After patients have a heart attack or heart surgery, interventional cardiologist Dr. Amit Keswani urges them to go into cardiac rehabilitation. The program of supervised exercise and counseling helps cardiac patients recover and lowers their risk of future heart attacks, chest pain, hospital admission and a slew of other medical problems.
But at most, only about half actually do it. “I wish that it would be more,” Keswani said. “I tell my patients: It's better than any medicine.”
Some patients can't afford the co-pays. Others live too far from the cardiac rehab facility that's part of Vanderbilt University Medical Center in Nashville, where Keswani works.
The problem is not unique to Keswani or to Nashville. Nationwide, fewer than 20% of patients who are eligible for cardiac rehab programs participate in them. In an effort to boost uptake, the government is planning to test whether paying hospitals to put eligible patients in cardiac rehab or intensive cardiac rehab will boost participation and save both lives and healthcare dollars.
Cardiologists and other advocates of cardiac rehab describe the experiment as a step in the right direction. But they doubt it's enough to address the most serious barriers—out-of-pocket costs and lack of transportation—stopping patients from enrolling in or completing cardiac rehabilitation programs. Those are challenges that won't be solved by financial incentives, they said
That experiment, the Cardiac Rehabilitation Incentive Payment Model, was finalized Tuesday in a rule issued by the CMS. It is part of a package of experimental payment models aimed at reducing healthcare spending while improving outcomes, including the expansion of CMS' mandatory bundled-payment program to include all care associated with bypass surgery and heart attacks.
Under the cardiac rehab payment model, the CMS plans to pay participating hospitals $25 per session of cardiac rehabilitation or intensive cardiac rehabilitation for the first 11 sessions. It would pay $175 per session thereafter, for a maximum of 36 total sessions. Those payments would apply only to Medicare beneficiaries with heart attacks and coronary artery bypass surgery.
The money could offset the costs of referral or coordination, such as transportation. It could also go to “beneficiary engagement incentives,” which are supposed to be “reasonably connected to medical care,” such as technology that monitors a patient's weight or vital signs, according to the final rule. (Hospitals “could not provide theater tickets, which would bear no reasonable connection to the patient's care,” CMS noted.)
Every year, 735,000 people in the U.S. have a heart attack. For 210,000 of them, it's not the first time.
Medical evidence strongly suggests that cardiac rehab reduces the risk of death and future heart attacks, and improves quality of life. A review published in January that examined 63 randomized controlled trials involving nearly 14,500 patients found that exercise-based cardiac rehabilitation services reduced cardiovascular mortality and improved patients' health-related quality of life, as well as their risk of hospital admission.
The CMS' five-year test to get more cardiac patients into these programs is slated to begin July 1, 2017, in 90 geographic regions encompassing approximately 1,320 hospitals. Half of those regions are also participating in Medicare's bundled-payment program for cardiac care because the CMS wants to gauge whether the cardiac rehab payments have different effects on utilization in fee-for-service versus episodic payment models.
The beauty of the incentive payments is that hospitals can spend the money according to their needs and to address the unique obstacles that their own patients face, proponents of the model said.
“This essentially encourages hospitals to have some interest in getting their patients to rehab,” said Dr. Nanette Wenger, a cardiologist and a professor of medicine at Emory University's School of Medicine in Atlanta. “It will vary very, very much with the hospital, the location and the problem,” she added. “But every hospital, looking at this incentive pay, will say, 'What can we do to overcome this barrier?' ”
A patient's lack of participation could be a matter of where they live, their age, their financial resources or a number of other factors, said Sue Nelson, the vice president of federal advocacy for the American Heart Association.
“What we think is so creative about this approach is it gives programs additional resources, and they can figure out how to solve the problem their patient population is facing,” Nelson said.
But that approach is also unlikely to cut down some of the biggest barriers to rehab.
Medicare Part B generally already covers cardiac rehab and intensive cardiac rehab for all Medicare beneficiaries who have had a heart attack or undergone coronary artery bypass surgery. But co-pays for those services can be prohibitive for patients, especially over dozens of sessions.
“The last patient I remember is someone who called and said, 'I have to pay $50 per session. I'm not going,' ” said Dr. Brent Muhlestein, an interventional cardiologist at Intermountain Medical Center in Murray, Utah. Even among his patients who are Medicare beneficiaries, co-pays vary significantly, he said.
Over the 36 sessions standard in a course of cardiac rehab, a relatively modest co-pay of $20 would add up to $720.
Medicare's incentive payment model would not change co-pays for cardiac services. The agency said in its final rule that most participating beneficiaries would not experience significant out-of-pocket costs, citing the statistic that in 2011, just 19% of traditional Medicare beneficiaries lacked supplemental coverage, which meant that the majority of beneficiaries did have extra coverage to offset out-of-pocket expenses.
“We do not believe it is necessary to lower or eliminate beneficiary copayments,” the agency said in its final rule.
A lack of transportation is the other major reason Muhlestein's patients don't enroll in rehab or stick with it, and the problem is particularly noticeable among Medicare patients.
“They have to drive to the hospital all the time, and it may not be convenient for them to drive to the hospital,” he said. “They may not have a driver's license. They have to get someone to take them, and they don't like getting people to take them, because that's an imposition.”
In these circumstances, distance matters less than logistics, Muhlestein said. “It's almost as hard to get somebody to take you three blocks as it is to take you 10 miles.”
That's why some cardiologists say it's time to think beyond financial incentives to put more patients in cardiac rehab services, such as finding ways for them to do rehab at home.
Several studies have shown home-based rehab, supervised remotely using smartphones or other technology, to be equally effective for patients, said Wenger, the Emory cardiologist. But Medicare doesn't cover home-based cardiac rehab.
One reason payers resist covering such services is that it's easier to control and assess the quality of care at a rehab facility. Judging the quality of rehab services at home is “more of a learning curve,” Wenger said. Nevertheless, she described such services as “the future of rehab.”
A self-guided version of home-based rehab is along the lines of what Keswani, the Nashville cardiologist, prescribes for patients who can't make it to the hospital for rehab for logistical, financial or other reasons. He suggests they join the local Planet Fitness for $9.99 a month and walk on the treadmill, at their own pace, for 30 minutes a day.
If joining a gym is not possible, he directs them to local parks or high school tracks. And he deflects protests about rain and the elements by urging patients to go to a Wal-Mart or the local mall to walk around for half an hour.
It's not the same as the supervised exercise and support for behavioral change offered in cardiac rehab, such as improving diet or quitting smoking. But, Keswani said, “at least they're out and doing something.”