CMS ‘Million Hearts’ CVD Risk Reduction Model Works


The Million Hearts Model, a US Centers for Medicare & Medicaid Services (CMS) initiative that encouraged and paid healthcare organizations to assess and reduce cardiovascular disease (CVD) risk, reduced first-time myocardial infarction (MI) and strokes among Medicare beneficiaries without significant changes in Medicare spending, a randomized trial finds.


  • Researchers assessed the Million Hearts CVD Risk Reduction Model in a pragmatic, cluster-randomized trial among 342 healthcare organizations — half in the intervention group and half in the standard care control group.

  • Among 218,684 medium- or high-risk Medicare beneficiaries (median age, 72 years), 130,578 were in the intervention group in which Medicare paid for guideline-concordant care including routine CVD risk assessment, and 88,286 were in the standard care group.

  • Outcomes included first time CVD events (eg, MI, stroke, transient ischemic attack), combined first-time CVD events and CVD deaths, and Medicare spending.


  • Over a median follow-up of 4.3 years, the intervention group had a 3.3% lower rate of CVD events than the control group (adjusted hazard ratio [HR], 0.97 [90% CI, 0.93 – 1.00]; P = .09) and a 4.2% lower rate of combined first-time CVD events and CVD deaths (HR, 0.96 [90% CI, 0.93 – 0.99]; P = .02).

  • These relative effects represent an absolute reduction of 0.3 percentage points in the probability of a CVD event over 5 years (7.8% intervention vs 8.1%) and 0.4 percentage points in the probability of a CVD event or CVD death over 5 years (9.3% intervention vs 9.7% control).

  • The intervention group also had a 4.3% lower death rate (HR, 0.96 [90% CI, 0.93 – 0.98]; P = .01; absolute reduction of 0.5 percentage points over 5 years).

  • Analyses by cause of death showed the largest relative declines (10.6%) among deaths due to coronary heart disease and CVD.

  • There was no significant between-group difference in Medicare spending on CVD events or in overall Medicare Parts A and B spending.


“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 authors write.

“The encouraging findings from the Million Hearts Model suggest that modernized payment models may be an affirmative strategy to [incentivize guideline-concordant CVD preventive care and improve outcomes], though further work is needed to ensure that these models are patient-centric, optimally deployed, and equity-enhancing,” add the editorial writers.


The study, with first author Laura Blue, PhD, Mathematica, Washington, DC, was published online October 17 in JAMA, with an accompanying editorial.


The main limitation is nonparticipation of many of the organizations (516 were randomly assigned to one of the study groups, 342 participated) and incomplete entry of beneficiary data into the registry, which could have led to systematic differences between the two groups. Bias due to the selective participation of organizations and beneficiaries cannot be ruled out.


Funding for the study was provided by CMS, Department of Health & Human Services. The authors have disclosed no relevant financial relationships.

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