Medicare pumps up cardiac rehab: Value well-documented

Patients who are hospitalized for a serious heart problem face a critical time upon discharge. Often they feel fragile and scared as they leave the cardiac unit's monitoring and support to return home. They may have questions about what they can do and what they should eat, or they may be thinking for the first time about quitting smoking.

The first few weeks and months of recovery are a time of opportunity and uncertainty, a time when outpatient cardiac rehabilitation can serve as a bridge to help heart patients cross from the acute care setting back into the community.

Cardiac rehab can make the difference between resuming a normal life, possibly even a better life, or heading toward another heart attack. Studies have shown that a physician-supervised program of prescribed exercise, nutrition counseling, stress reduction and medication can sometimes slow, or even stop, the progression of heart disease -- the nation's No. 1 killer of men and women.

Yet despite its well-documented benefits, cardiac rehabilitation is often given short shrift by public and private insurers and the medical community, according to many cardiologists. Reimbursement tends to be low, insurance coverage is spotty, and physicians fail to refer many eligible patients.

Cardiologists say the federal government's Medicare coverage policy has been part of the problem by setting too-narrow parameters on eligibility for cardiac rehab. But a recent policy change and a pilot project could remove some of the blockages, allowing more patients to flow into these programs.

Medicare published a national decision memorandum in March that extends coverage for outpatient cardiac rehabilitation to several new groups of patients: those who have had heart valve repair or replacement, angioplasty or stenting, or a heart or heart-lung transplant. Previously, only patients who had an acute myocardial infarction within the previous 12 months, coronary artery bypass surgery or stable angina pectoris were eligible for coverage.

Medicare stopped short of extending coverage to patients with congestive heart failure. Agency officials said they don't yet have sufficient evidence showing patients with CHF benefit from cardiac rehabilitation programs. But they plan to revisit the issue once they've seen the results of a trial, funded by the National Institutes of Health, that is looking at whether a tailored exercise program can improve outcomes for patients with the condition.

For eligible patients, Medicare has agreed to pay for up to 36 sessions for 18 weeks of "Phase II cardiac rehabilitation," which refers to outpatient, physician-supervised programs that typically begin one to three weeks after hospital discharge. Medicare contractors also have broad discretion to extend coverage up to 72 sessions for 36 weeks.

The move has been heralded by the American College of Cardiology and other groups that have long advocated for expanded coverage, including the American Hospital Assn., the American Heart Assn. and the American Assn. of Cardiovascular and Pulmonary Rehabilitation.

"It's a godsend," said Janet Wright, MD, a cardiologist at Enloe Medical Center in Chico, Calif., and an ACC trustee.

Medicare's decision "opened the door for many, many people who deserve this treatment and can gain so much from being under the care of [cardiac rehabilitation] professionals," she said.

Patients who have had a stent placed, for example, will greatly benefit from the new coverage, Dr. Wright said. Rehab nurses can immediately spot post-stent patients who, for one reason or another, are not on anti-platelet medication, which is critical to preventing another heart attack or stroke. "A terrible catastrophe can be avoided with that added surveillance," she said.

Reaching 52% more patients

The medical literature has long shown that comprehensive cardiac rehab programs can reduce mortality and improve functioning and quality of life. A study by the Mayo Clinic found that cardiac rehab raises a person's chance of surviving at least three years after a heart attack by more than 50%.

But Medicare's coverage policy had not kept up with the science -- until now.

Until this year, Medicare had paid for about 50,000 patients each year to go through Phase II cardiac rehabilitation.

That number is expected to climb to about 76,000 beneficiaries as a result of the coverage expansion, said Steve Phurrough, MD, director of the coverage and analysis group at CMS. The additional outlay will cost Medicare an estimated $30 million in the first year.

"This is a great breakthrough," said Nieca Goldberg, MD, chief of women's cardiac care at Lenox Hill Hospital in New York City and medical director of the cardiac rehab program at the 92nd Street Y in Manhattan.

That said, Dr. Goldberg would like to see Medicare expand coverage even further. "If you really want to see fewer procedures, ultimately we have to provide these programs for patients with risk factors, not just for those who already have heart disease."

Raising awareness

Just as important as the coverage expansion itself is the opportunity it provides to raise the visibility of cardiac rehab programs -- particularly among referring physicians.

Outpatient cardiac rehabilitation programs have long been underutilized. Although their benefits are well documented, participation is estimated to be only 10% to 20% of eligible patients who experience acute myocardial infarction or undergo coronary revascularization.

Among Medicare beneficiaries, participation has also been very low, a CMS spokesman said. Typically, only about 12% to 13% of beneficiaries eligible for coverage of outpatient cardiac rehabilitation actually enroll.

Low referrals, by both specialists and primary care physicians, are a large part of the problem, said doctors who run cardiac rehab programs.

"Physicians under-refer patients, particularly women," Dr. Goldberg said. "Cardiac rehab has been like the orphan child of cardiac disease management."

But cardiologists hope to turn that around.

"One of the most powerful drivers to get patients to participate in cardiac rehab is their physician's recommendation," Dr. Wright said. "What the decision memo did is give us another chance to encourage doctors to refer."

Those efforts may be paying off. At Enloe Medical Center, the cardiac rehab program already has seen its patient numbers more than double since the coverage expansion was announced, from 19 in March to 45 in August. The increase has been "really remarkable," particularly since the program usually sees its patient numbers decline during the summer months, Dr. Wright said. "Right now, they're trying to come up with extra sessions" to handle the additional patients.

Looking ahead

But even if more patients participate in cardiac rehabilitation, there is still the problem of making these efforts financially viable. Cardiac rehab programs are generally not profit centers for hospitals.

"They're almost a charity part of the hospital," Dr. Wright said. "Most hospitals have maintained these programs because they know they work and they're very good for community relations."

But some have had to cut back. Dr. Goldberg, who used to direct Lenox Hill Hospital's cardiac rehab program, saw it close three years ago when it ran into financial problems. "Unfortunately, that's happened to a lot of cardiac rehab programs across the country," she said.

Most programs simply hope to break even. Medicare pays, on average, about $34 per session of outpatient rehab -- whether that session lasts one hour or four hours. That comes far short of covering costs, said Erminia Guarneri, MD, a cardiologist and medical director of the Scripps Center for Integrative Medicine in La Jolla, Calif.

The Scripps Center offers one of the country's most comprehensive cardiac rehab and secondary prevention programs, called the Healing Hearts program. In addition to physicians and nurses, the staff includes two nutritionists, a yoga instructor, a cooking school chef, exercise physiologists and psychologists.

The program is able to help patients make lifestyle changes that significantly improve their risk profile and their quality of life.

"Over time, it is amazing," Dr. Guarneri said. "We have people come in who lose 68 pounds. Our average cholesterol on leaving the program is between 130 and 140. ... Plus, it's the deeper issues. People find they have a new meaning to their lives. They participate in group support sessions. They're taught techniques to handle stress. These are important pieces as well."

But adding up all of the pieces into one comprehensive program doesn't come cheap.

The Scripps Center has tried to make the Healing Hearts program as affordable as possible by charging self-pay patients $1,800 for the three-month program, Dr. Guarneri said. That doesn't cover the cost of the program, but it's significantly higher than Medicare's $34 per session. The program also bills insurers, but ends up subsidizing the care and providing scholarships to patients who can't afford it, she said. "We've done it because it's philosophically aligned with our thinking, and we believe in the work."

Medicare isn't planning to increase reimbursement for Phase II cardiac rehabilitation, say CMS officials. But the agency is considering a demonstration project that would offer cardiac rehab programs higher payments if they can show they achieve better outcomes by the end of the pilot.

"The demonstration would look at a particular cardiac rehab program, and if they had certain outcomes, they would get higher payments," Dr. Phurrough said.

Cardiologists say they think many cardiac rehab programs would be interested in participating. "Of all the potential areas of proving performance, rehab is a great area for that," Dr. Wright said. "But all the pieces need to be in place so that the outcomes can be demonstrated."

Proving results can be difficult, particularly when it comes to tracking patients in the outpatient arena.

Nevertheless, some programs seem willing to try. "I'm thrilled that Medicare is coming to recognize there's a role for prevention," Dr. Guarneri said. "We know people do better when they do lifestyle change."