Intro 

Cardiovascular disease (CVD) is not an emerging challenge. It is the defining one. CVD remains the leading cause of death in the United States, responsible for roughly 916,000 deaths annually. Nearly one in two adults is living with some form of cardiovascular condition. And from a system perspective, it represents one of the largest and least controlled drivers of total cost of care—an estimated $627 billion annually, projected to approach $1.8 trillion within the next two decades. 

Every health system, Accountable Care Organizations (ACO), and risk-bearing organization already understands this. CVD is not an issue that is ignored. It is not misunderstood. And it certainly is not lacking innovation. 

So why—despite decades of clinical advancement, new therapies, and an explosion of digital health tools—do outcomes remain stubbornly difficult to improve at scale? 

Because the constraint is not insight. It’s execution. And more specifically: It’s the absence of longitudinal ownership in a system designed around episodic care. 

Let’s talk about it.  

In this post, we’ll cover: 

• What the Industry Gets Right
• The Real Problem: Longitudinal Ownership
• Why Most Digital Health Solutions Fall Short
• The VBC Reality: Execution Becomes Financially Non-Negotiable
• What Actually Works: The Execution Model for CVD
• Reframing the Category: From RPM Vendor to Care Operator
• Strategic Implications for Your Organization
• The Line Between Insight and Impact 

 What The Industry Gets Right 

To its credit, the industry has made real progress on how it sees CVD. There is major alignment on several points.  

1. Cardiovascular disease requires continuous management, not episodic intervention
2. Early identification and treatment of risk factors—like hypertension and heart failure—are critical
3. Patient behavior, adherence, and engagement are central to outcomes
4. Remote patient monitoring (RPM) and digital care can extend care beyond the clinic 

There are some other things shaping the industry, too.  

Every year, there is movement toward value-based care models. Expansion of monitoring technologies and connected devices is becoming commonplace. Leadership knows we need earlier identification of cardiovascular risk with integration across cardio, kidney, and metabolic conditions. All of this is directionally correct. The momentum is even strategic. But we aren’t any closer to solving the CVD problem.  

Here’s the kicker: 

Knowing what to do is not the same as being able to do it—consistently, at scale, and between visits. And that is where most organizations struggle.

The Real Problem: Longitudinal Ownership & More 

Because when you examine how CVD is actually managed today, one reality becomes clear: 

Responsibility is everywhere, but accountability is nowhere. 

Cardiovascular disease is not a single condition. It’s a constellation—coronary artery disease, heart failure, stroke, arrhythmias, peripheral artery disease—affecting nearly half the adult population and driving hundreds of billions in cost. 

And yet, the delivery model remains largely unchanged. It’s still built around encounters. If you were to draw it out, it looks like an episodic loop. The cycle is repetitive and costly:  

1. Undetected or under-managed risk
2. Acute event (heart failure admission, myocardial infarction, stroke)
3. Hospital stabilization
4. Fragmented follow-up
5. Extended care gap with no clear owner
6. Rinse and repeat  

Sadly, this isn’t a rare case. Heart failure readmissions remain near 20% within 30 days. 

The good news? The system is highly effective at reacting to events. It’s far less effective at preventing them. 

Problem Breakdown: A Financial Problem Lives Between Visits 

Like a troll under the bridge, there is one important and overlooked truth: 

The majority of cardiovascular costs don’t accrue during clinical encounters. It accrues between them. 

What does that look like in real time? 

• Hypertension goes unmanaged for years
• Atrial fibrillation remains undetected until stroke
• Early heart failure progresses silently 

By the time patients meet providers, the cost has already materialized.

Problem Breakdown: The Illusion of Coverage 

On paper, cardiovascular patients are “managed” by many different parties: 

• Primary care providers
• Cardiologists
• Subspecialists
• Hospitals
• Rehabilitation services 

But in practice, this creates fragmentation—not continuity. Each stakeholder engages the patient at a point in time. No one owns the patient over time. 

Which leads to: 

• Gaps in follow-up
• Inconsistent medication titration
• Missed early warning signs
• Diffused accountability for outcomes 

Everyone participates. No one is responsible. 

Problem Breakdown: Snapshot Medicine vs. Continuous Reality 

The current model unintentionally operates on snapshot medicine. These snapshots look like a single blood pressure reading during a visit, a one-time rhythm check and periodic specialist consults. 

But we all know that cardiovascular disease evolves continuously. Effective management—especially for heart failure—requires multiple medication titration touchpoints over time, which rarely happen consistently in real-world care. Therefore, patients remain under-monitored, under-treated, and under-optimized.  

Therapies exist, but the system isn’t designed to apply them continuously.  

Problem Breakdown: Plenty of Data, Not Enough Action 

Ask any of your physicians. Across cohorts and populations, there is no shortage of ways you can collect data. Vitals from devices, clinical indicators, and risk signals are becoming more and more available. But if your providers are incredibly short on time and resources, all that data makes no difference.  

There is no room for timely, prioritized clinical action. The system, as it stands, just isn’t built for that. What does that mean? 

• Cardiology faces a projected 7,100 specialist shortage by 2037
• Wait times average 33 days and rising
• Nearly half of U.S. counties have no cardiologist access 

Problem Breakdown: Longitudinal Ownership 

At its core, cardiovascular care lacks one critical component: a longitudinal owner of the patient. No one is accountable for the things that move the needle:  

• Continuous monitoring
• Medication optimization
• Behavior reinforcement
• Early intervention 

Without that ownership, the system, and most cardiologists, default to reaction. It’s all they can do. It’s why outcomes stagnate, costs increase, and programs fail.  

It’s frustrating because it’s not that we don’t know what to do when facing this issue. It’s that no one can hold that responsibility over time.  

Why DO Most Digital Health Solutions Fall Short? 

Organizations facing CVD aren’t the only ones falling short. While remote care vendors and partners are heavily invested in solving CVD, they contribute the wrong things to the problem. They, too, fail to execute.  

• Data without action—RPM platforms generate insight but lack consistent intervention
• Tools without a care model—devices and dashboards exist without clear ownership and workflows
• Episodic thinking—remote care is also structed around check-ins and not continuous engagement 
• Ignoring operational pressure—digital partners provide insights and data but fail because execution relies on staffing, workflows, and infrastructure that most organizations lack  

True cardiovascular management at scale requires a lot. For example, tasks like patient onboarding, device education, data review, clinical triage, patient communication, documentation and compliance are ALL included. Where is your team supposed to fit that? 

That’s a huge reason most programs rarely outright fail, but rather they stall.  

The VBC Reality: Execution is Non-negotiable  

In FFS models, inefficiencies could be handled. They hurt, but they didn’t make you bleed. That is not the case with value-based care (VBC). In VBC models, poorly managed CVD leads to a direct blow to your financial performance. Your quality measures take a beating.  

• Increased hospitalizations
• Higher total cost of care
• Missed shared savings
• Margin instability 

This isn’t a new story. VBC may be flawed, but given the increasing momentum from CMS, it’s the future. As a result, organizations are left stuck between a rock and a hard place.  

What Actually Works? The Execution Model for CVD 

When you step back and understand that the problem is execution, you can then see the solution is a model. (It’s not adding another tool.) 

Organizations seeing results in this space share five characteristics:  

1. Patients are engaged continuously, not episodically
2. Each patient has a clear clinical owner
3. Data triggers clearly defined interventions in real time
4. Engagement cadence matches the needs of the patient and their condition
5. Programs are built for sustained operation, not just for pilots 

You might read that and panic because that sounds like an incredible lift involving way too many stakeholders that are all extremely short on time and resources. But that’s not the point here.  

The point is that your organization needs to reframe the category, meaning shift your view of digital care partners from “Vendors” to “Care Operators.” 

Reframe The Category: From Remote Vendors to Care Operators 

As value-based care and other cost-savings initiatives have gained traction, we’ve seen the old ways of thinking about remote care change.  

What used to be a conversation of devices, platforms, and features has now become something else. Now, we hear more concerns about who is actually talking to our patients. Who is delivering the care? 

Organizations are starting to recognize the major difference between a vendor that provides nice tools and a partner that operates the care model. In other words, they want an operational support system that owns patient engagement, provides clinical support, executes workflows, and shares responsibility for outcomes.  

The Implications for Your Organization 

If CVD is a priority, then your strategy must reflect the operational reality. Change the conversation from “how do we deploy RPM” to “how do we manage this population for years to come across this organization?” 

Ask your team the hard questions: 

• Where does ownership live?
• Do we have the capacity for continuous engagement?
• Does this program fill the gaps, or does it just look like it is?
• Are we structured for scale—or pilots? 

Without those answers, your ending becomes predictable. Your program stalls. Your problems remain unsolved. You spend more money than you want to. And you feel burned by remote care. 

The Tricky Balance Between Insight and Impact 

The healthcare industry is not operating from a place of ignorance when it comes to CVD. In fact, the clinical pathways are well established; the risk factors are well understood, and the interventions required to improve outcomes are not theoretical—they are known, validated, and widely accepted. Great! 

What remains unresolved is not what to do, but the system’s ability to do it with consistency, discipline, and scale.  

Cardiovascular disease is often framed as the next major hurdle for remote care, but that framing risks oversimplifying the challenge. The issue is not identifying CVD as a priority. Organizations have already done that.  

The issue is that most are still structured around care models that cannot sustain the level of continuous engagement, monitoring, and intervention that cardiovascular patients require. Awareness, on its own, has proven insufficient in its attempt to drive meaningful change. Without a corresponding shift in how care is delivered between visits, outcomes will continue to lag behind expectations. 

Sustained progress will come from building and operationalizing a model that supports longitudinal care as a default, not an exception. This means creating systems of accountability, clinical workflows, and patient engagement strategies that function every day, not just at the point of encounter. It requires the ability to translate patient data into timely action, to reinforce adherence through consistent touchpoints, and to intervene before deterioration becomes acute. Most importantly, it requires ownership—clear, continuous responsibility for the patient's journey over time. 

Cardiovascular disease is not under-recognized, nor is it underserved in terms of available tools or clinical knowledge. The persistent challenge lies in the failure to execute against what is already known. Until healthcare organizations close the gap between insight and action, between visibility and intervention, the outcomes—and the costs—associated with CVD will remain largely unchanged. 

Let’s talk about how your organization can close one of the most expensive gaps in healthcare history.