For more than a decade, value-based care has promised a simple but powerful idea: health care should reward better outcomes and value, not volume alone.
Today, that principle is widely accepted. The challenge is execution.
Delivering on that promise requires interventions that can consistently improve outcomes, enhance the experience for patients, and prevent disease progression and hospitalizations that drive so much of healthcare spending.
That imperative has become more urgent as more Americans enter Medicare with increasingly complex health needs. Despite extraordinary advances in medicine, too many patients still experience preventable complications and worsening chronic disease, while healthcare spending continues to outpace economic growth.
At agilon health, we believe clinical pathways are one way to meet that challenge. They are designed to close the gap between what evidence tells us should happen and what patients actually experience in everyday care.
Our pathways are powered by sophisticated intelligence, leveraged by agilon’s ability to converge and transform data from many disparate sources to create a complete and timely clinical story for each patient. agilon’s AI-powered platform then translates that information into actionable insights, integrated directly into physicians’ existing workflows—all while remaining grounded in clinical judgment and trusted relationships that exist between physicians and their patients.
We focus on conditions such as heart failure, dementia and chronic obstructive pulmonary disease (COPD)—diseases that drive a disproportionate share of poor outcomes and healthcare spending when left undiagnosed or undertreated.
To do that, we bring together physician partners, specialists and teams from across agilon to develop practical approaches for identifying disease earlier, supporting treatment decisions and helping patients receive recommended care.
Heart failure provides one of the clearest examples of what this approach can achieve.
Moving care upstream
Heart failure is one of the most consequential conditions facing older adults, driving high rates of hospitalization, mortality and healthcare spending. Yet the disease often progresses long before it is recognized. By the time many patients receive a diagnosis, opportunities for earlier intervention have been missed. In the US, about 38% of new heart failure cases are diagnosed in the acute care setting after the patient has already progressed to severe symptoms and crisis. [i]
That reality led us to ask a simple question: What if we could identify patients earlier and begin recommended, evidence-based treatment to improve functional outcomes and prevent further progression?
What we found was a significant opportunity.
The STOP-HF trial showed that screening people at risk for heart failure, combined with appropriate follow-up care, can reduce disease progression and cardiovascular hospitalizations. Yet many eligible patients were still not being screened. As we expanded screening programs across our partner practices, we found nearly half of the patients with newly identified heart failure were already experiencing symptoms.
They were already living with heart failure. We just didn’t know it.
Turning earlier diagnosis into better care
Identifying patients is only the beginning.
One of the lessons of modern medicine is that diagnosis alone rarely changes outcomes. Outcomes improve when diagnosis is translated into timely, evidence-based care.
Heart failure illustrates this point. We have strong evidence that guideline-directed therapies can reduce hospitalizations, improve symptoms and help patients live longer. Yet many patients never receive the full benefit of these treatments.
Through our heart failure clinical pathway and virtual pharmacy program, we focused on closing that gap. The pathway helps physicians identify and treat patients earlier, while our virtual pharmacy team works alongside primary care physicians and patients to optimize therapy over time, monitor response to treatment, address barriers to medication access and affordability and reinforce adherence.
The goal is not simply to prescribe the right treatment, but to help patients start, stay on and ultimately benefit from therapies proven to improve outcomes.
The results for our patients enrolled in a virtual pharmacy program—including both Medicare Advantage and Accountable Care Organization (ACO) populations—were significant:
- The percentage of heart failure diagnoses occurring during a hospitalization fell from our baseline of roughly 15% to 20% (already better than the national average) to approximately 5%, shifting diagnosis to earlier, lower acuity settings.
- Among symptomatic patients with heart failure with preserved ejection fraction, use of SGLT2 inhibitors increased from approximately 25% to 65%, nearly tripling adoption of a therapy associated with meaningful reductions in heart failure hospitalizations.
- Patients with heart failure with reduced ejection fraction increased from roughly two pillars of guideline directed medical therapy to three on average. Nationally, only about one in four eligible patients receive triple therapy. [ii]
- Approximately half of program graduates with reduced ejection fraction are now receiving all four pillars of recommended therapy at maximally tolerated doses.
What makes these results particularly encouraging is that they were achieved across multiple markets and physician groups. Progress of this magnitude can be difficult to achieve consistently even in highly specialized cardiac settings.
Yet their significance lies beyond the metrics themselves. They reflect a more fundamental shift, with more patients receiving the right care at a point when it can still meaningfully influence the course of their disease.
For patients with heart failure, that can mean fewer hospitalizations, better quality of life and more time living independently. Just as importantly, it means receiving care in ways that fit more seamlessly into their lives. Through our virtual pharmacy program, patients can receive ongoing support and medication management remotely, helping them get the care they need without extra trips to the clinic. Ultimately, that is the promise of value-based care: not simply delivering more care but delivering care that meaningfully improves people’s lives.
A model for what’s next
Heart failure has become proof of concept for a broader opportunity. While I’m encouraged by the progress we’ve made, I’m even more optimistic about what these results suggest may be possible across a much wider range of diseases.
Success in value-based care requires getting a handful of high-impact chronic conditions right. We are now applying these lessons to other conditions such as dementia, COPD, diabetes and chronic kidney disease, which disproportionately affect patients and drive poor outcomes, healthcare utilization and spending.
For physicians, this means greater visibility into disease, stronger clinical support and more confidence that patients are receiving care aligned with the best available evidence. For patients, it means a greater opportunity to maintain health, function and independence over time.
Healthcare has wrestled for decades with the fundamental challenge of how to improve outcomes while controlling costs. The results we see in heart failure through our clinical pathways suggest these goals need not be in conflict. In many cases, the interventions that improve patients’ lives may also be the ones that help avoid the costliest complications of disease.
This post is for informational purposes only and is not medical advice.
[i] Sandhu AT, Tisdale RL, Rodriguez F, Stafford RS, Maron DJ, Hernandez-Boussard T, Lewis EF, Heidenreich PA. Disparity in the Setting of Incident Heart Failure Diagnosis. Circ Heart Fail. 2021 Aug;14(8):e008538. DOI: 10.1161/CIRCHEARTFAILURE.121.008538.
[ii] Greene SJ, Butler J, Albert NM, DeVore AD, Sharma PP, Duffy CI, Hill CL, McCague K, Mi X, Patterson JH, Spertus JA, Thomas L, Williams FB, Hernandez AF, Fonarow GC. Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry. J Am Coll Cardiol. 2018 Jul 24;72(4):351-366. doi: 10.1016/j.jacc.2018.04.070. PMID: 30025570.
