Although studies have shown that cardiac rehabilitation can improve outcomes following MIs, heart failure and other cardiovascular events, most patients do not participate in such programs.
The federal government and some politicians are attempting to change that trend. Still, it’s unclear how effective they will be at convincing more people to enroll in the programs and persuading payers that the long-term benefits outweigh the short-term costs.
The American Heart Association defines cardiac rehabilitation as a medically supervised program following an MI, heart failure, angioplasty or heart surgery. The programs usually involve exercise counseling and training, education for heart-healthy living and counseling to reduce stress.
In February, a bipartisan group of legislators introduced a bill in the House of Representatives that would allow physician assistants, nurse practitioners and clinical nurse specialists to supervise cardiac rehabilitation. As of now, only physicians can supervise those programs, which could limit their uptake.
The proposal, which was sponsored by Republican Congresswoman Lynn Jenkins from Kansas, came two months after CMS finalized its cardiac rehabilitation incentive payment model.
CMS plans on introducing the model in 90 geographic areas in the U.S., although the agency announced last month that the start of the initiative would be delayed from July 1 to Oct. 1 at the earliest.
Under the model, participating hospitals will receive $25 per cardiac rehabilitation service for each of the first 11 services paid for by Medicare during the care period for an acute MI or CABG care episode and $175 per service during care period after 11 services.
CMS said it launched the model because cardiac rehabilitation has been under-used by Medicare beneficiaries. In fact, a 2015 study published in JAMA Internal Medicine found that only 23.4 percent of adults attended cardiac rehabilitation session within a year of hospital discharge for an acute MI between 2007 and 2010. The researchers analyzed a national quality improvement registry.
Lead researcher Jacob A. Doll, MD, of the Duke Clinical Research Institute, said at the time that CMS covered cardiac rehabilitation for 36 sessions. However, some patients had to $10 to $20 co-payments per session, which could be costly.
“To see, first of all, many patients not being referred and then probably more distressingly a lot of the referred patients not even making it to cardiac rehab really pointed out to us that referral is not enough,” Doll said. “You need to also help patients to actually get to cardiac rehab and follow up down the line to make sure that they could get the treatment they need.”
Another study found that 10.4 percent of patients with heart failure were referred to cardiac rehabilitation after hospital discharge between 2005 and 2014. And an NPR/Kaiser Health News report from last year found that fewer than one-third of eligible patients participate in cardiac rehabilitation programs.
Low participation rates are common even though several studies have indicated the benefits of such programs. For instance, a retrospective cohort study published last October in JAMA Cardiology found that patients who participated in cardiac rehabilitation had a significant improved overall survival in the year following an acute MI. In addition, a study published last March in Circulation found that cardiac rehabilitation with stress management training could lead to reductions in cardiac events, anxiety, distress and perceived stress.
If non-physicians are allowed to supervise cardiac rehabilitation, the programs could become more common and help patients, according to American College of Cardiology President Richard Chazal, MD.
“Cardiac rehabilitation can be a vital component of a patient's recovery from a heart attack, heart surgery or for management of heart failure,” Chazal said in a news release in February. “Supervision requirements for cardiac rehab are currently more stringent than other outpatient services; this negatively impacts access for our patients in areas with physician shortages and drives up costs for these programs. If enacted, this legislation will allow the cardiovascular community’s well-qualified advanced practice providers to provide the day-to-day supervision of cardiac rehab and help us meet the needs of our patients.”