The Qualifying Event: Why Prevention Cardiology Is Reimbursement-Asymmetric and How That Asymmetry Kills Patients

Methodology Note

This paper draws on peer-reviewed literature published in the New England Journal of Medicine, JAMA, The Lancet, Circulation, the Journal of the American College of Cardiology, Health Affairs, JAMA Internal Medicine, and allied journals. It also draws on publicly available CMS Physician Fee Schedule data (2024-2025), Medicare Severity Diagnosis Related Group (MS-DRG) payment tables (FY2025), MGMA productivity benchmarks, and published health policy analyses. All empirical claims carry an Honesty Scale designation immediately after the claim and before any DOI: Solid (RCT-supported or meta-analytic consensus), Promising (strong observational plus mechanistic support), Early (limited but plausible data), Theoretical (mechanism plausible, data thin), or Unsupported (circulating but not held up by the evidence). DOIs appear inline, approximately one per 300 to 500 words. Patient cases are labeled “Composite” where composited from clinical experience. Dr. Mogire has no industry funding relevant to this paper.

Executive Summary

The American healthcare system pays generously for cardiac catastrophe and almost nothing for the work that prevents it. This is not an accident. It is a structural consequence of how the system prices medical services, and understanding that structure is the first step toward doing something about it.

Consider five specific financial transactions, each representing a moment in the life of a patient’s cardiovascular system.

The first transaction: a 58-year-old man arrives by ambulance with a STEMI, an ST-elevation myocardial infarction, involving his left anterior descending artery. He undergoes primary percutaneous coronary intervention. His hospital is reimbursed under MS-DRG 280 (acute myocardial infarction, discharged alive with major complications or comorbidities) at a national average of approximately $26,000 to $32,000 for the facility payment alone, with additional professional fees to the interventional cardiologist under CPT 92941 adding several thousand dollars more. The 90-day episode cost, including cardiac rehabilitation and post-discharge management, routinely exceeds $40,000 to $50,000 in Medicare claims data 5 / Solid .

The second transaction: the same hospital system performs a coronary artery bypass graft on a different patient with triple-vessel disease. Under MS-DRG 236 (coronary bypass with cardiac catheterization, without major complications or comorbidities), the facility payment is approximately $28,000 to $35,000. For complex CABG with major comorbidities, MS-DRG 231, the payment exceeds $57,000. The surgeon collects a separate professional fee. The anesthesiologist bills separately. The perfusionist bills separately. The total encounter generates $80,000 to $120,000 in combined facility and professional revenue for a single operative case.

The third transaction: a structural heart disease patient undergoes transcatheter aortic valve replacement. Under MS-DRG 266 (endovascular cardiac valve replacement with major complications or comorbidities), the FY2025 Medicare national average base payment is approximately $42,754. Under MS-DRG 267, without major complications, it is approximately $34,000. The median total CMS reimbursement across institutions, accounting for institutional variation, was $45,884 (interquartile range: $40,331 to $53,627) in published claims analysis 5 / Solid .

The fourth transaction: a patient with symptomatic ventricular arrhythmia receives an implantable cardioverter-defibrillator. Under MS-DRG 228 (major cardiovascular disorders with MCC), the facility payment is approximately $35,000 to $43,000. Additional professional fees apply.

The fifth transaction: a preventive cardiologist in Chicago sees a 48-year-old executive who has asked for a thorough cardiovascular risk assessment. They spend 45 minutes together. The physician reviews the patient’s lipid panel in detail, explains why LDL alone is inadequate risk stratification, discusses the role of ApoB and Lp(a), interprets the patient’s coronary artery calcium score, reviews cardiorespiratory fitness data, and constructs a 10-year prevention plan. The physician bills CPT 99215, the highest-level established patient office visit, plus the new G2211 complexity add-on code finalized in CY2024. The combined Medicare payment: approximately $175 to $195.

Before examining those five transactions in detail, a word about what this paper is and is not. This paper is not an argument that cardiac procedures are unnecessary or overpriced. Primary PCI for STEMI is one of the most important clinical interventions in the history of medicine. CABG for multivessel disease in the right patient is evidence-based and survival-prolonging. TAVR transformed the management of severe aortic stenosis in patients who could not survive surgical valve replacement. ICDs save lives in patients with documented arrhythmic risk. These interventions earn their reimbursement.

This paper is an argument that the system which pays generously for these procedures has failed to create equivalent payment for the prevention work that reduces their necessity. The two things are not in tension; the system could do both. It simply has not. And until it does, the clinical and social consequences of that failure will continue to accumulate: in emergency departments, in cardiac catheterization laboratories, in the waiting rooms of cardiac rehabilitation programs, and in the small rooms off emergency department corridors where families are told the news.

The ratio between the first four transactions and the fifth is not 2-to-1. It is not 5-to-1. The TAVR procedure pays 220 times more than the prevention visit. The primary PCI for STEMI pays 130 to 160 times more. The CABG pays 400 to 600 times more if professional fees are included.

This is the reimbursement asymmetry.

It does not mean that STEMI intervention is overpriced. Primary PCI for STEMI with door-to-balloon time under 90 minutes reduces 30-day mortality, and the absolute risk reduction is large enough that the intervention earns every dollar it collects 5 / Solid 17018-9). CABG for triple-vessel disease with reduced ejection fraction is one of the most evidence-backed interventions in all of cardiovascular medicine 5 / Solid . These procedures are not overvalued. The problem is that prevention is catastrophically undervalued.

The consequence of this structure is not subtle. It shapes which conversations cardiologists have time for. It shapes which patients get seen in what settings. It shapes which tests get ordered, which biomarkers get measured, and which risk factors get addressed before they kill someone. The cardiologist operating under the current reimbursement architecture cannot spend 45 minutes with a well patient discussing ApoB, Lp(a), coronary calcium, VO2max, and fasting insulin and maintain a practice that pays her salary and covers her overhead. The math does not work. So the conversation does not happen.

And when the conversation does not happen, the patient eventually experiences what the billing system calls the “qualifying event”: the heart attack, the stroke, the cardiogenic shock, the arrhythmic arrest. The event that qualifies them for the expensive care they should have received five years earlier.

This paper is not a polemic against interventional cardiology. It is an analysis of a broken incentive structure, what created it, what it costs in human terms, what is being done to change it, and what patients and physicians can do right now while the system works out its politics.

The answer to the reimbursement asymmetry is not to defund cardiac catheterization laboratories. It is to build a parallel system that prices prevention honestly, serves it directly, and does not wait for CMS to rewrite its fee schedule before someone’s ApoB gets measured.

That is what Stop Dying Early is doing. This paper is the argument for why it matters.

The Patient Who Did Not Need to Be in the Cath Lab

The Ambulance Call

The following is a Composite case, constructed from clinical experience across multiple patients. No individually identifying information is included.

The call came in at 6:14 on a Thursday morning. The dispatch code was chest pain, diaphoresis, likely cardiac. The paramedics reached the patient, a 58-year-old man, in under four minutes. He was sitting on his kitchen floor, leaning against the refrigerator, shirt soaked through. His wife was next to him, holding his wrist as though she could feel his pulse slow with her fingers.

The paramedics ran a 12-lead EKG in the kitchen. What they saw on that tracing belongs in a teaching file. The leads II, III, and aVF showed no acute changes. The anterolateral leads told a different story. There were tombstone elevations in V1 through V4: ST segments rising 4 to 5 millimeters above baseline, convex upward, merging with the T waves in a pattern that leaves no diagnostic ambiguity. The pattern has a name in emergency medicine. It is called a tombstone STEMI because the morphology of the raised segment, that steep upward slope with the rounded apex, resembles the shape of a gravestone. The name is not accidental.

The paramedic called the destination hospital on the radio at 6:17. By 6:19, the catheterization laboratory team was being paged from their homes. By 6:41, the patient was on the table.

His name, for the purposes of this paper, will be Leonard. He worked in supply chain logistics. He coached youth soccer on weekends. He had two daughters. His wife’s name was Denise, and she followed the ambulance in her car, driving too fast, and waited in a small room off the main emergency department corridor for what she later described as the longest ninety minutes of her life.

What the EKG Showed

The 12-lead EKG documented ST elevation greater than 1 millimeter in two contiguous precordial leads, meeting the universal definition of STEMI established in the 2018 Fourth Universal Definition of Myocardial Infarction 5 / Solid . The culprit pattern, with maximal elevation in V2 and V3 and reciprocal depression in the inferior leads, was consistent with proximal left anterior descending artery occlusion, what interventionalists call the “widow-maker” lesion because of its historically high mortality when untreated.

The door-to-balloon time, the interval from hospital arrival to coronary artery reopening by balloon inflation or stent deployment, was 71 minutes. The American College of Cardiology and American Heart Association target is 90 minutes for patients presenting directly to a PCI-capable hospital 5 / Solid . Leonard’s team hit their target. They were excellent at what they do.

The culprit vessel, as confirmed by coronary angiography, was the proximal left anterior descending artery. There was a 99% stenosis at the origin of the first diagonal branch. The plaque had ruptured. A thrombus had formed across it. The entire anterior wall of the left ventricle, the largest functional territory of the heart, had been without blood flow for approximately 90 minutes before reperfusion was achieved.

The interventional cardiologist deployed a single drug-eluting stent, 3.0 by 28 millimeters, across the culprit lesion. TIMI 3 flow was restored. The ST elevations began to resolve on the monitoring leads.

Leonard survived. His ejection fraction on echocardiogram at discharge was 38%, down from the normal range of 55 to 70% that he had almost certainly had before that morning. The anterior wall was hypokinetic, moving poorly, the muscle shocked by the ischemic injury. He was started on aspirin, a P2Y12 inhibitor, a high-intensity statin, an ACE inhibitor, and a beta-blocker. He was referred to cardiac rehabilitation. He went home on day four.

What Was Never Measured

Here is what Leonard had never had done in the five years before that morning.

His ApoB had never been measured. Apolipoprotein B is the structural protein on every atherogenic lipoprotein particle. One ApoB, one particle. The particle count, not the cholesterol mass, is the primary driver of atherosclerotic plaque progression 5 / Solid . His last lipid panel had shown an LDL of 118 mg/dL. His primary care physician had counseled him on diet and exercise. He had declined a statin, citing concerns about muscle side effects. The LDL of 118 looks borderline. The ApoB, had it been measured, might have told a different story, because small dense LDL particles carry less cholesterol per particle than large buoyant LDL, and a man with many small dense particles can have a modest LDL and a very high ApoB. That is the scenario in which standard lipid panels are most misleading.

His Lp(a) had never been measured. Lipoprotein(a) is a genetically determined cardiovascular risk factor that is present at high levels in approximately 20% of the population 5 / Solid . It is not modifiable by diet or most medications. It is measured once, because it does not change meaningfully over time. If Leonard’s Lp(a) was high, it would have qualified him for more aggressive risk management years before his STEMI. Nobody had ever checked.

His coronary artery calcium score had never been obtained. A CAC score is a non-contrast CT scan of the chest that quantifies calcified atherosclerotic plaque in the coronary arteries. It costs approximately $75 to $150 in most markets, is typically not covered by insurance for primary prevention, and takes about 10 minutes. A CAC score of zero in a patient like Leonard would have been meaningfully reassuring; it would have suggested that his coronary arteries were not yet significantly diseased and that a deferral of statin therapy was reasonable. A CAC score of 200 or 400 in his early 50s would have been a clinical alarm, placing him in the category where the MESA trial data clearly support statin initiation and aggressive risk factor modification 5 / Solid . A CAC score was never ordered.

His VO2max had never been measured or estimated. Cardiorespiratory fitness is an independent predictor of cardiovascular mortality, with predictive power comparable to traditional risk factors 5 / Solid . Patients in the lowest fitness quintile have three to four times the cardiovascular mortality of patients in the highest quintile. Leonard ran on a treadmill at the gym three times a week, but nobody had ever quantified his fitness level. A sub-maximal exercise test or a validated submaximal protocol could have estimated it. Nobody had prescribed one.

His fasting insulin had never been measured. Fasting insulin, in the context of a full metabolic panel, is a sensitive marker of insulin resistance, the pre-diabetic state that drives endothelial dysfunction, inflammation, and atherosclerosis years before glucose crosses the diabetic threshold 4 / Promising . His fasting glucose had been 98 mg/dL two years earlier, technically normal but near the impaired fasting glucose threshold. His HbA1c was 5.7%, also at the prediabetes boundary. Nobody had put those numbers together with his family history of type 2 diabetes, his central adiposity, and his sedentary work pattern and said: this man has insulin resistance and it is quietly damaging his arterial walls.

What It Would Have Cost

An ApoB at Quest Diagnostics or LabCorp costs approximately $30 to $45 out of pocket in 2025. Many commercial insurers cover it with a relevant diagnosis code, but Medicare does not cover it for screening purposes.

An Lp(a) costs approximately $30 to $60 out of pocket at major reference laboratories.

A coronary artery calcium score at most hospitals and imaging centers costs $75 to $150 as a self-pay study. Some centers, particularly those serving academic medical systems, charge less. Some community hospitals charge $400 as a facility-bundled price. The range is wide, but the low end is accessible.

A submaximal exercise test to estimate VO2max can be conducted in 20 minutes and does not require a treadmill laboratory. The Bruce protocol, administered by a nurse, with a physician review, is billable under CPT 93015 and CPT 93018. The combined professional fee payment under Medicare is approximately $90 to $120.

Fasting insulin is approximately $20 to $30 out of pocket.

The total preventive workup: ApoB, Lp(a), CAC score, a submaximal exercise test, and fasting insulin, along with a 45-minute physician visit to interpret and synthesize them, would have cost approximately $500 to $700 in out-of-pocket expenses had Leonard’s insurance not covered them, or approximately $200 to $350 if his commercial insurer covered the visit and the tests under a preventive benefit.

Leonard’s STEMI cost approximately $42,000 in acute hospital charges. His 90-day episode cost, including the cardiac rehabilitation program he attended twice weekly for twelve weeks, the medications, the cardiology follow-up visits, and the echocardiogram to reassess his ejection fraction, was approximately $68,000 in total healthcare expenditure. His ejection fraction at three months was 42%, modestly improved but not normal. He was told he would likely need to remain on heart failure medications indefinitely.

Denise, his wife, took six weeks off work to care for him. That cost does not appear in the healthcare billing system.

Denise’s Perspective

There is a dimension of the STEMI story that the clinical literature does not measure and the billing system does not capture: the caregiver experience.

Denise, Leonard’s wife, drove behind the ambulance at 6:19 in the morning. She had been awake since 5:45, when she heard him get up, then heard something that was not quite the sound of the kitchen. She found him on the floor at 5:51. She had called 911 at 5:53. In the fourteen years since, researchers studying post-MI caregiver outcomes have documented what Denise experienced in the weeks and months following Leonard’s event: post-traumatic stress symptoms in approximately 24% of partners of STEMI patients, clinically significant anxiety in approximately 40%, and depression in approximately 30% 4 / Promising . These outcomes are not measured in the billing system. They do not appear in the DRG calculation. They are not tracked in the cardiac rehabilitation quality metrics.

Denise took six weeks off work. She managed Leonard’s medication regimen, which included seven drugs at discharge: aspirin, clopidogrel, rosuvastatin 40 mg, lisinopril 5 mg, carvedilol 6.25 mg, eplerenone 25 mg, and a proton pump inhibitor for gastrointestinal protection. She drove him to cardiac rehabilitation twice weekly for twelve weeks. She changed her cooking habits overnight, removing saturated fat and adding omega-3-rich fish, without being given any specific guidance about what that meant in practical terms. She Google-searched “foods to eat after heart attack” and found a different answer on every page she clicked.

She was never offered a caregiver support visit. There is no CPT code for spousal counseling after a STEMI. There is no DRG payment for teaching Denise which symptoms warrant a 911 call versus a next-day cardiology call. These services, which would have been clinically meaningful, economically rational, and personally necessary, are not in the billing architecture. They happened if a cardiac rehabilitation nurse took extra time, or if the cardiologist’s 20-minute post-discharge visit included a moment to look at Denise and ask how she was doing.

The total cost of Leonard’s STEMI to his family is not $68,000. It is $68,000 plus six weeks of Denise’s salary, plus the psychological costs of the acute event and its aftermath, plus the insurance premium increases that followed, plus the cost of the heart failure medications he now takes indefinitely, plus the annual echocardiograms to track his ejection fraction, plus the secondary prevention cardiology visits for the rest of his life. It is the sum of all the events that flow from the morning he was not quite in the kitchen.

None of that cost appears in the argument for why prevention is worth paying for. It should.

The Asymmetry in a Single Life

Leonard was not unlucky. He was undertreated. The system did not fail to treat his STEMI; it treated the STEMI with extraordinary technical skill. The system failed to prevent the STEMI. And the reason the system failed is not because his doctors were careless. His primary care physician was attentive, well-trained, and busy. His occasional cardiologist visits were efficient and guideline-compliant. The reason the system failed is that nobody had the financial incentive, the allocated time, or the reimbursement structure to spend 45 minutes with Leonard, run the full biomarker panel, order the CAC, and have the conversation about who he was going to be at 65.

The prevention visit that might have changed Leonard’s trajectory was worth $175 to the billing system. The intervention that addressed its consequences was worth $42,000.

That is the reimbursement asymmetry. It is not abstract. It is Leonard’s kitchen floor at 6:14 in the morning, and his daughters driving to the hospital behind the ambulance, and Denise in the small room off the corridor, waiting.

The Reimbursement Map

How Cardiology Services Are Priced

To understand the reimbursement asymmetry, you need to understand how Medicare prices physician services. The system is called the Resource-Based Relative Value Scale (RBRVS), and it was designed by William Hsiao and colleagues at Harvard at the request of Congress, with the first iteration published in 1988 5 / Solid . Every physician service in the United States is assigned a number of Relative Value Units (RVUs). The RVU has three components: physician work, practice expense, and malpractice expense. Medicare multiplies the total RVU for a service by a conversion factor, currently $33.29 per RVU for most of CY2024 (following legislative adjustments), to calculate the dollar payment.

The critical variable is the work RVU, which is supposed to represent the physician’s time, skill, effort, and cognitive intensity. It is the component that is set by a body called the AMA Relative Value Scale Update Committee (RUC), which was established in 1991 and has been the primary mechanism for valuing physician services under Medicare ever since.

The RUC process, and its consequences, will be examined in Section 4. What matters for the present accounting is the specific payment values that result from this system.

Evaluation and Management Codes: The Prevention Visit

The highest-level established patient office visit is CPT 99215. In CY2024, its Medicare payment is approximately $148 to $175 depending on the geographic practice cost index applied. CPT 99214, the mid-level established patient visit typically used for straightforward follow-up, pays approximately $111 to $130. The complexity add-on code G2211, finalized in CY2024 for use with office E/M codes when the physician provides ongoing continuity of care for a patient’s single serious or complex condition, pays an additional $16.57.

A cardiologist who bills 99215 + G2211 for a 45-minute prevention consultation collects approximately $165 to $192 from Medicare.

For new patient visits, CPT 99205 (the highest-level new patient visit, appropriate for a new patient with a complex medical problem) pays approximately $215 to $235.

For preventive medicine visits specifically, CPT 99396 (periodic preventive medicine evaluation and management, established patient, age 40 to 64) pays approximately $121 per Medicare allowed amount. CPT 99397 (age 65 and older) pays approximately $130. However, a cardiologist is not typically the provider performing annual preventive medicine visits; these codes are generally billed by primary care physicians.

Intensive behavioral counseling codes do exist. CPT 99401 through 99404 cover preventive medicine counseling, individual, from 15 minutes to 60 minutes. These are valued at $26 to $60 in the Medicare fee schedule. The obesity counseling code, G0447, pays approximately $28 for a 15-minute session.

Advanced cardiovascular risk assessment counseling is not a separately reimbursed service. When a cardiologist spends time discussing ApoB trajectory, Lp(a) risk stratification, CAC score implications, and VO2max optimization, that work is subsumed into the E/M visit level. There is no add-on code for preventive cardiology complexity. There is no fee for the 20 additional minutes required to actually explain why the CAC score matters.

Laboratory Testing: The Biomarker Gap

ApoB (CPT 83700): Apolipoprotein B testing has a Medicare approved amount of approximately $20 to $27. However, Medicare Part B does not cover ApoB as a screening test. Coverage is available when a relevant diagnosis code is appended, typically a lipid disorder or established cardiovascular disease. For a patient without established disease presenting for prevention, ApoB is typically patient-pay. At major reference laboratories, patient-pay pricing is approximately $30 to $45.

Lp(a) (CPT 83695): Medicare coverage for Lp(a) is similarly restricted. The approved payment amount is approximately $20 to $30. Without a relevant diagnosis code, Lp(a) is typically not covered for routine prevention screening. Patient-pay cost: $30 to $60.

High-sensitivity CRP (CPT 86141): hsCRP has Medicare approved payment of approximately $14 to $22. Coverage is inconsistent for primary prevention without established disease.

Fasting insulin (CPT 83525): Approximately $15 to $25 as a Medicare approved amount. Coverage for prevention screening is limited.

Advanced lipid testing (CPT 83704): Lipoprotein fractionation by ultracentrifugation, gradient gel electrophoresis, or nuclear magnetic resonance spectroscopy. Medicare has restricted coverage for this category; many advanced lipid tests are non-covered for preventive screening and require patient payment or commercial insurance authorization.

Imaging: The Calcium Score and Coronary CTA

Coronary artery calcium scoring (CPT 75571): The professional component is approximately $40 to $55 under Medicare. The technical component (the scan itself) is separate and paid to the facility. Combined, total payment is approximately $75 to $100. Critically, Medicare does not cover CAC scoring as a primary prevention screening tool for asymptomatic patients. The USPSTF concluded in its 2018 recommendation that current evidence is insufficient to assess the balance of benefits and harms of using non-traditional risk factors, including CAC, to screen for cardiovascular disease in asymptomatic adults 5 / Solid . This classification means Medicare does not cover it for the patients who most need it: those making statin initiation decisions who have borderline risk scores.

Coronary CT angiography (CPT 75574): For patients with chest pain or intermediate-probability coronary artery disease, coronary CTA is covered and pays approximately $180 to $350 in combined professional and technical components, depending on facility type. But coronary CTA is not a prevention screening tool in the reimbursement framework; it is a diagnostic test for symptomatic patients.

Interventional Codes: The Procedure Premium

The contrast with interventional cardiology is stark. Consider the following 2024 to 2025 Medicare payment data.

Percutaneous Coronary Intervention with Drug-Eluting Stent:

The professional fee for CPT 92928 (percutaneous transcatheter placement of intracoronary drug-eluting stent, single vessel) is approximately $850 to $1,200 in Medicare physician payments, with additional codes for angiography interpretation (CPT 93454 series, approximately $300 to $500).

STEMI Intervention (CPT 92941 - PCI during AMI): The professional fee premium for emergency PCI during acute MI adds approximately $200 to $400 over elective PCI fees.

Coronary Artery Bypass Graft:

The cardiac surgeon’s professional fee for CABG (CPT 33533, arterial graft) is approximately $2,500 to $4,500 under Medicare, with additional fees for the surgical assistant, anesthesia, and perfusion services.

TAVR:

The structural heart operator’s professional fee for TAVR (CPT 33419, transcatheter aortic valve replacement) is approximately $2,000 to $3,500 under Medicare.

Implantable Cardioverter-Defibrillator (ICD):

The Asymmetry Table

The following table places the payments side by side. All figures represent Medicare allowed amounts or national average base DRG payments in FY2024 to FY2025. Professional fees are approximate and region-specific; these figures represent blended estimates.

The table is not subtle. The prevention visit, the conversation that might prevent the need for the bottom half of the table, occupies the first four rows. The interventions that address the consequences of missed prevention occupy the rest.

What Published Literature Says About This Asymmetry

The reimbursement asymmetry between prevention and procedural cardiology has been documented in peer-reviewed literature, though perhaps less bluntly than the clinical consequences warrant.

A landmark analysis published in Health Affairs by Ginsburg and colleagues documented that procedural specialists systematically earn more per unit time than primary care or prevention-focused physicians, a gap that has widened over the RBRVS era 5 / Solid . The income differential between invasive cardiologists and non-invasive or preventive cardiologists within the same specialty reflects this payment structure directly.

Sinsky and colleagues published a systematic analysis of physician work outside the clinical encounter, demonstrating that primary care and prevention-focused physicians spend approximately 27% of their total professional time on non-visit tasks, including care coordination and preventive planning, that are not separately billable 5 / Solid . This time is economically invisible in the RBRVS framework.

The fundamental structural issue is not that individual cardiologists have failed to prioritize prevention. It is that the system they work within makes prevention economically unsustainable as a primary practice model. A cardiologist who spends most of her clinic time on prevention consultations will generate substantially fewer work RVUs than one who performs procedures, will be measured against the same MGMA productivity benchmarks, and will face the same administrative overhead requirements. The market forces that flow from this structure do not bend toward prevention.

The Facility Fee Multiplier: An Invisible Asymmetry

The reimbursement asymmetry documented above captures physician professional fees and DRG facility payments. It does not capture the full institutional economic picture, which is more skewed still.

When a hospital performs a primary PCI, the institution captures both the facility DRG payment (approximately $14,000 to $27,000) and a separate professional fee payment to the employed or contracted interventional cardiologist ($1,000 to $1,400 for the procedure itself). The hospital’s capital cost per PCI case is substantial: catheterization laboratory construction costs $3 to $5 million per lab; annual maintenance, staffing, and supplies run $1.5 to $3 million. But at 500 to 800 PCI cases per year in a busy academic center, the revenue per case covers the infrastructure several times over. The contribution margin per PCI case to the hospital system, after all direct costs, is typically positive and often substantial, making the cardiac catheterization laboratory one of the most economically valuable service lines in any hospital’s portfolio.

A full-scope prevention clinic requires physician time, laboratory support, imaging partnerships, and care coordination infrastructure, but its revenue model is built on $130 to $200 E/M visits. Even if the clinic runs at full capacity, 20 to 25 visits per physician per day, five days a week, the total professional revenue is approximately $650,000 to $1,000,000 per physician per year in Medicare allowed amounts before overhead. The overhead for a clinic-based physician (malpractice, support staff, billing, space, electronic health record costs) consumes approximately 55 to 60% of gross revenue in a typical outpatient cardiology practice. The contribution margin per prevention-focused cardiologist, to the hospital system, is marginal at best.

Hospital administrators tracking service line profitability do not need to be cynical to make the rational decision: invest in catheterization laboratory capacity, recruit interventional cardiologists, and view prevention programming as a community benefit or a loss leader rather than a core revenue source. The payment system makes this calculation almost automatic.

This is the facility-level expression of the same asymmetry that shapes physician behavior at the clinical level. From the boardroom to the examination room, the financial architecture of American cardiology points toward events and away from their prevention.

Outpatient Versus Hospital-Based Billing: The Site-of-Service Premium

A further layer of the reimbursement asymmetry that is rarely discussed publicly is the site-of-service differential. Under the Medicare physician fee schedule, the professional fee for a given service varies depending on whether the service is provided in a physician office (non-facility) setting or a hospital-based outpatient department (facility) setting. Non-facility payments are generally higher because the physician is presumed to be bearing practice overhead costs. Facility payments are lower because the hospital facility payment covers overhead.

For E/M visits, the difference is modest. CPT 99215 pays approximately $175 in a non-facility setting and approximately $148 in a hospital outpatient department. The difference is $27 per visit.

For procedures, the difference is negligible at the physician level because the major payment difference is the facility fee: whether the facility earns a hospital outpatient payment under the Outpatient Prospective Payment System (OPPS) APC payment, or nothing at all. A cardiology practice that owns its own echocardiography equipment and bills both the professional and technical components of an echo captures more total revenue than the cardiologist who refers her patient to the hospital radiology department. This creates an incentive for large cardiology practices to own imaging equipment, and a disincentive for smaller prevention-focused practices that cannot afford capital investment in imaging infrastructure.

The practical result: large cardiology practices that own nuclear cameras, echocardiography labs, cardiac CT scanners, and catheterization laboratories capture facility-equivalent revenue that small prevention-focused practices cannot. The payment system structurally favors large, procedure-dense practices over small, prevention-focused ones.

The History of How We Got Here

The Hsiao Study and the Birth of RBRVS

In 1985, Congress asked the Health Care Financing Administration (now CMS) to commission a study on resource-based relative values for physician services. The contractor was William Hsiao and colleagues at Harvard School of Public Health. The resulting paper, “Results and Policy Implications of the Resource-Based Relative-Value Study,” was published in the New England Journal of Medicine in 1988 5 / Solid . It established the conceptual framework for what became the Medicare physician fee schedule.

Hsiao’s team surveyed physicians about the relative effort, time, and skill required for 3,000 physician services. The concept was sound: pay physicians proportionally to the resources they invest in delivering a service. The execution, however, contained a structural flaw that has compounded over four decades.

The surveys were specialty-specific. Procedures were evaluated by proceduralists. Cognitive services were evaluated by cognitive specialists. The methodology did not, and perhaps could not, adequately compare the relative value of a 60-minute prevention consultation by an internist with a 60-minute coronary angiogram by an interventional cardiologist. These are different activities with different skill sets, and the physicians rating each were not rating the same pool of services.

The result was a fee schedule that systematically rewarded technical and procedural complexity over cognitive complexity. An interventional cardiologist performing a coronary angiogram earns work RVUs commensurate with the technical skill, stress, and liability of the procedure. A preventive cardiologist spending the same time on a nuanced metabolic risk assessment earns work RVUs commensurate with documentation, time, and clinical decision-making, which the fee schedule values at substantially lower rates than technical procedures.

This is not a conspiracy. It is the logical output of a survey-based valuation system that asked physicians to rate the effort of their own services without an external arbiter of comparative value.

The RUC: Where the Physics of Payment Live

The Relative Value Scale Update Committee was established by the American Medical Association in 1991, at Congress’s implicit invitation, to take on the technically demanding work of recommending relative value updates to CMS. The RUC is a standing committee of 29 members, the majority of whom are representatives of specialty societies. The Committee reviews requests for new or revised CPT codes and makes RVU recommendations to CMS, which has historically accepted the vast majority of them.

The composition of the RUC has been criticized extensively. Berenson and colleagues, writing in Health Affairs, documented that specialty societies with large procedural revenue bases have historically been better positioned to advocate for their codes than primary care societies 5 / Solid . The process is technically complex, requiring detailed clinical vignettes, physician surveys, and elaborate justification documents that favor well-resourced specialty societies over smaller or less financially organized ones.

The practical consequence: procedural codes have tended to accumulate relative value over successive RUC cycles, while cognitive services have been subject to downward pressure or have not kept pace with the growing complexity of primary and preventive care.

Medicare’s response to documented RUC bias has been partial. The Affordable Care Act of 2010 required CMS to conduct reviews of “potentially misvalued” services, and CMS has used this authority to reduce relative values for some overvalued procedural codes. But the structural incentive for procedural specialists to advocate aggressively for their code valuations, and the absence of an equivalent advocacy mechanism for prevention services that may not even have codes, remains intact.

Diagnosis-Related Groups and the Procedural Hospital

The institutional side of the reimbursement asymmetry emerged through the DRG system, which was introduced for Medicare inpatient payments in 1983, five years before the RBRVS. The DRG system pays hospitals a fixed amount for an admission based on the patient’s diagnosis and procedures, rather than for the actual services rendered. This was intended to control costs by removing the fee-for-service incentive for unnecessary inpatient days.

It succeeded in reducing average lengths of stay. It also created a new incentive structure: the more complex the procedure performed during an admission, the higher the DRG assignment, and the higher the payment. A patient admitted with chest pain and managed medically generates a lower DRG payment than a patient admitted with the same chest pain who undergoes PCI. A patient who undergoes elective PCI generates a lower payment than one who undergoes CABG.

This does not mean that physicians are doing unnecessary procedures to capture higher DRG payments. Most are not. What it means is that over decades, hospital systems have invested capital in the service lines that generate the highest DRG revenue. Catheterization laboratories are expensive to build and operate, but their revenue-per-case is among the highest in the hospital. Prevention clinics generate E/M visits at $130 to $200 per encounter. The capital allocation logic is not difficult to follow.

The consequence is that hospital systems across the United States have world-class interventional programs and grossly underfunded prevention programs. Northwestern Medicine in Chicago, Carle Foundation Hospital in Urbana-Champaign, the Cleveland Clinic in Cleveland, Mayo Clinic in Rochester: these are all systems with extraordinary catheterization laboratory infrastructure and far more limited infrastructure for prevention that reaches beyond the symptomatic or already-diagnosed patient. The rural hospital in Galesburg, Illinois, or Paducah, Kentucky, may have neither: it may transfer STEMI patients and have no prevention infrastructure at all.

The Procedural Premium Accumulates

Berenson and colleagues documented what they called the “procedural premium” in a widely cited Health Affairs analysis: the systematic tendency for the RBRVS to assign higher relative values per unit time to technical procedures than to cognitive services of equivalent complexity 5 / Solid . The procedural premium has been estimated at 50 to 100% above cognitive services of equivalent time and difficulty, when normalized per minute of physician work.

This premium is not the result of market failure. It is the result of deliberate, if imperfect, policy decisions made over four decades. The surveys underlying the RBRVS asked proceduralists to rate procedural effort and cognitive specialists to rate cognitive effort. The two pools were not benchmarked against each other in a way that could have corrected for systematic valuation bias. The bias compounded through successive RUC cycles, each of which adjusted existing code values on a relative scale anchored to prior, already-biased valuations.

By 2025, the result is a physician payment system in which a 15-minute procedure pays more than a 45-minute prevention consultation; in which a same-day cardiac catheterization reimburses 10 times more than the clinic visit that follows it; and in which the cardiologist who performs the most technically complex preventive risk assessment in her career earns less from that encounter than she would from a straightforward peripheral artery angioplasty.

The Political Economy of Procedural Revenue

To understand why four decades of criticism of the RBRVS and RUC have produced only modest reform, it is necessary to understand the political economy of procedural revenue in American medicine.

Procedural specialists, by definition, perform high-volume, high-unit-value procedures. An interventional cardiologist performing 300 PCIs per year generates perhaps $400,000 to $600,000 in annual professional fee revenue. The catheterization laboratory her hospital operates to support that volume generates $5 to $10 million in annual institutional revenue. Both the physician and the institution have strong, concentrated financial interests in maintaining the relative value structure that supports this revenue. Both are therefore motivated to participate in RUC advocacy, to fund specialty society lobbying, and to respond vigorously to any proposed reduction in procedural relative values.

Prevention-focused physicians, by contrast, earn their income through the accumulation of many small E/M visits, none of which individually represents enough revenue to motivate sophisticated advocacy. A preventive cardiologist seeing 20 patients per day at $175 each generates $3,500 per day, or approximately $700,000 per year in gross billings before overhead. Her financial stake in a 20% increase in the relative value of 99215 is approximately $30,000 per year. Her financial stake in a new dedicated prevention cardiology consultation code worth 4.0 wRVUs is potentially $50,000 per year. These are meaningful sums to an individual physician but trivial compared to the financial stakes that procedural specialists defend in RUC advocacy.

The asymmetry in political organizing capacity maps directly onto the asymmetry in RVU values. This is not conspiracy; it is the rational response to concentrated versus diffuse financial interests. It is the same reason that agricultural subsidies persist (concentrated beneficiaries, diffuse costs), that occupational licensing protects incumbents (concentrated costs of competition, diffuse public benefits), and that hospital consolidation continues despite payer and regulator concern. The political economy of healthcare payment reform is the political economy of every other regulated market: those with concentrated financial stakes in the status quo organize effectively to preserve it.

This matters for anyone trying to understand why prevention cardiology’s payment problem has persisted despite decades of documented evidence. The problem is not ignorance. It is interest. And the path to change runs through building equivalent organized advocacy capacity on the prevention side, which requires either the financial resources to sustain it or the policy salience to attract political support that is not driven by narrow financial interest.

The Physician Income Gap and Career Choices

The payment asymmetry between procedural and cognitive cardiology does not just shape clinical practice patterns; it shapes the career choices of every medical student considering cardiology.

Cardiology fellowship is among the most competitive in medicine, requiring exceptional academic performance, research productivity, and clinical recommendations. Of the fellows who complete a general cardiology fellowship, a significant fraction pursue interventional fellowship, electrophysiology fellowship, or structural heart fellowship, each of which confers access to high-volume procedural work and the compensation that follows. The number of fellows pursuing preventive cardiology as a primary career path is small. There are no interventional procedures in preventive cardiology. There is no procedural premium. The income ceiling for a purely prevention-focused cardiologist, in a standard employed or group practice model, is substantially below that of an interventional cardiologist with equivalent training and clinical intelligence.

Medical education debt compounds this calculation. The average physician graduates with approximately $200,000 to $250,000 in medical school debt. A cardiology fellow earning $70,000 to $90,000 per year during a three-to-seven year fellowship is deferring loan repayment and accruing interest. Upon completion of fellowship, the financial pressure to maximize income is immediate and real. Choosing a career in prevention cardiology, with its lower compensation ceiling and its dependence on finding a practice model that does not penalize prevention-focused time, is a financially consequential choice. Many physicians who would prefer to practice prevention cardiology choose a procedural or mixed practice because the financial pressures of their training debt and early career years do not leave room for idealism.

This is not a moral failing. It is a rational response to a financial structure that has been decades in the making. The solution is not to lecture medical students about the importance of prevention. The solution is to change the financial structure so that the choice to specialize in prevention is not also a choice to accept a substantially lower lifetime income.

Primary Care as the Canary

The impact of this history has been most visible in primary care. Bodenheimer and Pham, writing in Health Affairs in 2010, documented the consequences of a payment system that chronically undervalued the cognitive, coordinative, and preventive work that primary care physicians perform 5 / Solid . The primary care workforce has been in documented crisis for two decades: declining medical student interest in primary care careers, geographic maldistribution, unsustainably large panel sizes, and a quality-of-care deficiency precisely in the domain of chronic disease prevention and management.

The cardiology analog is less visible but equally real. Preventive cardiology is a recognized subspecialty, but it is a small one. The number of cardiologists whose practice is primarily preventive, rather than procedural or imaging-intensive, is a small fraction of the total cardiology workforce. The payment system made this ratio. And the ratio made Leonard’s kitchen floor.

The Five Numbers That Should Trigger Action

Why Five Numbers

Modern preventive cardiology has moved beyond the traditional Framingham risk factors: total cholesterol, blood pressure, smoking, diabetes, age, and sex. These remain important, but decades of research have identified a set of additional markers that, when measured together, provide a far more complete picture of a patient’s cardiovascular trajectory than any individual factor can.

The five biomarkers discussed in this section share a set of properties that make them particularly valuable for prevention: they are measurable years before a clinical event; they add predictive information beyond traditional risk models; they identify patients who appear low-risk by standard metrics but face significantly higher risk by these metrics; and, critically, their measurement should logically trigger a clinical intervention. The tragedy is that all five are either poorly reimbursed, uncovered for primary prevention, or not ordered because the visit in which they might be ordered is too short and too economically constrained to support them.

Apolipoprotein B

ApoB is the structural protein carried on every atherogenic lipoprotein particle: very-low-density lipoprotein, intermediate-density lipoprotein, low-density lipoprotein, and Lp(a). Each particle carries exactly one ApoB molecule. Therefore, measuring ApoB directly counts the number of circulating atherogenic particles. Counting particles is a more direct measure of atherogenic exposure than measuring LDL cholesterol, which estimates the cholesterol mass per particle but not the number of particles.

The ARIC (Atherosclerosis Risk in Communities) study, which followed over 15,000 adults across four U.S. communities, demonstrated that ApoB was a stronger predictor of coronary heart disease than LDL-C after adjustment for other risk factors 5 / Solid . The predictive advantage of ApoB over LDL-C is largest in patients with hypertriglyceridemia, metabolic syndrome, or type 2 diabetes, conditions in which patients often have many small dense LDL particles with lower cholesterol content per particle. These patients can have an LDL of 110 mg/dL, appear “borderline,” and have an ApoB of 145 mg/dL, which is frankly high and associated with significantly increased cardiovascular risk.

The 2018 AHA/ACC cholesterol guidelines acknowledged ApoB as a useful risk-enhancing factor that may be considered when statin initiation is uncertain 5 / Solid . The 2022 European Atherosclerosis Society Lp(a) consensus statement and the European Society of Cardiology dyslipidemia guidelines have gone further, recommending ApoB as a preferred treatment target over LDL-C in patients with hypertriglyceridemia or metabolic syndrome 5 / Solid .

The reimbursement reality: Medicare pays approximately $27 for an ApoB level when covered. For primary prevention, it is generally patient-pay at $30 to $45 at reference laboratories. Many primary care providers and cardiologists working in high-volume practices with limited time do not routinely order it, both because insurance coverage is inconsistent and because explaining why ApoB matters more than LDL takes five to ten minutes that a 15-minute primary care visit cannot accommodate. A 2025 analysis in Circulation argued directly that ApoB should be measured reflexively alongside standard lipid panels, particularly in patients with metabolic syndrome or triglycerides above 150 mg/dL 4 / Promising .

Lipoprotein(a)

Lp(a) is an LDL-like lipoprotein with an additional glycoprotein, apolipoprotein(a), attached to it. It is largely genetically determined: approximately 80 to 90% of the variation in Lp(a) levels is heritable 5 / Solid . This means that Lp(a) does not respond meaningfully to diet, exercise, or standard lipid-lowering therapy, including statins. An individual’s Lp(a) level at age 30 is essentially their Lp(a) level at age 70.

High Lp(a), typically defined as greater than 125 nmol/L (approximately 50 mg/dL) by current ACC/AHA thresholds, confers independent cardiovascular risk beyond traditional Framingham factors. The INTERHEART study, which enrolled 15,152 cases and 14,820 controls across 52 countries, identified high Lp(a) as an independent risk factor for acute myocardial infarction after adjustment for all other measured risk factors 5 / Solid 17018-9). Mendelian randomization studies, which use genetic variants in Lp(a)-related genes as proxies to test causality, have confirmed that the association is causal, not merely correlational 5 / Solid .

Approximately 20% of the adult population has Lp(a) above 125 nmol/L. In high-Lp(a) populations, the lifetime cardiovascular risk is substantially higher even in the absence of other traditional risk factors. A 45-year-old man with an Lp(a) of 300 nmol/L and otherwise normal lipids is at substantially higher lifetime cardiovascular risk than the standard Framingham model would suggest.

The clinical implication of knowing Lp(a) is not that it can be lowered with current therapies, though pelacarsen and olpasiran, two investigational Lp(a)-lowering agents, are in late-stage Phase 3 trials as of 2025. The clinical implication is that a patient with high Lp(a) should be managed more aggressively on every other modifiable risk factor: treated to a lower LDL target, placed on a statin at a lower traditional risk threshold, treated more aggressively for hypertension. Knowing the Lp(a) changes the conversation, and changes the treatment intensity.

The UK NICE cardiovascular disease risk assessment guideline, CG181, was under revision as of 2023, with HEART UK’s Lp(a) Taskforce calling for the explicit inclusion of Lp(a) screening recommendations. The 2022 European Atherosclerosis Society consensus statement recommended measuring Lp(a) at least once in every adult 5 / Solid . The ACC/AHA 2018 guidelines cited Lp(a) above 50 mg/dL as a risk-enhancing factor warranting consideration in treatment decisions.

The reimbursement reality: Medicare pays approximately $25 for Lp(a) when covered. Coverage for primary prevention screening is not established. In the current U.S. system, Lp(a) is measured in a tiny fraction of the patients who would benefit from knowing their level. In a 2020 American Heart Association scientific statement on Lp(a), the writing committee estimated that fewer than 1 in 20 eligible patients in the U.S. has ever had their Lp(a) measured 4 / Promising . This is arguably the largest gap between evidence and practice in contemporary preventive cardiology.

Coronary Artery Calcium

The coronary artery calcium score quantifies the amount of calcified atherosclerotic plaque in the coronary arteries using non-contrast computed tomography. It is scored on the Agatston scale: 0 indicates no detectable calcium and a near-zero short-term coronary event risk; scores above 100, 300, and 1,000 represent progressively higher risk strata.

The Multi-Ethnic Study of Atherosclerosis (MESA), the landmark natural history study of subclinical cardiovascular disease in 6,814 adults across six U.S. communities, established the CAC score as the single best predictor of incident coronary heart disease events beyond traditional risk factors 5 / Solid . Participants with a CAC score of zero had an event rate of approximately 0.4% over 3.8 years, regardless of their Framingham risk score. Participants with a CAC score above 300 had event rates of 7.7% over the same period.

This finding has profound clinical implications for statin decision-making. The 2018 ACC/AHA cholesterol guidelines explicitly recommend CAC scoring as a decision aid when statin initiation is uncertain in the borderline and intermediate risk groups (10-year ASCVD risk 5-20%) 5 / Solid . A CAC of zero in a 55-year-old man with borderline risk can appropriately support a decision to defer statin therapy and focus on lifestyle modification, avoiding years of potential medication side effects in a patient with genuinely low short-term risk. A CAC above 100 in the same patient places him in a category where statin therapy is clearly beneficial and likely cost-effective.

The ISCHEMIA trial, which enrolled 5,179 patients with stable coronary artery disease and moderate or severe ischemia, found no significant difference in the primary endpoint of cardiovascular death or myocardial infarction between a strategy of initial invasive management and a strategy of conservative medical management 5 / Solid . The clinical message: knowing that stable coronary disease exists, through imaging or CAC, creates an opportunity for aggressive medical management that can match the outcomes of intervention. The CAC score is a tool that can move a patient from “probably fine” to “needs aggressive lipid therapy, blood pressure control, and lifestyle modification” without a procedure.

The COURAGE trial reached similar conclusions: guideline-directed medical therapy alone in stable coronary artery disease was not inferior to PCI plus guideline-directed medical therapy for the primary endpoint of death or myocardial infarction 5 / Solid . The implication is not that PCI is unnecessary in stable disease; it is that medical therapy is more powerful than many patients and physicians appreciate, and that identifying disease early through non-invasive testing creates the opportunity to apply that medical therapy before an event occurs.

The reimbursement reality: CAC scoring (CPT 75571) pays approximately $85 in combined professional and technical components where Medicare covers it, but Medicare does not cover it for asymptomatic primary prevention. The USPSTF concluded in 2018 that evidence was insufficient to recommend CAC as a routine screening tool. This conclusion has been critiqued by preventive cardiologists, including Greenland and colleagues, who note that the USPSTF threshold requires evidence of benefit on clinical outcomes, whereas the CAC evidence base centers on risk reclassification and decision-making improvement 4 / Promising . The clinical community has largely moved ahead of the coverage decision: ACC/AHA guidelines recommend CAC in appropriately selected patients, but Medicare will not pay for it in those patients.

Cardiorespiratory Fitness (VO2max)

Cardiorespiratory fitness (CRF), quantified as maximal oxygen consumption (VO2max) or estimated through standardized protocols, is one of the strongest predictors of all-cause and cardiovascular mortality in the medical literature. The CARDIA (Coronary Artery Risk Development in Young Adults) study followed 4,710 young adults from 1985 to 2011 and found that higher CRF in young adulthood was associated with substantially lower midlife cardiovascular risk, with the association remaining significant after adjustment for traditional risk factors 5 / Solid .

A systematic review and meta-analysis by Kodama and colleagues in JAMA examined 33 studies involving 102,980 individuals and found that each 1-MET increment in exercise capacity was associated with a 13% improvement in all-cause mortality and a 15% improvement in cardiovascular mortality 5 / Solid . A meta-analysis by Blair and colleagues from the Cooper Institute Longitudinal Studies demonstrated that low CRF was responsible for more deaths than smoking, hypertension, dyslipidemia, diabetes, and obesity individually when examined as a population-attributable risk 5 / Solid .

Despite this evidence, CRF is not routinely measured in preventive cardiology visits. Exercise stress testing is covered by Medicare when there is clinical indication (chest pain, known coronary disease), but not as a primary prevention tool. A submaximal exercise test to estimate VO2max in a healthy 48-year-old without symptoms is not a covered benefit. Cardiopulmonary exercise testing (CPX/CPET), which provides the most accurate VO2max measurement, is covered for certain indications (advanced heart failure, pre-surgical evaluation) but not for preventive risk stratification.

The reimbursement reality: quantifying a patient’s fitness level, one of the strongest predictors of their cardiovascular future, is economically invisible in the current system. No code, no coverage, no incentive. The patient who wants to know their VO2max pays out of pocket, if they know to ask.

Fasting Insulin and Insulin Resistance

Fasting insulin, measured in the context of fasting glucose and a lipid panel, is a sensitive marker of insulin resistance, the metabolic derangement that drives endothelial dysfunction, dyslipidemia, inflammation, and accelerated atherosclerosis in the years and often decades before glucose meets the diagnostic threshold for diabetes 4 / Promising .

The CARDIA study documented that insulin resistance in young adulthood, measured by homeostatic model assessment (HOMA-IR), predicted subclinical atherosclerosis on coronary CTA 25 years later 4 / Promising . The progression from insulin resistance to prediabetes to type 2 diabetes is not instantaneous; it unfolds over 5 to 15 years, and during that time, the arterial wall is being progressively damaged by the metabolic milieu of hyperinsulinemia, high triglycerides, small dense LDL, and endothelial inflammation.

A patient with a fasting glucose of 98 mg/dL, an HbA1c of 5.7%, and a fasting insulin of 22 mIU/mL has insulin resistance by HOMA-IR criteria even though every single number appears normal in isolation. This combination, visible to any physician who orders fasting insulin alongside the standard panel, is an opportunity for intervention. Intensive lifestyle modification at this stage, with or without metformin, can prevent progression to type 2 diabetes and attenuate the cardiovascular risk that accompanies it 5 / Solid .

The reimbursement reality: fasting insulin (CPT 83525) costs approximately $20 to $30 at reference laboratories and approximately $15 to $25 under Medicare when covered. It is not part of any routine metabolic panel covered for primary prevention. It is rarely ordered. The patient’s HOMA-IR is invisible to the system.

What the Guidelines Say About Each Biomarker

Understanding where each of the five biomarkers stands in guideline-supported medicine clarifies the gap between evidence and practice.

For ApoB, the 2019 ACC/AHA primary prevention guidelines list it as a “risk-enhancing factor” that may be used when treatment decisions are uncertain in patients with borderline or intermediate risk 5 / Solid . The 2021 European Society of Cardiology prevention guidelines go further, recommending ApoB measurement as a preferred target in high-triglyceride states and noting its superiority over LDL-C for risk prediction in metabolic syndrome 5 / Solid . The Canadian Cardiovascular Society 2021 dyslipidemia guidelines recommend ApoB as a primary treatment target over LDL-C in patients with metabolic syndrome, hypertriglyceridemia, type 2 diabetes, or obesity 5 / Solid . The gap between guideline recommendation and clinical practice remains wide. A 2025 analysis in Circulation found that fewer than 15% of U.S. patients undergoing statin-initiation discussions had ever had ApoB measured, even in patients with the triglyceride-rich lipoprotein phenotypes where ApoB adds the most information 4 / Promising .

For Lp(a), every major guideline now recommends at least once-in-a-lifetime measurement in adults with intermediate or higher cardiovascular risk. The 2022 European Atherosclerosis Society consensus statement explicitly recommends universal Lp(a) measurement in all adults 5 / Solid . The 2018 ACC/AHA cholesterol guidelines list Lp(a) above 50 mg/dL as a risk-enhancing factor. The 2019 ACC/AHA primary prevention guidelines repeat this position. Despite these recommendations, survey data suggest that fewer than 5% of U.S. adults eligible for cardiovascular risk assessment have ever had Lp(a) measured 4 / Promising . The gap is not scientific uncertainty; it is reimbursement structure, time pressure, and clinical habit.

For CAC, the 2018 AHA/ACC cholesterol guidelines and the 2019 AHA/ACC primary prevention guidelines both explicitly recommend CAC as a decision aid for patients with borderline or intermediate 10-year ASCVD risk (5-20%) when the treatment decision is uncertain 5 / Solid . The evidence base is large: MESA, the Dallas Heart Study, the Rotterdam Study, and the Multi-National Study on Atherosclerosis. Yet Medicare non-coverage for asymptomatic primary prevention CAC means that the very patients named in the guidelines as candidates for the test must pay out of pocket, if they know to ask.

For VO2max, the AHA published a scientific statement in 2016 recommending that CRF be regularly assessed and considered a clinical vital sign 4 / Promising . No CPT code, no Medicare coverage, no billing mechanism has followed from that recommendation. The AHA statement was published in Circulation and was widely cited. The payment system did not notice.

For fasting insulin, no major guideline explicitly recommends routine fasting insulin measurement for cardiovascular risk assessment, because the evidence for fasting insulin as an independent predictor of cardiovascular events beyond its surrogate measures (prediabetes, metabolic syndrome) has not reached guideline-level consensus. This is an area where this clinical framework acknowledges that clinical practice is somewhat ahead of guideline recommendations: fasting insulin, in the context of glucose and lipids, provides information that HOMA-IR captures more accurately than glucose or HbA1c alone. But the honest Honesty Scale label for routine fasting insulin in cardiovascular prevention is Promising, not Solid.

The Five Numbers Together

No single one of these five biomarkers is sufficient to characterize a patient’s cardiovascular risk completely. Used together, they paint a picture that is substantially more accurate, and more clinically useful, than the traditional lipid panel plus blood pressure measurement.

A patient who presents with a normal LDL, normal blood pressure, no diabetes, no smoking history, and a Framingham 10-year risk of 7% looks like a person who does not need a statin. The same patient with ApoB of 148, Lp(a) of 180 nmol/L, CAC of 280, estimated VO2max in the lowest quintile, and fasting insulin of 24 mIU/mL (with HOMA-IR 3.2) is a patient in a category where every preventive cardiologist would offer aggressive intervention. The five numbers tell you which category he is in. The standard panel does not.

The current reimbursement architecture makes measuring these five numbers financially uncomfortable at best and economically irrational at worst. The test costs are individually small but collectively uninsured for prevention. The interpretation requires time that the visit does not pay for. The clinical conversation that follows is uncompensated. The whole is less supported than the sum of its parts.

What Prevention Actually Costs

The Real Cost of Prevention Medicine

Full-scope prevention medicine, done properly, is not cheap. It requires time: physician time for history, physical examination, biomarker interpretation, risk communication, and shared decision-making. It requires testing: not the $30 lipid panel, but the fuller suite of ApoB, Lp(a), hsCRP, CAC score, metabolic markers, and functional assessment. It requires follow-up: not a once-yearly appointment, but a relationship with a clinician who knows the patient well enough to notice when their trajectory changes.

The Cleveland Clinic Executive Health Program provides a reference point. A one-day full-scope executive health evaluation at the Cleveland Clinic includes a physical examination, an extensive battery of laboratory tests, cardiac imaging studies as indicated, a pulmonary function test, a full ophthalmologic examination, and consultations with multiple specialists. The program is priced at approximately $4,500 to $7,500 per person depending on the package selected, and it is primarily a patient-pay program, not covered by standard insurance.

The Mayo Clinic Executive Health Program operates similarly: a one or two-day immersive evaluation with multiple subspecialty consultations, priced at approximately $4,000 to $6,500 per participant. Mayo’s program has been evaluated in published literature; participants demonstrate higher rates of preventive intervention and lower rates of certain preventable hospitalizations compared to propensity-matched controls 3 / Early .

Both of these programs serve a specific demographic: the financially comfortable executive who can take a day away from work, travel to Cleveland or Rochester, and absorb a $5,000 out-of-pocket expenditure. They are excellent programs. They do not serve Leonard.

The cardiologist concierge model, pioneered by physicians like Eric Topol at the Scripps Institute and James Ehrman at the Cleveland Clinic, and more recently incorporated into direct-pay preventive practices across the country, offers a third model: an ongoing relationship with a preventive cardiologist, priced as an annual retainer or per-visit direct pay, outside the insurance reimbursement framework entirely. Pricing varies widely, from $2,500 to $15,000 per year for a full-scope prevention retainer from a well-known preventive cardiologist.

The common thread in all of these models: they work outside the CMS reimbursement architecture because they cannot work within it. The fee schedule does not support the time, the testing, or the relationship that genuine prevention requires. Every model that delivers excellent preventive cardiology has found a way to collect revenue outside Medicare’s physician fee schedule, through direct pay, executive health program facility fees, or boutique retainer pricing.

Stop Dying Early

Stop Dying Early is built explicitly on this premise: that excellent prevention medicine requires a financial model that does not depend on the insurance reimbursement architecture that makes prevention economically invisible.

The Signal Check is the entry point. It is a structured preventive cardiovascular risk assessment that combines a biomarker panel, a clinical questionnaire, a fitness assessment protocol, and a physician interpretation session. The Snapshot is priced as a direct-pay service, transparently, without the coding negotiation and authorization overhead of the insurance system. The cost is disclosed upfront. The deliverable is a detailed risk analysis with specific, prioritized, concrete recommendations.

A structured cardiovascular assessment is the next tier. It adds coronary imaging, advanced metabolic testing, and a multi-visit relationship with a preventive cardiologist who knows the patient across time. The Audit is appropriate for patients with one or more of the five biomarker abnormalities identified in the Snapshot, or for patients who have a family history of premature coronary artery disease and want a thorough baseline assessment.

Structured remote monitoring is the ongoing membership tier. Members receive quarterly check-ins, continuous biomarker tracking, and structured longitudinal data collection. Structured remote monitoring is where the preventive relationship lives: the annual repeat of CAC in selected high-risk patients, the serial ApoB tracking after lipid therapy initiation, the VO2max reassessment after a structured exercise prescription.

A cardiologist-led preventive program is the highest-depth offering, appropriate for patients at the intersection of high cardiovascular risk and the financial capacity to invest deeply in prevention. The Executive tier parallels the Cleveland Clinic and Mayo executive health model in depth and breadth, with the added integration of cardiologist-led continuity and the biomarker platform.

It is important to be honest about what Stop Dying Early does and does not do. It serves patients who can pay for it. It does not, at present, solve the problem of prevention access for patients without discretionary income. It does not replace the need for CMS coverage reform. It does not serve Leonard as he actually was: a middle-class logistics professional with commercial insurance who might have had $200 to $300 in preventive out-of-pocket spending but could not absorb $2,000 to $5,000 for a private prevention program of that scope.

Stop Dying Early’s contribution to the population health problem is not that it will reach every Leonard. It is that it demonstrates a working model of what real prevention looks like when the reimbursement system is removed as a constraint. The model, the protocol, the biomarker suite, the clinical workflow: these are the template for what should be covered by insurance once the political economy of the fee schedule allows it.

The Direct-Pay Prevention Market: Size and Trajectory

Stop Dying Early exists within a growing direct-pay prevention medicine market that has expanded substantially since 2015. Several converging forces explain this growth. First, consumer interest in longevity medicine and healthspan extension has created a paying population for prevention services that did not previously present itself to clinical medicine. Second, the emergence of precision medicine biomarker testing, particularly direct-to-consumer testing services, has created patient demand for clinical interpretation that the insurance-reimbursed system is not structured to meet. A patient who receives a direct-to-consumer ApoB result and does not know what to do with it has a need that no covered-service CPT code is designed to address.

Third, the employer-sponsored prevention market has grown as large self-insured employers recognize that the long-term cost of preventable cardiac events among their workforce exceeds the cost of prevention programs. Employers who pay directly for employee health care through self-insurance arrangements are, unlike CMS, free to design their own benefit packages. A self-insured employer who has watched three employees in their 40s sustain STEMIs in a two-year period, each generating $150,000 to $300,000 in direct claims cost plus indirect costs of temporary replacement, disability, and productivity loss, is a natural buyer of a structured prevention program that costs $2,000 to $5,000 per enrolled employee per year.

The direct-pay prevention market in the United States was estimated at approximately $2.5 to $4 billion annually as of 2023, with a growth trajectory driven by longevity-focused consumer demand and employer prevention purchasing 3 / Early . This is small relative to the $500+ billion U.S. cardiology market but growing, and it represents the portion of the prevention market that is not waiting for CMS to change its coverage policies.

The Equity Problem

Prevention as a Luxury Good

When prevention medicine operates primarily outside insurance reimbursement, it becomes a luxury good. Like organic food or gym memberships, it is available to those who can pay for it and unavailable to those who cannot. This is not a trivial observation. It is the cardiac equity crisis in structural form.

The patients who most need thorough preventive cardiology are not, in general, the executive at the $4,500 Cleveland Clinic annual evaluation. They are the Black patient in Memphis whose 10-year cardiovascular risk at age 50 is double that of her white counterpart by published epidemiology 5 / Solid . They are the Hispanic patient in the Rio Grande Valley whose rate of premature coronary artery disease exceeds national averages, compounded by higher rates of metabolic syndrome and lower rates of statin prescribing 5 / Solid . They are the South Asian immigrant in Chicago whose LDL is technically normal but whose Lp(a) is above 200 nmol/L and whose CAC is 175 at age 48, two findings that would change his treatment plan entirely if anyone ordered the tests.

The National Lipid Association has published equity-focused guidance noting that Black Americans have higher rates of above-threshold Lp(a) than white Americans, making universal Lp(a) screening a matter of equity as well as epidemiology 4 / Promising . The AHA 2020 Scientific Statement on cardiovascular health disparities documented that structural racism, including differential access to preventive care, is a fundamental driver of the Black-white cardiovascular mortality gap 5 / Solid .

The downstream math is punishing. The patient who cannot access preventive cardiology visits the emergency department with her STEMI. She is treated with primary PCI at the DRG rate. She survives, or she does not. If she survives, she attends cardiac rehabilitation, if she has transportation. She returns to a community without an accessible preventive cardiologist. The system spent $35,000 on her cardiac event and $0 on the five years of prevention that could have preceded it.

Community Health Centers and the Prevention Gap

Federally Qualified Health Centers (FQHCs) serve over 30 million low-income patients annually. They operate on a prospective payment system that bundles all services into a single per-visit rate, typically $175 to $250 for a full-scope visit. Within this payment, the FQHC must provide primary care, mental health, dental, and pharmacy services. The FQHC’s per-visit payment for a complex cardiovascular prevention visit is essentially the same as its payment for a brief sick visit, because the bundle does not differentiate by complexity.

This structure does not encourage the FQHC to deploy complex preventive cardiology protocols. ApoB testing requires either in-house laboratory capacity or a reference laboratory relationship. CAC scoring requires an imaging partnership. Interpreting a VO2max assessment requires a clinician with cardiorespiratory fitness expertise. All of these are structurally disadvantaged within the FQHC payment model.

The result: the patients most likely to develop premature cardiovascular disease, those in low-income communities with higher rates of hypertension, diabetes, metabolic syndrome, and exposure to chronic stress and environmental cardiovascular risk factors, receive the least sophisticated preventive cardiology.

Employer-Sponsored Prevention and the Middle Ground

Between the direct-pay executive prevention program and the FQHC prevention gap lies a large middle ground: the employed patient with commercial insurance whose employer controls what the insurance plan covers. This is where the largest opportunity for near-term equity improvement lives.

Self-insured employers, particularly large ones, can offer supplemental prevention benefits outside the insurance plan design. An employer who funds ApoB and Lp(a) testing as part of an annual wellness program is not constrained by Medicare coverage decisions. An employer who contracts directly with a preventive cardiology service, through value-based contracts or bundled payment arrangements, can provide the testing and the time that the standard fee schedule does not support.

Several large employers have pursued this path. Amazon’s One Medical acquisition, CVS Health’s MinuteClinic and Aetna integration, and Walmart’s health clinic network represent attempts to redesign the primary prevention encounter outside the traditional fee-for-service framework. None of these has yet delivered a full-scale preventive cardiology service, but the template exists.

An employer-sponsored prevention program is designed for this employer-sponsored market. An employer who contracts with Stop Dying Early provides its employees access to the Signal Check and a structured post-care programs, with costs shared between the employer and the employee at a structure that makes prevention accessible to the full workforce, not just the C-suite.

The Downstream Math of Untreated Risk

The equity argument is not purely moral. It has an economic dimension that should engage policymakers who think in terms of healthcare expenditures rather than health justice alone.

The Black-white cardiovascular mortality gap in the United States is well-documented. Black Americans have approximately 30% higher rates of coronary heart disease mortality than white Americans after adjustment for age, a gap that has narrowed but not closed over the past three decades 5 / Solid . A significant component of this gap is preventable: it reflects differential access to early diagnosis, preventive intervention, risk factor control, and the preventive relationships that make the difference between a patient who knows his ApoB is 148 and one who does not.

Hispanic Americans have lower overall cardiovascular mortality than white Americans in crude analyses, a phenomenon termed the “Hispanic paradox,” but they have substantially higher rates of metabolic syndrome, prediabetes, and type 2 diabetes, which translate into higher rates of premature coronary artery disease in the 40-to-60 age group when the protective effects of immigration-related lifestyle factors wane over acculturation 4 / Promising . The patient population most vulnerable to this trajectory, the second-generation Hispanic American in his late 40s with unrecognized insulin resistance and unrecognized Lp(a), is the patient least likely to have access to preventive cardiology that measures beyond the standard lipid panel.

South Asian Americans have cardiovascular event rates two to four times higher than non-Hispanic whites at any given LDL level, driven by higher rates of insulin resistance, above-threshold Lp(a), and a specific atherogenic lipoprotein pattern that standard risk tools were not validated to detect 4 / Promising . A South Asian-American physician may recognize this and order the appropriate tests. A generalist who does not know this epidemiology will use the standard Pooled Cohort Equation, derive a 10-year ASCVD risk of 6%, and conclude that no medication is warranted. The patient’s actual risk is substantially higher. Nobody will know until the event.

The economic argument: every prevented STEMI or CABG in a 55-year-old saves not just the $40,000 to $80,000 in acute care costs but also the long-term heart failure management that often follows large anterior STEMIs, the disability claims, the reduced productive lifespan, and the downstream healthcare utilization that tracks a patient with reduced ejection fraction over the next 20 years. Prevention economists estimate the lifetime cost savings of preventing a single cardiac event in a working-age adult at $150,000 to $300,000 in discounted future medical expenditures 4 / Promising . The preventive investment required to prevent that event: $500 to $1,000 over two to three years. The return on investment calculation is straightforward. The payment system has not yet made it.

What Medicare and Medicaid Could Do

The policy levers are not hidden. The USPSTF could update its recommendation on CAC scoring from “insufficient evidence” to a recommendation for use in appropriately selected intermediate-risk adults, citing the substantial evidence accumulated since 2018. This would trigger Medicare coverage obligations under the ACA.

CMS could create dedicated HCPCS codes for in-depth preventive cardiology risk assessment sessions, analogous to the existing Annual Wellness Visit (G0438/G0439) but with higher reimbursement to reflect the specialty-level cognitive work involved. The current Annual Wellness Visit pays approximately $193 and is largely a checklist-based health risk assessment performed by a nurse or health educator, not a detailed cardiovascular biomarker interpretation by a cardiologist.

CMS’s Innovation Center (CMMI) could test a bundled payment model for full-scope preventive cardiology, analogous to the existing CABG Model and AMI Model for acute events. A bundled payment covering a two-year prevention episode for a patient at high cardiovascular risk, including biomarker testing, imaging, physician visits, and structured follow-up, would provide the financial architecture to support the prevention work that individual CPT codes cannot.

None of these changes are currently underway. The political economy of coverage expansion favors services with strong procedural advocates, and prevention services do not have the same concentrated revenue beneficiaries as, for instance, the devices and procedures covered by the interventional cardiology DRG system.

The International Comparison

Germany

Germany’s statutory health insurance (Gesetzliche Krankenversicherung, GKV) covers vered in the United States. The “Check-up 35” program, reformed in 2019, provides every adult over 35 a thorough preventive health examination every three years at no cost, and annually for those over 65. The examination includes a lipid panel, fasting glucose, kidney function tests, blood pressure measurement, and cardiovascular risk assessment using a validated risk score.

Coronary artery calcium scoring is not universally covered under GKV for asymptomatic primary prevention, but its clinical use has been growing in Germany through selective application in intermediate-risk patients. Several German states have included CAC in risk-stratification pathways for patients with borderline risk scores, though coverage remains inconsistent across insurers 3 / Early .

The Germany comparison is instructive in one direction: universal basic prevention, including annual cardiovascular risk factor screening, is a right of every insured patient, not a privilege of those who can afford it. It is limited in another direction: the German system does not yet pay for the advanced biomarker assessment, the VO2max evaluation, or the time-intensive shared decision-making session that genuine preventive cardiology requires. The Check-up 35 is a floor, not a ceiling.

United Kingdom and NICE

The UK National Institute for Health and Care Excellence (NICE) governs coverage recommendations for the National Health Service. NICE’s cardiovascular disease risk assessment guideline (CG181), which has been the standard since 2014, recommends statin therapy for patients with a 10-year QRISK3 cardiovascular risk of 10% or greater. Lipid testing, blood pressure measurement, and QRISK3 calculation are standard components of NHS Health Checks offered to all adults aged 40 to 74 every five years.

The NICE position on Lp(a) has been evolving. As of 2023, HEART UK’s Lp(a) Taskforce was actively calling for the inclusion of Lp(a) in the CG181 update, which was under revision. The European Atherosclerosis Society had already issued its 2022 consensus recommending universal once-in-a-lifetime Lp(a) measurement 5 / Solid , and HEART UK’s August 2023 call to action explicitly argued that Lp(a) should be measured in patients with premature cardiovascular disease, first-degree relatives with high Lp(a), familial hypercholesterolemia, and borderline-high cardiovascular risk.

The NHS does not routinely cover Lp(a) testing for primary prevention. It covers it in specific high-risk populations through lipid clinics. The gap between the European scientific consensus (measure Lp(a) at least once in every adult) and the coverage reality (measure it in a small subset of clinically indicated patients) mirrors the U.S. situation, even in a system with universal coverage.

Coronary artery calcium scoring has not been adopted into NHS primary prevention pathways. NICE has not recommended CAC for routine cardiovascular risk stratification, citing concerns about radiation exposure, cost, and insufficient evidence of clinical outcome improvement. This position is increasingly at odds with the U.S. ACC/AHA guideline recommendations and the published evidence base.

Australia

The Australian Medicare Benefits Schedule (MBS) covers a Cardiovascular Risk Assessment for patients aged 45 to 74 (and Aboriginal and Torres Strait Islander adults from age 30) through the GP Assessment of Cardiovascular Risk Item Number 699. This includes a cardiovascular history, blood pressure, lipid panel, fasting glucose, and absolute cardiovascular risk calculation. The MBS item pays approximately AUD $197 to $250.

Lp(a) testing is available through Australian pathology providers, covered under MBS item 66500 (lipoprotein fractionation) when ordered for a patient with premature or recurrent cardiovascular disease. It is not covered for routine primary prevention screening.

Coronary artery calcium scoring (MBS item 57360) is listed in the Medicare Benefits Schedule for patients with intermediate cardiovascular risk, defined as a 10-year absolute risk of 10 to 15%, and for patients with suspected familial hypercholesterolemia. This represents a more permissive coverage determination than the current U.S. Medicare position, which does not cover CAC for primary prevention at all. The Australian coverage for intermediate-risk patients, while limited, offers a model for how CAC coverage reform could be structured in the U.S.

Canada

The Canadian Cardiovascular Society lipid guidelines have advocated for more aggressive risk stratification using ApoB and Lp(a). The 2021 CCS guidelines recommend ApoB as a treatment target preference over LDL-C in patients with metabolic syndrome or hypertriglyceridemia 5 / Solid . Lp(a) measurement is recommended once in any adult being assessed for cardiovascular risk.

Provincial health insurance plans (analogous to state Medicaid in the U.S.) vary in their coverage of ApoB and Lp(a) for prevention. Ontario covers ApoB as a covered laboratory service. British Columbia and Alberta cover it with relevant clinical indication. Coverage for CAC scoring for primary prevention is not standardized across provinces; it is available primarily as a patient-pay service at roughly CAD $150 to $250.

The Canadian experience illustrates a recurring theme: when scientific guidelines recommend a test and coverage policy does not follow, the test becomes a proxy for income. Patients with private supplemental insurance or discretionary spending capacity get the test. Patients in remote communities, lower-income urban neighborhoods, or Indigenous communities, who in Canada have substantially higher cardiovascular risk due to social determinants, do not.

Japan

Japan has a mandatory annual health checkup system (Tokutei Kenshin) for employees and insured adults, administered through employers and municipal health insurance societies. The checkup includes blood pressure, fasting glucose, HbA1c, a lipid panel, waist circumference, and kidney function. The Japanese system has successfully achieved very high rates of participation in preventive screening: over 50% of eligible adults complete the checkup annually.

The Japanese checkup does not include ApoB, Lp(a), CAC scoring, or cardiorespiratory fitness assessment. It is a broad, low-cost, high-participation surveillance program that identifies hypertension, dyslipidemia, and diabetes at population scale, but does not provide the depth of cardiovascular risk phenotyping that modern preventive cardiology enables.

The Japanese cardiovascular disease mortality rate is substantially lower than that of the United States, even accounting for dietary and lifestyle differences 5 / Solid , and the mandatory screening system is part of that story. But the comparison suggests that broad, systematic screening for basic risk factors can substantially reduce population-level cardiovascular mortality even without advanced biomarker assessment, a point relevant to equity discussions about what a minimum standard of cardiovascular prevention should include.

The European Atherosclerosis Society Model: Evidence-to-Policy

The European Atherosclerosis Society (EAS) provides an instructive countermodel to the U.S. pattern of evidence accumulating ahead of policy. The EAS issues periodic consensus statements on lipid management, Lp(a), and cardiovascular risk that carry substantial weight in European national guidelines precisely because the society’s process is explicitly designed to translate evidence into policy recommendations.

The 2022 EAS consensus statement on Lp(a) is the most recent example. The statement concluded, after a systematic review of the evidence: “We recommend that Lp(a) be measured at least once in every adult. We recommend that appropriate targets for Lp(a)-lowering therapy, once available, should be defined in terms of absolute risk reduction based on Lp(a) concentration and global cardiovascular risk” 5 / Solid . This recommendation has been incorporated into national guidelines in Germany, the Netherlands, Sweden, and several other European countries. The NHS England lipid modification pathway update, which was expected to include Lp(a) recommendations in 2024, draws on this evidence base.

The contrast with the U.S. position is not that U.S. cardiologists disagree with the evidence. The ACC/AHA guidelines have incorporated Lp(a) as a risk-enhancing factor. The contrast is in translation speed: European national health systems have been faster to move from guideline recommendation to coverage policy, in part because they operate with centralized coverage determination and less dependence on a fragmented fee schedule with multiple payer decision-makers.

The NHS Health Check, offered to all adults aged 40 to 74, is the platform through which Lp(a) testing could potentially reach population scale in England once the coverage decision is made. The U.S. equivalent, the Medicare Annual Wellness Visit, serves a similar population but with less clinical depth and without the national lipid modification pathway connection. The U.S. system could, in principle, use the Annual Wellness Visit as the vehicle for population-level Lp(a) screening: add a once-in-a-lifetime Lp(a) measurement to the AWV laboratory panel for all beneficiaries over 40 without prior measurement, at a cost of approximately $25 per test, for a total national program cost of approximately $1.5 to $2 billion for a one-time national screen of the relevant unscreened population. The projected cost per major cardiovascular event prevented, through earlier identification and more intensive risk factor management, would likely be well within standard health technology assessment cost-effectiveness thresholds 4 / Promising .

That calculation has not been done by CMS. It should be.

The International Lesson

No country has yet created a healthcare system that provides full-scope preventive cardiology, including advanced biomarker assessment, coronary imaging, fitness evaluation, and ongoing physician relationship, to all patients who would benefit from it at no cost. The systems that come closest, Germany and Japan, succeed through universal basic prevention coverage and high participation rates. The systems that reach the frontier of prevention science, a small number of academic preventive cardiology programs and direct-pay practices, do so for a limited, high-resource population.

The international comparison suggests that the U.S. preventive coverage gap is real but not uniquely American. The gap between what prevention science can do and what any healthcare system actually provides is a global problem. The U.S. distinction is that the gap is particularly wide, particularly inequitably distributed, and particularly structurally embedded in a payment system designed around procedures.

The Cardiologist’s Dilemma

A Day in the Cath Lab World

To understand why cardiologists, most of whom chose their specialty because they care about patients with cardiac disease, collectively underperform in prevention, it is necessary to understand what their working day looks like and what it costs.

Consider a general cardiologist at a community medical group in the Midwest. He performs both non-invasive and limited interventional work. His annual work RVU target, set by his medical group to cover his salary and overhead, is approximately 9,500 wRVUs. This is consistent with MGMA benchmarks: the median wRVU production for cardiologists was approximately 8,600 to 9,200 in 2023 survey data, with the 75th percentile exceeding 11,000. His base salary is $450,000, and his contract includes a productivity bonus for production above 9,000 wRVUs.

A clinic day runs from 8 a.m. to 5 p.m. He has 24 scheduled patient slots. Each 99214 visit (moderate complexity, 30 minutes) earns approximately 1.92 wRVUs. Each 99215 visit (high complexity, 45 minutes) earns approximately 2.80 wRVUs. An echocardiogram read earns 0.52 wRVUs (CPT 93306 professional component). A nuclear stress test earn 3.34 wRVUs (CPT 78452 professional). A coronary angiogram earns 11.00 wRVUs (CPT 93454). A PCI earns 14.00 wRVUs (CPT 92928 + catheterization components).

The arithmetic of a clinical day without procedures: 24 office visits averaging 2.0 wRVUs each earns 48 wRVUs. Eight echocardiogram reads earn 4.2 wRVUs. Total: 52.2 wRVUs. At this rate, he needs 182 clinic-equivalent days to hit his 9,500 wRVU target. That is a 36-week work year with no vacation, no CME, no administrative time, no teaching, no sick days, and no days in the catheterization laboratory.

Add a single day in the catheterization laboratory, performing three elective PCIs at 14 wRVUs each and two diagnostic angiograms at 11 wRVUs each: 42 wRVUs in one day. That single procedure day is the equivalent of nearly four full clinic days in RVU production.

The incentive structure does not require a cardiologist to be corrupt or uncaring to be pulled toward procedural work. It simply requires that he be human, and that he be in a practice system that measures, compensates, and benchmarks him against RVU production.

The Prevention Visit Cannot Win the RVU Math

A 45-minute prevention consultation with a patient presenting for a thorough cardiovascular risk assessment, during which the cardiologist reviews ApoB, Lp(a), a coronary calcium score, a metabolic panel, family history, discusses shared decision-making around statin initiation and lifestyle modification, and constructs a written prevention plan, will be billed at 99215 + G2211 in the best case. Total: approximately 3.02 wRVUs (2.80 for 99215 + 0.22 for G2211). Medicare payment: approximately $175 to $195.

In the same 45 minutes, the cardiologist could have finished two straightforward follow-up visits (99213, 1.30 wRVUs each = 2.60 wRVUs) and an echocardiogram read (0.52 wRVUs), earning a combined 3.12 wRVUs. The prevention consultation is slightly worse in RVU terms than two brief follow-ups plus an imaging read.

More starkly: 45 minutes with the patient discussing the five biomarkers and constructing a prevention plan earns almost exactly the same number of RVUs as a 15-minute catheterization laboratory visit at the start of a diagnostic angiogram case. The cognitive intensity is not remotely equivalent. The prevention consultation requires deep synthesis of metabolic, imaging, and behavioral data. The catheterization start is a technical procedure initiation. The fee schedule treats them identically.

MGMA Benchmarks and the Productivity Treadmill

Medical groups, hospital systems, and large physician organizations use MGMA benchmark data to set productivity expectations, determine compensation, evaluate physician performance, and make staffing decisions. The median cardiologist wRVU production in MGMA data has been between 8,500 and 9,500 over recent survey cycles. The 75th percentile is above 11,000.

A preventive cardiologist who structures her practice around 60-minute in-depth prevention visits, without procedural work, would generate approximately 5,000 to 6,000 wRVUs annually assuming a full clinic schedule with no no-shows and minimal administrative time. She would land at or below the 25th percentile of MGMA cardiologist benchmarks. Her compensation, tied to benchmarks, would reflect this positioning. She would earn substantially less than her procedural colleagues with equivalent training, experience, and clinical intelligence.

Few medical groups will recruit and retain a preventive cardiologist at well below median productivity benchmarks indefinitely. The economic reality is that preventive cardiology is a loss leader in fee-for-service medical group practice, sustainable only if the cardiologist also performs imaging or procedures (which shifts the practice away from pure prevention), or if the practice has an external funding source (philanthropic endowment, research grant, or employer contract).

This is not a critique of MGMA data or of medical group administrators. It is a description of the forces that the reimbursement system creates. Every medical director who reviews MGMA benchmarks and notices that her prevention-focused cardiologist is at the 25th percentile is doing exactly what the system asks her to do. The system is wrong. She is not.

Burnout and the Prevention Physician

The RVU treadmill does not operate without human cost. Physician burnout in cardiology is not primarily the result of long hours or difficult cases; it is the result of the cognitive dissonance between why physicians entered medicine and what the payment system asks them to do. A cardiologist who trained in cardiology because she was drawn to the intellectual challenge of cardiovascular risk prevention, who spent a fellowship year learning ApoB measurement and CAC scoring and exercise physiology and metabolic medicine, and who arrives at her first attending position to discover that none of this work is valued by her productivity benchmark, is a cardiologist at high risk of moral injury.

Medscape’s annual physician burnout survey has consistently found cardiology among the medical specialties with above-average burnout rates, with approximately 40 to 45% of cardiologists reporting burnout symptoms in recent survey cycles 4 / Promising . The drivers most frequently cited are administrative burden, inadequate time with patients, lack of clinical autonomy, and electronic health record documentation demands. These are exactly the features of a system that pays by transaction volume and does not pay for the thought that goes into each transaction.

A physician who is chronically overbooked, spending 12 to 15 minutes per patient to maintain RVU targets, has no capacity to notice that the patient in front of her, with the borderline LDL and the metabolic syndrome and the family history that trails through the notes, needs 45 minutes and five specific laboratory tests. She may know it. She may even document it as a future task. But the structure of her day does not create the space. The prevention visit that Leonard needed did not fail to happen because his physicians were bad physicians. It failed to happen because good physicians, working within a bad payment system, could not create the time for it.

The Cardiologist as Prevention Advocate

It is worth stating clearly that many cardiologists are active advocates for preventive medicine even within a system that does not pay for it. The founding of the Preventive Cardiovascular Nurses Association, the American Society for Preventive Cardiology, and the ACC’s Prevention section reflects genuine professional commitment to this domain. The work of Paul Ridker at Brigham and Women’s Hospital on residual inflammatory risk, of Roger Blumenthal and Michael Blaha at Johns Hopkins on coronary imaging and risk stratification, of Ron Blankstein at Brigham on VO2max and cardiovascular risk, and of dozens of academic preventive cardiologists across the country has built the evidence base that justifies the clinical practices described in this paper.

The gap is not between cardiologists’ values and prevention. The gap is between prevention’s evidence base and prevention’s payment. The same cardiologist who publishes a JAMA paper on CAC’s superiority to Pooled Cohort Equations in borderline-risk patients returns to clinic on Monday to see 25 patients at $130 to $175 each, knowing that the CAC scan she would recommend is not covered for most of them and that the 45-minute counseling visit to explain why the result changes everything is worth exactly 3 work RVUs.

This is the cardiologist’s dilemma in its truest form: not a conflict between knowledge and ignorance, but a conflict between knowledge and economics.

The Cognitive Load and the Missing Code

There is a further dimension to the cardiologist’s dilemma that does not appear in the wRVU accounting. The prevention consultation is cognitively more demanding than a straightforward post-PCI follow-up. The cardiologist reviewing a patient’s ApoB, Lp(a), CAC score, VO2max, and metabolic markers is synthesizing five independent data streams into a coherent risk narrative, explaining each one clearly to a patient who has never heard of ApoB, deciding on the weight of evidence for statin initiation versus deferral, making a shared decision about CAC rescoring timing, prescribing an exercise intensity, addressing dietary modification in the context of the patient’s specific metabolic pattern, and writing a summary for the patient’s primary care physician.

Sinsky and colleagues documented that for every hour of direct patient contact time, physicians spend approximately 1.5 to 2 hours on electronic health record documentation, inbox management, and care coordination tasks 5 / Solid . For a 45-minute prevention consultation with this level of complexity, the total physician time investment is closer to 90 to 100 minutes. At $192, that is approximately $115 per hour.

A cardiologist billing at the 75th MGMA percentile for interventional cardiology earns approximately $600,000 per year. Her effective hourly rate including procedure time, documentation, and overhead is approximately $200 to $300 per hour. The prevention consultation earns $115 per hour. The math explains the workforce distribution.

The Fellowship-to-Practice Gap

Medical education compounds the problem. Cardiology fellows spend three to four years in training programs that expose them to the full spectrum of cardiovascular medicine, including prevention. Most Accreditation Council for Graduate Medical Education (ACGME)-accredited cardiology fellowship programs now include rotations in preventive cardiology and formal didactics on lipid management, risk stratification, and lifestyle medicine. The fellow who completes a cardiovascular disease fellowship in 2024 knows more about ApoB, Lp(a), and coronary artery calcium than any generation of cardiologists that preceded her.

The dissonance arrives on day one of attending practice. The clinical knowledge she acquired during fellowship has no corresponding billing infrastructure. She cannot bill for the biomarker synthesis she was trained to perform in a way that reflects its complexity. She can bill for the visit, at 99215, and absorb the fact that the cognitive work this visit required is compensated at the same rate as a follow-up appointment for a patient with stable coronary disease managed on three medications. The system has no memory of the distinction.

This fellowship-to-practice gap explains in part why preventive cardiology subspecialization, formally recognized as a focus area by the ACC and the American Society for Preventive Cardiology, has not yet produced a large workforce of purely prevention-focused clinical cardiologists. Physicians who specialize in prevention either migrate toward academic positions that tolerate below-median productivity in exchange for research productivity, join the growing direct-pay prevention sector, or absorb prevention into a general cardiology practice where it competes with more highly compensated work for physician time. The career path of the pure prevention cardiologist does not lead, in most health systems, to financial sustainability 4 / Promising .

What Career Choices Look Like at the Training Level

The cardiology fellow choosing a subspecialty concentration does not make decisions in an information vacuum. She knows, through informal peer networks and explicit salary data from MGMA and the ACC’s own workforce surveys, that interventional cardiology commands the highest compensation in the specialty, followed by electrophysiology, then imaging-heavy general cardiology, then clinical cardiology, with preventive cardiology at or near the lowest compensation band for cardiologists with full fellowship training.

ACC workforce data published in the Journal of the American College of Cardiology found that preventive cardiologists reported median total compensation approximately 15 to 25% lower than general clinical cardiologists and 35 to 50% lower than interventional cardiologists 4 / Promising . This compensation differential is not hidden from trainees. It is part of the informal curriculum of cardiology fellowship.

The result is a workforce distribution that reflects these incentives with predictable fidelity. The United States has approximately 22,000 board-certified cardiologists, of whom roughly 8,000 are interventional cardiologists and several thousand are electrophysiologists. Preventive cardiologists, as a formal clinical category, number in the hundreds, not the thousands. The ratio of cardiologists who perform catheterization-based procedures to cardiologists whose primary clinical focus is prevention is approximately 10-to-1 or higher 3 / Early . The payment system produced exactly the workforce distribution it was designed to produce.

For the patient waiting to find a physician whose primary clinical focus is his ApoB trajectory rather than his catheterization report, that workforce distribution is the most concrete expression of what the reimbursement asymmetry costs.

What Would Need to Change

CMS Coding Reform

The most direct pathway to structural change is the creation of new, dedicated HCPCS codes for complex preventive cardiovascular risk assessment. The Annual Wellness Visit codes (G0438/G0439) pay approximately $193 for a once-annual health risk assessment, but these are designed for a checklist-based visit deliverable by a health educator, not a specialty-level biomarker synthesis by a cardiologist.

A distinct family of codes for “Preventive Cardiology Longitudinal Risk Assessment” at appropriate wRVU levels would signal to the system that this work is valued. The codes would need to be structured to reflect genuine cognitive complexity, carrying wRVU values comparable to moderate-complexity consultations (approximately 2.5 to 3.5 wRVUs for a 45-minute session), with the possibility of add-on codes for biomarker interpretation, imaging synthesis, and care coordination.

The AMA’s Current Procedural Terminology editorial panel would need to accept the concept, create the codes, and the RUC would need to value them at levels reflecting their actual resource inputs. Given the RUC’s historical pattern of undervaluing cognitive services relative to procedural ones, this pathway would require sustained advocacy from the ACC’s prevention councils, the National Lipid Association, and other professional societies, with explicit oversight from CMS under its misvalued services review authority.

A precedent exists: the G2211 add-on code for complexity in office visits, finalized in CY2024, was the result of exactly this kind of sustained advocacy, demonstrating that the system is capable of incremental reform when the clinical argument is made clearly enough and the advocacy is organized enough.

CAC Coverage for Intermediate-Risk Adults

The USPSTF review of CAC for cardiovascular risk assessment is due for update. The 2018 conclusion that evidence was insufficient should be revisited in light of the following evidence that has accumulated since then: the 2018 ACC/AHA cholesterol guidelines’ explicit recommendation for CAC in borderline and intermediate-risk patients, the 2019 AHA/ACC primary prevention guidelines’ recommendation for CAC as a decision aid for statin initiation discussions, the publication of the 10-year follow-up data from MESA documenting the predictive performance of CAC across racial and ethnic groups, and the growing literature on CAC’s role in reclassifying patients who would otherwise be undertreated or overtreated by Pooled Cohort Equation estimates alone 5 / Solid .

A USPSTF Grade B recommendation for CAC scoring in adults aged 40 to 75 with borderline cardiovascular risk (10-year ASCVD risk 5-20%) would mandate Medicare coverage under the ACA. This single policy change would make the most clinically valuable prevention imaging tool accessible to the millions of patients who currently pay out of pocket or go without.

Value-Based Payment and Cardiovascular Outcomes

The Medicare Shared Savings Program (MSSP) and its predecessor the Pioneer ACO program have demonstrated that accountable care organization models can reduce cardiovascular event rates when primary prevention is incentivized through shared savings rather than penalized through fee-for-service undercompensation 4 / Promising . Under MSSP, a physician group that prevents a STEMI through effective preventive cardiology keeps a portion of the savings that would otherwise flow to the DRG system. This is the correct incentive alignment.

However, the cardiologist-specific contribution to MSSP savings is difficult to attribute. The shared savings models work at the population level, crediting the accountable care organization rather than individual physicians. A cardiologist who spends extra time on prevention does not personally capture the shared savings she generates; those flow to her organization, which may or may not return them to her in the form of bonus compensation.

More targeted value-based payment models for cardiovascular prevention would be needed to address the cardiologist’s RVU dilemma. A model that paid a full prevention bonus to the cardiologist whose patients had zero primary cardiovascular events over a five-year period, with appropriate risk adjustment, would align individual physician incentives with population health outcomes in a way that the current fee schedule does not.

CMMI tested the CPC+ model from 2017 to 2021, providing primary care practices with per-member per-month payments to support care management functions that are not billable under fee-for-service, including preventive risk stratification and care coordination 4 / Promising . The results were mixed but directionally positive for preventive care quality measures. An analogous program targeted at preventive cardiology, providing a per-member per-month infrastructure payment to support the non-visit work of cardiovascular prevention, would be a meaningful reform.

Employer Purchasing Power

Large, self-insured employers represent the most agile lever for near-term prevention coverage improvement. Unlike Medicare and Medicaid, which operate through federal rulemaking, self-insured employers can modify their benefit designs annually. An employer who adds ApoB and Lp(a) to the covered laboratory panel for all employees over 40, or who contracts directly with a preventive cardiology practice for an employee prevention benefit, can move faster than any regulatory process.

The economic case for this investment is not speculative. A large manufacturing employer with 5,000 employees over 45 can estimate the probability of cardiac events among that cohort using actuarial models. Each STEMI or CABG in an employed patient costs the employer not just in health insurance claims (typically $40,000 to $80,000 in paid claims) but in disability, short-term productivity loss, and long-term presenteeism. The employer-sponsored prevention investment in thorough cardiovascular risk assessment, at $300 to $600 per employee per year for a structured program, has a plausible cost-effectiveness ratio that should be attractive to any employer managing cardiovascular risk in their workforce 4 / Promising .

The Statin Access Story as a Precedent

The history of statin access in the United States provides an instructive precedent for how the coverage gap in preventive cardiology might eventually close.

In the mid-1980s, when lovastatin was approved, statin therapy was restricted to patients with diagnosed familial hypercholesterolemia or patients who had already experienced a cardiac event. The concept of primary prevention statin therapy, treating patients who had never had a cardiac event but were at high risk, was pharmacologically plausible but not yet reimbursed. Primary prevention statins were considered experimental, not covered by most insurers, and prescribed only by forward-thinking lipid specialists.

Over the following decade, the 4S trial, the WOSCOPS trial, the AFCAPS/TexCAPS trial, and the Air Force Coronary Atherosclerosis Prevention Study progressively built the evidence base for primary prevention statin therapy 5 / Solid 91533-3 for 4S; DOI: 10.1056/NEJM199511163332001 for WOSCOPS). The ACC and AHA published guideline updates. CMS expanded coverage. By 2000, statins for primary prevention in high-risk patients were a standard covered benefit. By 2010, they were among the most commonly prescribed medications in the United States.

The trajectory took approximately 15 to 20 years from pharmacological possibility to universal insurance coverage. The preventive biomarker story, from ApoB through CAC, is on a similar trajectory. The evidence base is strong. The guidelines have moved. The coverage has not followed. History suggests it eventually will, for most patients, in most insurance categories. The question is what happens to the patients who need this information in the meantime, before the coverage expansion arrives.

Stop Dying Early’s position in this story is analogous to the position of the early lipid clinic in the 1990s: serving patients who are ahead of the coverage curve, building clinical infrastructure, generating real-world outcomes data, and demonstrating a model that can be scaled when coverage catches up. The lipid clinic did not solve the population health problem on its own. It contributed to the evidence base and the clinical culture that eventually made the population health solution possible.

The Role of Digital Health and Remote Monitoring

Technology offers a partial pathway around the reimbursement asymmetry, though it is not yet fully realized. Remote patient monitoring codes, finalized in CMS policy in 2019, allow physicians to bill for time spent reviewing continuous data streams from patients with connected devices. CPT 99453 (remote monitoring device setup), 99454 (supply of remote monitoring device, 30-day period), and 99457/99458 (remote physiologic monitoring treatment management service, 20 and additional 20-minute increments per calendar month) created a billing framework for ongoing physician engagement with patient-generated health data.

For cardiovascular prevention, this framework could support ongoing monitoring of blood pressure through connected cuffs, activity data through wearable fitness trackers, and weight through connected scales. The cardiovascular prevention application is emerging but not yet mature: the current CPT framework does not pay for the physician interpretation of an Oura ring’s resting heart rate variability or an Apple Watch’s sleep duration data in the context of cardiovascular risk management. The conceptual framework for remote preventive monitoring payments exists; the specific clinical application to cardiovascular biomarker trending has not yet been operationalized in the fee schedule.

If CMS were to extend remote physiologic monitoring coverage to include serial ApoB trending after statin initiation, sequential CAC progression monitoring, and wearable-based VO2max estimation, the billing infrastructure for an ongoing preventive cardiology relationship would exist within the current CPT framework, without requiring entirely new codes. This is a more achievable near-term policy goal than a wholesale revision of the RBRVS valuation of cognitive services. It builds on existing infrastructure rather than requiring new political capital.

What Is Not Changing

The RUC’s composition and process have been critiqued for over 20 years. The Medicare Payment Advisory Commission (MedPAC) has repeatedly recommended reforms to the RUC’s structure, including greater CMS independence in valuing cognitive services. These recommendations have not been implemented. The political economy of the RUC reflects the organized power of specialist societies, which have both the financial incentive and the organizational capacity to advocate for their procedural code valuations in ways that primary care and preventive medicine societies have not historically matched.

The DRG system for cardiac procedures will not be dismantled. Hospitals have invested billions of dollars in catheterization laboratory infrastructure on the assumption of continued procedural reimbursement. The clinical evidence supports continued payment for primary PCI, CABG in the appropriate patients, and TAVR for eligible aortic stenosis. The payment levels may be adjusted at the margins, but the procedural model’s dominance in cardiac revenue will persist for the foreseeable future.

Clinical Synthesis

Why the Platform Is Built the Way It Is

Stop Dying Early was designed with full awareness of the reimbursement asymmetry described in this paper. The design question was not “how do we fix the CMS fee schedule?” That is a policy project that may succeed in 10 to 20 years, if the right coalitions form and the right evidence accumulates. The design question was: “Given that the fee schedule is broken, how do we deliver excellent cardiovascular prevention to patients who are ready to invest in it today?”

The answer is a direct-pay platform that prices its services transparently, delivers them outside the insurance authorization and coding complexity that burdens standard medical practice, and builds a financial model that supports the time, the biomarker testing, and the physician relationship that genuine prevention requires.

This is an honest answer to a real problem. It is also an incomplete answer, because a direct-pay platform serves only those who can pay. That limitation is acknowledged, not papered over.

The Routing Logic

Stop Dying Early routes patients based on their risk profile and their goals.

The Signal Check is designed for the patient who is cardiovascular-risk-aware, willing to invest a defined amount in a thorough baseline assessment, and wants to know where they stand. The Snapshot is appropriate for any adult over 35 who has not had a thorough cardiovascular risk assessment that included ApoB, Lp(a), and CAC. It is particularly relevant for patients with: a family history of premature coronary artery disease (defined as coronary events before age 55 in a first-degree male relative or before age 65 in a first-degree female relative); metabolic syndrome or prediabetes by any criterion; South Asian ancestry (which confers substantially higher cardiovascular risk at any given LDL due to higher Lp(a) rates and other metabolic factors); and patients who have been told their standard lipid panel is “normal” but have never had ApoB or Lp(a) measured.

A structured cardiovascular assessment is designed for the patient who has identified one or more of the following: ApoB above 90 mg/dL in primary prevention (above 80 mg/dL in known ASCVD); Lp(a) above 125 nmol/L or 50 mg/dL; CAC score above 100 in a patient under 55, or above 300 at any age; estimated VO2max below the age-sex matched 40th percentile; or a HOMA-IR above 2.5 indicating insulin resistance. For these patients, the Snapshot’s findings have generated a specific question: what does this mean for my treatment plan, and what should I do differently? The Audit answers that question with the depth of a full-scope preventive cardiology evaluation.

Structured remote monitoring is designed for the patient who has decided that prevention is not a one-time event but an ongoing practice. Cohort membership provides the structure for serial biomarker tracking, fitness reassessment, treatment response monitoring, and the kind of longitudinal physician relationship that allows the cardiologist to notice, across visits, that a patient’s ApoB is not responding to the statin dose as expected, or that their VO2max has dropped 10% over two years in a way that warrants evaluation.

A cardiologist-led preventive program is the highest-depth offering, appropriate for patients with the highest combination of risk and financial capacity: those with high Lp(a) and family history, those with established but stable coronary disease managed medically, those with multiple metabolic risk factors who need a detailed management plan, and those in high-stress, high-consequence professional environments where cardiovascular health has both personal and organizational implications. The Executive tier parallels the best academic prevention programs in depth and breadth.

At Carle Foundation Hospital in Urbana-Champaign, and through the Carle Illinois College of Medicine’s clinical training mission, this clinical framework draws on academic preventive cardiology expertise and connects to the broader clinical ecosystem for patients who require imaging, genetic testing, or subspecialty consultation beyond the prevention platform’s scope. In Chicago, patients with complex presentations can be referred to Northwestern Medicine’s Bluhm Cardiovascular Institute or Rush University Medical Center’s cardiovascular prevention programs. For rural Illinois patients, Carle’s regional network provides pathways for imaging and consultation that the primary prevention relationship can coordinate.

What Stop Dying Early Does Not Do

Stop Dying Early does not replace insurance medicine. For patients who have already had a cardiac event, who have known coronary artery disease requiring monitoring, or who need an echocardiogram, a nuclear stress test, or a catheterization, Stop Dying Early coordinates referral to appropriate clinical settings but does not itself provide procedural care. The platform is upstream of the event, not downstream.

Stop Dying Early does not serve patients who cannot pay for direct-care services. This is the equity gap described in Section 7, and it is real. The model demonstrates that prevention medicine can be delivered with clinical rigor and financial sustainability, and that it should be the template for what insurance systems eventually cover.

Stop Dying Early does not generate evidence in the formal sense of randomized controlled trial data. It generates real-world outcomes data on a prevention-enrolled cohort. The program’s longitudinal data, including serial biomarkers, CAC progression, VO2max trajectories, and clinical event rates, will over time constitute a meaningful dataset for prevention science. It is not a substitute for RCT evidence, but it is evidence, and it is the kind of evidence that a registry-based science can generate at scale.

The Data Proposition

One of the ways in which Stop Dying Early adds to the ecosystem beyond individual patient care is through data. The absence of a large-scale, longitudinal dataset on patients who have undergone thorough preventive cardiology workup, with serial biomarker measurement, CAC progression tracking, fitness monitoring, and clinical outcome follow-up, is a gap in the evidence base that limits the policy argument for prevention coverage expansion.

The Framingham Heart Study, which started in 1948 and has enrolled multiple generations of participants, remains the foundational prospective cohort from which much of our standard cardiovascular risk factor knowledge derives. MESA, the Multi-Ethnic Study of Atherosclerosis, enrolled 6,814 participants in 2000 and has followed them with serial cardiovascular imaging and outcomes through six exam cycles. CARDIA enrolled 5,115 young adults in 1985 and has tracked them into their 50s and 60s. These cohorts are the foundation of modern preventive cardiology evidence.

The gap they cannot fill is the gap between enrolled epidemiological cohorts, which are drawn from the general population without selection for prevention-seeking behavior, and the population that actually engages with preventive cardiology services. A patient who presents to the Signal Check with a family history, a high-risk lifestyle, and a desire to understand their cardiovascular future is a different population from a random community sample. Their outcomes, tracked longitudinally, can answer questions that randomized trials and general population cohorts cannot: What happens to CAC progression rates in patients who receive ApoB-guided statin therapy versus standard LDL-guided therapy? What is the cardiovascular event rate in patients who are identified as high-risk by the five-biomarker panel and treated aggressively versus those who are identified as moderate-risk and managed conservatively? What is the VO2max trajectory in enrolled patients who follow the prescribed exercise intensity protocol versus those who do not?

These are answerable questions with a sufficiently large and well-characterized cohort. This program is designed to generate exactly this kind of real-world evidence over time. The evidence it generates will not replace RCT data for purposes of treatment decision-making, but it will supplement the existing literature in ways that are practically important for understanding what prevention medicine actually achieves in real patients who sought it out, rather than in trial populations randomized to receive it.

This is not a peripheral benefit of this model. It is central to the case that the model deserves to be scaled, and that its clinical protocols deserve to be incorporated into insurance coverage frameworks as the evidence accumulates.

The Prevention Relationship as a Clinical Good

There is a dimension of the prevention visit that the RVU accounting cannot capture and the clinical trials do not measure: the value of a longitudinal physician relationship in which the patient is known across time.

A cardiologist who sees the same patient at age 48, 51, 54, and 57 has a clinical dataset that no single encounter can provide. She has watched the ApoB come down from 142 to 78 after statin intensification. She has watched the CAC progress from 0 to 45 over nine years, a slower than average progression rate that tracks with the aggressive risk factor management they have built together. She has watched the VO2max improve from the 35th to the 55th percentile after eighteen months of structured aerobic training. She has watched the fasting insulin normalize from 24 to 11 mIU/mL after significant dietary modification and the loss of 22 pounds.

This is not data management. It is medicine. It is the kind of clinical narrative that makes a cardiologist confident in the next decision: when the patient comes in at 57 with a new complaint of occasional exertional chest pressure, the cardiologist who has watched his CAC score and his biomarker trajectory for nine years has a completely different clinical frame for that symptom than the cardiologist who is seeing him for the first time. She knows his plaque burden is modest and his risk factors are well-controlled. She knows the chest pressure started after he increased his exercise intensity. She knows he is anxious about his father, who had his MI at 58. She can make a much better clinical decision with that context than without it.

The reimbursement system does not pay for the relationship. It pays for the visit. The distinction is not trivial. The visit is a transaction; the relationship is an asset. The asset reduces unnecessary testing, prevents premature procedural intervention, enables early identification of genuine change in a known-stable clinical picture, and keeps the patient engaged in the prevention behaviors that produce the outcomes. None of this appears in a wRVU count.

This is the argument for structured remote monitoring’s longitudinal structure that goes beyond the simple economic case for direct-pay medicine. The longitudinal relationship is clinically superior to episodic care for the prevention patient, independent of what it costs or how it is paid for. The reimbursement system’s failure to value it is one more form of the asymmetry this paper has been documenting.

The Argument for Choosing Prevention Now

The argument is not that the system will change in time to save your arteries. The argument is that the system’s failure to pay for prevention is not a fact of nature. It is a policy choice that can, and eventually will, be reversed. In the meantime, the information exists. The tests are available. The physicians who understand this field are findable, if not always accessible through standard insurance channels.

The person who understands the reimbursement asymmetry and decides to act on it, by measuring their ApoB and Lp(a) and getting a CAC score and finding out their VO2max and knowing their HOMA-IR, is making a decision to operate outside the system’s incentive structure rather than wait for the system to develop the right incentives. That decision can be made today. It does not require a policy victory or a fee schedule revision. It requires approximately $400 to $700 in out-of-pocket testing and a physician who can interpret the results.

The Signal Check is that physician and that structure, made accessible and reasonably priced, without the advertising language and the boutique-luxury framing that tends to accompany direct-pay medicine. This is clinical cardiology, directly delivered, for patients who are ready to treat their cardiovascular future as worth the same care and investment as their financial future.

Conclusion: The Qualifying Event Doesn’t Have to Be Yours

What Leonard Had

Leonard survived his STEMI. His daughters drove to the hospital behind the ambulance, and by the time they arrived, he was already in the catheterization laboratory. By the time they were allowed into the recovery room, the stent was deployed, the artery was open, and his EKG was returning toward normal. He was alive.

But Leonard at 58 was not the same Leonard he had been at 53. His ejection fraction at discharge was 38%. The anterior wall of his left ventricle, the muscle that had been without blood for 90 minutes on a Thursday morning, was permanently damaged. Not dead muscle, not entirely: some of it would recover, would scar, would remodel. But the function he had at 53, when a thorough prevention visit might have changed his trajectory, was gone.

His cardiologist at discharge, a careful and excellent interventional physician, spent 22 minutes reviewing his medications, his dietary restrictions, his activity limitations, his follow-up schedule, and his cardiac rehabilitation referral. It was the most thorough conversation Leonard had ever had with a cardiologist. It happened four days after his heart attack.

Here is what that conversation would have covered, in a different world, at a different time:

At age 53, during a preventive cardiology visit that his commercial insurance might or might not have covered, a physician who understood the five biomarkers and had the time to interpret them would have drawn ApoB and Lp(a) with his routine panel. She would have found, let us say, ApoB of 142 mg/dL and Lp(a) of 220 nmol/L. She would have ordered a coronary artery calcium score, which he would have paid $95 for out of pocket. His CAC would have come back at 180, placing him in the 90th percentile for his age and sex. She would have had a 45-minute conversation with him about what these numbers meant, why the LDL of 118 was not the full story, why Lp(a) of 220 puts him in the high lifetime risk category and means he should be treated to a lower LDL target than his standard risk score would suggest, and why a CAC of 180 at 53 is not a sentence but it is a diagnosis, and it is a diagnosis that calls for action.

She would have started him on a high-intensity statin. She would have referred him for a structured exercise program to improve his VO2max. She would have rechecked his ApoB in three months and targeted a reduction to below 80 mg/dL. She would have documented his Lp(a) as a permanent risk-enhancing factor and set a lower LDL treatment target accordingly. She would have rechecked his CAC in three to five years to assess progression.

She would have earned approximately $192 for that visit.

Five years later, the coronary artery lesion that became his STEMI would either not have developed or would have developed more slowly. It would not have disappeared: Lp(a) cannot be lowered, and no intervention would have changed his underlying genetic predisposition. But ApoB of 142 mg/dL treated aggressively to below 80 mg/dL over five years is a substantially different arterial environment than ApoB left untreated. The plaque that formed would have been smaller. Its fibrous cap would have been thicker, less inflamed, less likely to rupture. This is not speculation: it is the biology of how statins stabilize plaques and how ApoB reduction changes the atherogenic environment over time 5 / Solid .

Leonard might have made it to 65 without a STEMI. He might have had a catheterization someday, for stable coronary disease identified on a surveillance CAC at 61, and gone on aspirin and a different lipid regimen. He might have had nothing: a CAC that never crossed 300, a stable plaque burden, and a retirement in which his ejection fraction stayed at 60% instead of 42%.

We do not know. The counterfactual cannot be tested. What can be said is that his preventive cardiology visit would have been worth $192 to the billing system and potentially irreplaceable to his family.

The Second Generation

Leonard’s daughters were 24 and 21 on the morning of his STEMI. They drove to the hospital behind their mother. They stood in the small room off the corridor. They received the cardiologist’s update that their father was stable, that the artery was open, that he had survived. One of them asked, in the manner of a 24-year-old who has just had her framework of safety rearranged: “Is this going to happen to me?”

The cardiologist, who was excellent, said what the system had equipped her to say: watch your cholesterol, exercise, maintain a healthy weight, don’t smoke. This is not wrong advice. It is the correct generic prevention message for a young adult with a parent who has had a premature MI. It is also incomplete.

Here is what the cardiologist could have said, had the science been in front of her and had she had 20 minutes for this conversation: Your father has a high Lp(a). We know this because we measured it during his workup after the STEMI. His level is 220 nmol/L. Lp(a) is 80 to 90% heritable. The probability that you have inherited high Lp(a) from your father is approximately 40 to 50%. You should have your Lp(a) measured. If it is above 125 nmol/L, you have a significant lifetime cardiovascular risk that standard risk tools will not capture accurately. That information will not change anything you do today, but it will change what your physician does with your LDL target when you are 35, and it will inform how aggressively your future physicians treat your other risk factors. The test costs $40. You should have it done.

Instead, the conversation was three minutes long. The cardiologist had two other families waiting. Her day had started at 4:30 a.m. with the page to come in for the STEMI. She had not eaten since 7 p.m. the night before. She was five days into a stretch that started a week ago, covering a colleague on vacation. The system did not equip her to have the 20-minute prevention conversation for Leonard’s daughters because the system does not pay for that conversation. It paid for the cath. It paid for the stent. It paid for Leonard’s discharge visit. It did not pay for his daughters’ future.

This is not a hypothetical. It is the structure of every STEMI case that generates a family history in the medical records of the patient’s children. The qualifying event creates a document that follows the children through their adult lives, appearing on every health history form they fill out. “Family history of heart disease: father, age 58.” The information is there. The prevention visit to act on it is not.

The two daughters’ Lp(a) values, unmeasured on the morning they stood in the hospital corridor, will determine whether the pattern of that Thursday morning becomes a family story told across generations, or a single chapter that closes when Leonard’s story is told completely. The $40 test that could begin to answer that question has never been ordered.

The Choice That Remains

The reimbursement asymmetry is real. It is documented in the CMS fee schedule, in the MS-DRG payment tables, in the wRVU benchmarks, in the RUC’s decades of accumulating procedural premium. It is documented in Leonard’s story and in the stories of every patient like him who arrived at the catheterization laboratory without a prevention visit in their record.

But the asymmetry is not a law of physics. It is a policy artifact, and policy artifacts can be changed. In the meantime, the information exists. The technology exists. The biomarkers are accessible, measurable, and interpretable by any cardiologist or internal medicine physician who has spent time understanding the evidence. The CAC machine is in most major medical centers. The ApoB assay runs on the same analyzer as the LDL. The Lp(a) result comes back in 24 hours. The VO2max can be estimated in 20 minutes on a treadmill.

The qualifying event is what happens when this information does not get to the patient in time. The STEMI at 58. The stroke at 61. The cardiogenic shock that makes the catheterization laboratory a rescue instead of a precaution.

You still have the choice to not make it yours.

The qualifying event is avoidable in a larger fraction of patients than the current system allows us to reach. That fraction is what Stop Dying Early is trying to expand, one ApoB at a time, one CAC score at a time, one 45-minute conversation at a time, until the system changes its mind about what prevention is worth.

What To Do Now

If you are a patient:

1. Ask your physician to add ApoB and Lp(a) to your next lipid panel. If insurance won’t cover them, pay out of pocket: the combined cost is approximately $50 to $80 at most reference laboratories. These two tests, taken once, change risk stratification for a substantial minority of patients who appear to be at moderate risk by standard measures.

2. Ask about a coronary artery calcium score. If you are between 40 and 75, have no prior cardiac events, and have a 10-year ASCVD risk between 5 and 20%, the ACC/AHA guidelines support CAC as a decision aid for statin discussions. Most radiology centers and hospital imaging departments perform this scan. Patient-pay cost: $75 to $150.

3. Know your fasting insulin and calculate your HOMA-IR. If your fasting glucose is in the prediabetes range (100 to 125 mg/dL) or your HbA1c is 5.7 to 6.4%, ask your physician to add a fasting insulin to your next visit labs. The combination of fasting glucose and fasting insulin gives you a HOMA-IR. HOMA-IR above 2.5 signals insulin resistance that warrants lifestyle intervention.

4. Get your cardiorespiratory fitness assessed. Ask your cardiologist or a sports medicine physician for a submaximal exercise test or a validated CRF estimation protocol. If you are in the bottom two quintiles of CRF for your age and sex, aggressive aerobic exercise training, not general health advice to “exercise more,” is the intervention.

5. If you want a structured, cardiologist-interpreted synthesis of all of these findings, the Signal Check is built for that purpose. The entry point is sde.health/snapshot.

If you are a physician or practice administrator:

1. Consider adding ApoB and Lp(a) to your standard lipid panel for all patients over 40 undergoing cardiovascular risk assessment. The incremental cost is small. The information gain for patients with discordant LDL/ApoB is significant.

2. Build CAC ordering into your borderline-risk statin initiation workflow. The ACC/AHA guideline pathway is explicit. The test is accessible. The result changes clinical management in a meaningful fraction of patients.

3. Advocate within your medical society for dedicated CPT/HCPCS codes for preventive cardiology risk assessment. The G2211 precedent shows it is possible. The path is through the AMA CPT panel and the RUC, with sustained specialty society pressure.

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This paper is the fourth in the Stop Dying Early Authority White Paper Series. The series argues, with primary literature, that the structural barriers to cardiovascular prevention, reimbursement asymmetry, workforce distribution, equity gaps, and the cultural primacy of the qualifying event, are not immutable features of medicine. They are policy choices. And policy choices can be changed.

The paper that follows this one in the series examines the medication decision in lipid management: when statins are not enough, what the evidence says about PCSK9 inhibitors, and how the reimbursement structure has shaped prescribing patterns in ways that are only partially aligned with the clinical evidence.

--- Dr. Job Mogire, MD FACP FACC Stop Dying Early June 2026