A coordinated approach to cardiovascular cost and quality.
Connect between-visit patient support with physician decision support. Cubie works with your plan and participating cardiology practices to define the population, organize delivery, and evaluate cost and quality.
Where the program can focus
Admissions and transitions
Patient follow-up and coordination around changes in care
Medication follow-up
Information and recommendations for physician review
Appropriate testing
Context to support the next clinical decision
Connect patient support with clinical decisions.
Between-visit support and clinical decisions need to inform each other. Cubie brings the care team, physician recommendations, and the engine that prepares them into one coordinated program.
Cubie Atlas
The care team organizes patient check-ins, follow-up questions, and coordination tasks in a shared workspace.
Cubie Compass
Relevant context and recommendations reach the physician for review. Treatment decisions remain with the treating clinician.
Cubie Waypoint
All of the patient data that the partnership makes available is brought together by Waypoint to prepare a prioritized next step.
We agree on how this work complements your existing care-management programs and provider relationships, including where responsibilities meet and how information is shared.
Focus attention where it is needed next.
Across the attributed population, Cubie helps prioritize enrollment and organize outreach cohorts. Once patients enroll, the engine helps guide touchpoint cadence and the issues to address, from clinical changes and medication questions to practical barriers to following the care plan.
Cubie Waypoint
Patient intelligence engine
What goes in
- Records and labs
- Historical claims
- Encounters (HIE + EMR)
- Admission & discharge (ADT)
- Home readings
- Patient-reported needs
What comes out
- Risk score
- Prioritization
- Next step
- Provider follow-up
- Titration step for review
- Continue the current plan
- Attributed population + Available historyPrioritize enrollment outreachOrganize the next outreach cohort.Atlas — care-team work
- Discharge update + Patient contextPrioritize follow-upReview transition needs and outstanding questions.Atlas — care-team work
- Medication question + Check-in notesAddress medication questionsPrepare the next patient touchpoint.Atlas — care-team work
- Reported practical barrier + Patient contextFollow up on access needsClarify what is blocking the care plan.Atlas — care-team work
- New results + Clinical contextPrepare a recommendationAwaiting physician review.Compass — physician review
- Follow-up completed + Updated contextContinue the current planReassess as new information becomes available.Atlas — care-team work
Prioritize outreach across the attributed population.
Guide touchpoint cadence and the topics to address.
Update priorities as new information becomes available.
How a partnership takes shape.
The program starts with a shared definition of the work: who it supports, how it operates, and how it will be evaluated.
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Define the population and scope
Agree on the patient population, program priorities, and responsibilities across the plan, participating practices, and Cubie.
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Establish the operating workflow
Confirm available data, recommendation delivery, patient communication, and coordination with existing programs.
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Launch and review together
Begin the agreed program and review engagement, clinical measures, utilization, and implementation needs on a defined cadence.
Program scope and implementation requirements are agreed with each partner.
How we measure impact.
We agree on the evaluation approach before the program starts, including how results will be compared and what the analysis can support.
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Define the population
Document attribution, inclusion criteria, and exclusions so the evaluated population is clear.
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Establish the baseline
Describe historical utilization and spending, with an agreed approach to risk adjustment and data quality.
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Design the comparison
Choose a comparison design appropriate to the available data and program, and document its limitations.
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Set the measures
Agree on the definitions, data sources, and reporting cadence for program, clinical, utilization, and financial measures.
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Review the results
Report against the agreed approach, including uncertainty, implementation findings, and results that do not meet expectations.
What the evaluation covers
Program activity
Outreach, participation, engagement, and completion of agreed follow-up tasks
Clinical quality and utilization
Relevant clinical measures, admissions, readmissions, and testing utilization
Financial evaluation
Spending for the defined population, including program costs and the agreed comparison
An evaluation approach agreed upfront
Before launch, we agree on the population, measures, comparison approach, and reporting cadence. Results are evaluated against that framework, including program costs and uncertainty.
These are evaluation categories, not reported Cubie outcomes. The specific measures and methodology are agreed with each partner.
A broader shift toward coordinated specialty care.
CMS’s Ambulatory Specialty Model begins in 2027. Participation is required for selected physicians who meet CMS eligibility criteria, including specialty, geography, and attributed episode volume. The heart failure cohort includes cardiology.
- Begins in 2027
First performance year.
- Selected physicians
Participation depends on CMS eligibility and selection.
- Payments affected in 2029
The first payment adjustments follow 2027 performance.
For a plan, this is context rather than a requirement: it is one reason participating cardiology practices are being asked to coordinate more closely around the care plan, which is the work a partnership with Cubie supports.
Source: CMS. Model details are drawn from published summaries and are being confirmed against the final rule. CMS determines participation and payment adjustments. Cubie does not guarantee an ASM score or financial result.