Value-based Health Care Impact on Cardiovascular and Metabolic Diseases

metabolic changes starting with insulin resistance, dyslipidemia, hypertension, and obesity that affect the cardiovascular system. In Brazil, cardiovascular diseases were the leading cause of death in 2019, with coronary disease and stroke being on top, with a population prevalence of 6.1%.1 It is estimated that more than 17 million Brazilians have diabetes, 46% of whom are unaware of the disease. Associated illnesses such as ischemic disease, stroke, and diabetes represent a high economic burden on health systems, justified by their high incidence, population aging, and increasing incorporation of more expensive technologies. Central Illustration: Value-based Health Care Impact on Cardiovascular and Metabolic Diseases


Issue
Technological boom What can be done?
→ Increase in unhealthy habits → Payment model not considering health outcomes → High mortality rates due to cardiometabolic diseases Focusing on primary care while considering the concepts of value-based health care has resulted in overall population health improvements, particularly for diseases that are strongly associated with prevention and lifestyle habits. For such results, technologies that allow greater patient engagement have expanded.
Seven systematic reviews have already explored the use of self-care technologies with a focus on cardiometabolic diseases. The following are common factors among results: → Focus on self-management of diabetes, obesity, and hypertension; → Use of mobile applications (mHealth); → Focus on improving quality of life and also on primary outcomes of each disease. → Aims to centralize care on the actual needs of patients and incorporate technologies into health systems in order to manage and generate value.
The steps to establish a value-based health model for cardiometabolic diseases in Brazil are: → Disseminate mobile technologies that provide awareness and self-care education and can be easily accessed by the population; → Advance towards implementing a measurement culture in PHC, sharing results with specialized care institutions and funding sources; and → Establish a better capacity for longitudinal monitoring of individuals in the lines of care, which can be driven by a change in the specific remuneration strategy for each of such lines.
Increased health spending without evidence of population health improvements has led to major changes in how health systems are defined and managed. In the search for strategies to contribute to the system's capacity to stimulate the generation of better results with existing resources, the concept of value-based health care has emerged. It consists of converting available investments into better healthcare results for the population. 2 The concept was introduced just over a decade ago, 3 in which primary health care (PHC) and education about population health and prevention are considered the pillars for the establishment of a value-based health system. 4,5 PHC ensures cardiometabolic diseases are tracked, prevented and managed at a non-advanced stage or after an intervention in specialized care, and best practices for implementing specific programs have already been developed. 6 For PHC to perform its duty, however, it is important to encourage prevention, selfcare, and healthy habits, which can be done through remuneration models. 7 Remuneration strategies that include health outcome measures are required for implementing value-based healthcare 8 and, when it comes to PHC, it also refers to measuring whether prevention, tracking and education activities are being delivered to the assisted population in each unit. 9 However, the implementation of strategies and programs that reward the achievement of better health results and promote prevention and self-care initiatives require an accurate ability to organize measurement at the individual level. 10 Technological advances facilitates measurement, especially of diseases that allow tracking and monitoring by the individuals themselves. As an example, the HEARTS application was implemented by Latin American countries to collaborate in the identification of patients with cardiovascular risk in the PHC. 11 Based on variables answered by the patients when arriving at the PHC, the application suggests the level of cardiovascular risk, facilitating medical conduct within alternatives available in public and supplementary health. It collaborates with patient-centered care, particularly when established lines of care exist. They describe patient routines, including information on actions and activities towards promotion, prevention, treatment, and rehabilitation, to be developed in health care units, while defining the role of each member of the process and, therefore, reducing waste and increasing guidance assertiveness in the health care system. 12 When considering the behavioral and self-care factors in the prevention and screening of cardiometabolic diseases, the establishment of value-based management models for this care pathway can achieve better results with the adoption of technologies used by patients. From educational solutions to self-monitoring of blood glucose levels, examples with positive results are widely known and summarized in systematic reviews of the literature on diabetes, obesity and post-infarction conditions. Table 1 describes the main contributions of these systematic reviews.
Consolidated evidence in systematic reviews indicates that the use of technologies by individuals favors the centralization of self-care, patient involvement in health-related decisions, early diagnosis and, consequently, greater adherence to the care pathway. These are the expected results of strategies aimed at generating value, as implemented in the context of PHC and cardiometabolic diseases. In the United States, the Centers of Medicare & Medicaid Services (CMS) launched a Bundled Payments Initiative, with a fixed portion for the delivery of a service and a variable portion for the outcome. Performance evaluation is based on measures of process results and assisted individuals related to monitoring cardiometabolic diseases, such as blood pressure and diabetes control, cancer screening, individual care planning, and patient experience. 5 In addition, the American Heart Association has also launched initiatives to better integrate primary and specialized care for diseases such as heart failure. 20 In Brazil, existing projects incorporate these concepts, such as the Previne Brasil program, instituted by Ordinance No. 2979, of November 12, 2019. 9 The new funding model for PHC by SUS (Brazilian public health system) alters some forms of transferring funds to municipalities, which are now distributed based on four criteria: weighted capitation, payment for performance, incentives for strategic actions and financial incentives based on population criteria. For the pay-for-performance indicators, seven indicators are considered, two of which related to chronic conditions, such as the proportion of people with hypertension and blood pressure measured in the last semester and people with diabetes with glycated hemoglobin measured. This proposal is based on structuring a financing model focused on increasing people's access to PHC services and the link between population and HC team, based on mechanisms that induce managers and professionals to be responsible for the people assisted. An analysis of the Program in the State of Minas Gerais units showed an important increase in hypertension and diabetes indicators, from 2% in 2019 to 11% in 2021 and 5% to 23%, respectively. 21 This still preliminary and focal data corroborate the concepts of the importance of relating the care provided to chronic conditions with metrics and payment models leading to better results for both patients and overall population health in the future. Central illustration elucidates new technological alternatives to monitor/ deal with cardiovascular diseases.

Final considerations
The development of a value-based health system that is centered around individual needs and scaled to deliver the best health outcomes within a budget constraint is possible and favored by structural changes to the system, such as payment methods and a technology base that enables real-life data-driven management. PHC centralization and the interconnection with data shared between the assisted population and specialized care systems seem to be a requirement for greater capacity for tracking, diagnosing, and managing cardiometabolic diseases in the health system. For Brazil's current scenario, the challenges start with the precarious measurement culture and remuneration strategies that are centered on payment for the service delivery rather than the impact they have on population health.
As primary steps to establish a value-based health model for cardiometabolic diseases in Brazil, seeking inspiration from existing evidence, the following are recommended: start by disseminating mobile technologies that provide education and self-care and can