians. For instance, a rural area may need to lean more than heavily on master care clinicians, while more than urban areas may place increased responsibleness on specialists. A model should be flexible plenty to be used across multiple environments with differing clinician mixes and permit for the utilise of innovative care pathways.

Edifice Value-Based Competencies and Infrastructure

Organizations besides cite that major barriers to participation in culling payment models include developing finance, wellness Information technology, and governance competencies. Financial capital is often a barrier, as the organization must secure the capital and build the infrastructure required to start in a VBP model.⁶⁵ Organizations must as well keep investing in their wellness It construction and identify the new capabilities they will need to successfully participate in a new payment reform. Finally, the leadership of the organization must commit to pursuing value-based models and support clinicians in the transition.⁶⁵ There are existing resources that could be helpful for understanding and building the necessary competencies to develop a longitudinal VBP model.⁶⁵

Given all of the pieces needed to implement a new model, smaller and more fragmented organizations will probable face increased difficulty in moving towards value-based care. While VBP implementation may be doable for well-resourced, mature organizations, other organizations may demand technical assistance in standing up models or upfront financing for capacity development. However, smaller organizations may be more nimble when incentives are designed appropriately, and rural organizations may be well-connected with all other care commitment groups in the community, allowing for easier coordination and co-direction. Further strategies are needed for implementing VBP in less resourced or smaller organizations. The MSSP grappled with this issue early on on and developed the ACO Investment Model to provide advanced, prepaid savings to be used as capital for infrastructure building for organizations in rural and underserved areas.⁶⁶ This was associated with significantly more than savings to CMS in the end,⁶⁷ offer promise to payers that this may be a successful arroyo for a HF VBP model that benefits both underserved organizations and the payer.

Utilizing Implementation Scientific discipline and Available Implementation Pilot Learnings

In addition to the yet-developing evidence base of operations for value-based models¹⁴ and variation of results past model and condition,¹⁵ there are known implementation challenges. Implementation challenges have been identified in the rollout of prior models, such as the potential for intendance disparities,⁶⁸ the lack of testing before implementation, and not measuring patient-focused outcomes. More research is needed to decide the true effectiveness of many VBP models in lowering costs and improving outcomes, specially in cardiovascular care.

Implementation scientific discipline may assistance foster success when putting a new model into exercise. Organizations should look to those who have experienced success in implementing payment reform and learn from their experiences. 1 pilot instance is an ongoing partnership betwixt the American Heart Association and Novartis in Dallas-Fort Worth called Rise Above Heart Failure that provides on-site didactics to clinicians, patients, and families around HF self-management and preventing readmissions.⁶⁹ These efforts can provide implementation learnings on how to engage clinicians, patients, and families in HF payment models, only farther research is needed on how best to put other components of the VBP framework into exercise.

Aligning With Existing Models, Allowing Flexibility, and Incremental Change

There are many payment models in the United States, some with meaning overlap. Oftentimes, clinicians must attribute payments beyond multiple models. Thus, the Learning Collaborative emphasized that this model would ideally be supported by and aligned with preexisting quality measures, structures, and widespread VBP models—most notably, the ACO model could exist used as a courage for the HF VBP model. Further, CMS' models intended to be adjacent steps after ACOs, such every bit the Direct Contracting and Primary Care Showtime models, could exist useful to consider because that they are designed to enable increased date of providers directly (including specialists).

Moreover, CMS should consider identifying a short list of other highly morbid, population health-affecting chronic weather condition and follow a like process equally described by our Learning Collaborative. The generation of small number of other MSSP-aligned sub-tracks around those prioritized conditions may have particular value when there are shared risk factors or comorbidities, such as diabetes mellitus or chronic obstructive pulmonary illness.

In that location are other payers and healthcare provider groups that could serve as implementation partners. Medicare Advantage plans, which receive capitated rates for providing Medicare services and supplemental benefits, are growing in popularity and implementing a range of payment and benefit reforms spanning different VBP model categories.⁷⁰ The flexibility to work inside the capitated charge per unit to provide Medicare services allows for innovations in care commitment and in sharing accountability with providers for price and quality.^lxx Further, Medicare Reward plans take the highest percentage of all healthcare dollars flowing through VBP models.¹⁰ While the lack of transparency on what plans are doing results in little data on how payment reform is occurring, the available data suggests that they are improving quality scores and outcomes⁷⁰ but not necessarily while lowering costs.⁷¹

Additionally, in that location are organizations that specialize in developing value-based competencies and infrastructure for healthcare delivery organizations and providing technical assistance that could be of use in both the population health and specialized care spaces. Organizations should keep in mind that they do not need to take on everything at once, and in fact, success is likely facilitated past doing a limited number of steps at one time and expanding over time.

Conclusions

In that location is a pressing need for a longitudinal VBP model to improve care and reduce costs for patients with HF. Current cardiovascular culling payment models are largely based on curt-term episodes, focus on acute events or procedures, and leave a gap for patients with HF who demand long-term intendance coordination and prevention strategies to maintain and meliorate function and help avert those events and procedures. This article describes a conceptual framework for a payment model adult with a Learning Collaborative that focuses on a stage C HF population. This model as well could include a parallel or optional track targeting college-risk stage B pre-HF patients to prevent development of stage C HF. The article outlines model components, including the payment arroyo, patient population, care delivery model, triggers to enter the model, data sources, and quality measurement. Challenges in implementing a value-based model remain, such as ensuring acceptable workforce and building organizational competencies and infrastructure. However, using implementation science, looking to examples of success, and designing this model to build on already-existing widespread payment models can help ensure the viability of this new model.

To move from concept to implementation, the American Heart Clan Value-Based Models Learning Collaborative calls for collaborative action beyond the healthcare ecosystem. There is an opportunity for:

Individual and public payers to incorporate the proposed payment model into value-based model pilots to preclude HF from becoming advanced and to foreclose pre-HF from turning into HF;
Clinicians and health systems to appraise variation in care cost and quality outcomes of their patients with HF and participate in this value-based model; and
The American Center Association to adapt Get With The Guidelines Middle Failure to be uniform with outpatient care for preventing the transition of pre-HF to HF to advanced HF and to work with payers, clinicians, wellness systems, and experts in implementation science on their pattern, implementation, and evaluation.

Acknowledgments

We would similar to formally recognize Madeleine Konig, Mark Japinga, and Mathew Alexander for their of import contributions to this work.

Sources of Funding

The American Middle Association Value-Based Models Learning Collaborative is part of the broader Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Wellness Policy at Duke University. The broader Value in Healthcare Initiative is supported in office by the American Heart Association and industry partners (Amgen, Bristol-Myers Squibb, the Bristol-Myers Squibb-Pfizer Alliance, and the Sanofi-Regeneron Alliance). American Center Association volunteers (clinicians, patient representatives, and other experts) received reimbursement for travel to project meetings, but no other compensation was provided to Learning Collaborative members. Meet Appendix 2 in the Data Supplement for total list of members of the American Heart Association Value-Based Models Learning Collaborative. The views of this commodity do not necessarily represent the views of the Learning Collaborative members or the organizations that they represent. Learning Collaborative members provided feedback on the content of this commodity, simply the content of the article was independently determined by the Duke-Margolis Eye, which is part of Duke University, and as such honors the tradition of academic independence on the part of its faculty and scholars. Neither Knuckles nor the Margolis Center takes partisan positions, just the individual members are free to speak their minds and express their opinions regarding important issues. The Duke-Margolis Center received funding from the American Heart Association for this piece of work.

Disclosures

Dr Joynt Maddox receives inquiry back up from the National Heart, Lung, and Blood Institute (R01HL143421) and National Institute on Aging (R01AG060935), and previously did contract piece of work for the US Department of Health and Man Services. She reports no commercial fiscal conflicts or other significant conflicts of interest. Dr Bleser has previously received consulting fees from Merck on vaccine litigation unrelated to this work and serves as Board Vice President (uncompensated) for Shepherd'due south Clinic, a clinic providing free healthcare to the uninsured in Baltimore, Physician. Dr Saunders has a Consulting Agreement with Yale-New Oasis Health System for evolution of measures and development of quality measurement strategies for CMMI Culling Payment Models under CMS Contract Number 75FCMC18D0042/Task Lodge Number 75FCMC19F0003, "Quality Measure Evolution and Analytic Support," Base Period. Dr McClellan is an contained board member on the boards of Johnson & Johnson, Cigna, Alignment Healthcare, and Seer; co-chairs the Accountable Intendance Learning Collaborative and the Guiding Committee for the Health Care Payment Learning and Activity Network; and receives fees for serving as an counselor for Cota and MITRE. The other authors study no conflicts.

Footnotes

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