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 remove 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 in a standard 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 have extra coverage to offset out-of-pocket expenses.
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.”