The Three Foundational Elements of a Preventative Care Model for CVD

by | Feb 23, 2021 | Blog

The rise in cardiovascular disease has reached epidemic proportions. According to the CDC, approximately 655,000 Americans die from heart disease each year, making it the leading cause of death in the US.[1] Many experts believe that the growing prevalence of chronic conditions is to blame.

The Comorbidity Connection

The risk factors for CVD are complex, but comorbidities are proven to play a significant role. According to research published by the NIH, the top five non-cardiovascular comorbidities are “low vision, diabetes mellitus, back/neck problems, osteoarthritis, chronic obstructive pulmonary disease (COPD), and cancer.”[2] Of those, diabetes is one of the most prolific. For example, individuals living with diabetes are up to four times more likely of dying from CVD than those without the disease.[3] For those living with osteoarthritis, the risk of developing CVD or heart failure is three times that of those without the disease.[4]

The real culprit, according to the CDC, is a failure to adequately manage chronic disease—a failure that leads to increased hospitalizations, poorer outcomes, and higher levels of morbidity and mortality.[5] This is especially true for patients living with CVD and multiple comorbidities.

Proactive care vs treatment

The most effective way to truly win the battle against CVD is by reducing or preventing risk factors for comorbidities that lead to CVD or complete management of the disease. To do this requires mass adoption of comprehensive chronic care management (CCM).

The benefits of CCM

The benefits of a CCM program for patients are significant. Besides receiving more timely and regular care, they also experience a 68% reduction in ED visits and a 35% reduction in hospitalizations.[6] This, in turn, increases patient satisfaction and care plan adherence,[7] and improves continuity of care.[8]

The benefits to cardiologists are considerable as well. Now that the CMS allows clinicians other than the physician to manage patients within a CCM program, cardiologists have more time to spend with patients, can see more patients, and can significantly improve their revenue stream.[9]

The role of telehealth in CCM

The impact on patients and cardiologists becomes even greater when telehealth is included in a comprehensive CCM program. Telehealth, as we all know, has been widely adopted since the start of the COVID-19 pandemic. The technology is already in place, workflows have been established, and reimbursement has increased. Patient adoption has been overwhelming as well; surveys have shown that patients not only accept telehealth but they would also like it offered as a permanent option.[10]

Telehealth can enhance timely delivery of care and critical interventions, increase care plan adherence, and improve the effectiveness of disease management for patients with CVD.[11]

The role of Remote Patient Monitoring (RPM)

According to a report by MGMA, “Remote patient monitoring (RPM) is more than just fancy activity trackers.”[12] RPM reduces hospital admissions and readmissions, improves outcomes, and lowers healthcare costs for patients, providers, and payers alike. As such, RPM plays a critical role in a successful CCM program.

While implementation of an RPM program may have been difficult a decade ago, that’s no longer the case. Consumers are now using wearables and digital tools to monitor their health, and features like heart rate sensors and electrocardiogram apps are now offered on many of the newer devices. While older technology like pulse oximeters required patients to track and report their own vitals, newer devices automatically report measurements to the care team in real-time, which allows for more proactive interventions. This can be especially beneficial for post-op heart surgery patients who have transitioned to recovery at home.

Providers can receive an extra $210 per month for each RPM patient, according to Medical Economics.[13]

Preventative care as the go-forward model

In our new value-based care environment, having a preventative care model is really a financial imperative.Cardiologists and other providers have made great strides towards reducing cardiovascular disease. Yet chronic conditions such as diabetes, osteoarthritis, COPD, and others have interfered with these efforts. To make long-lasting progress requires a comprehensive preventative approach that includes all significant chronic conditions that influence CVD. CCM, telehealth, and RPM are the foundation of a highly performing preventive care model—one that can truly turn the tide.


[1] https://www.cdc.gov/mmwr/volumes/69/wr/mm6924e2.htm

[2] https://pubmed.ncbi.nlm.nih.gov/31064742/

[3] https://www.heart.org/en/health-topics/diabetes/why-diabetes-matters/cardiovascular-disease–diabetes

[4] https://www.arthritis.org/health-wellness/about-arthritis/related-conditions/other-diseases/osteoarthritis-could-be-risky-to-your-heart

[5] https://www.cdc.gov/mmwr/volumes/66/wr/mm6645a2.htm

[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6834207/

[7] https://innovation.cms.gov/files/reports/chronic-care-mngmt-finalevalrpt.pdf

[8] https://pubmed.ncbi.nlm.nih.gov/30511284/

[9] https://www.acpjournals.org/doi/10.7326/M14-2677

[10] https://www.healthcareitnews.com/news/telemedicine-during-covid-19-benefits-limitations-burdens-adaptation

[11] https://www.acc.org/latest-in-cardiology/articles/2020/09/15/14/14/telehealth-and-cardiovascular-disease-prevention

[12] https://www.mgma.com/resources/health-information-technology/optimzing-your-telehealth-services-during-covid-19

[13] https://www.medicaleconomics.com/view/remote-patient-monitoring-update-developments-opportunities-for-physicians

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