A Question of Incentive: Will Bundles Give Cardiac Rehab a Boost?

A plan for increasing use of cardiac rehabilitation (cardiac rehab, or CR) was a few months short of launch when the Centers for Medicare and Medicaid Services (CMS) tapped the brakes.  

Experiment delayed

CMS developed three episode payment models (EPMs) to help transition its reimbursement system from paying for quantity to rewarding quality. The program had already been delayed once, but July 1, 2017, was set to be the start date. The metropolitan statistical areas (MSAs) had been announced. Participation would be mandatory for hospitals in those areas. For approximately five years, those hospitals would receive bundled payments for services related to treating certain Medicare patients who experienced acute myocardial infarction (AMI) or underwent coronary artery bypass graft (CABG) surgery. Approximately 1,320 acute care hospitals also would participate in the Cardiac Rehabilitation Incentive Payment Model—the EPM aimed at increasing cardiac rehab use “to improve patient outcomes and help keep patients healthy and out of the hospital,” according to the CMS website. Those hospitals could earn retrospective incentive payments when eligible Medicare beneficiaries attended CR sessions in the first 90 days after an AMI or CABG episode of care.

The EPMs hit a bump in the road on March 20, when an interim final rule announced that program implementation would be delayed at least three months, until Oct. 1, and possibly longer, until 2018. The delay is to allow time for CMS to modify the policy, if needed, and give participants more time to prepare, the interim rule says.

The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is “comfortable with CMS delaying the go-live date to October, as we feel many programs needed more time to prepare,” says Thomas A. Draper, MBA, the association’s president and vice president of hospital operations at Sanger Heart & Vascular Institute in North Carolina. He and other AACVPR leaders had already concluded that “administrators are just beginning to get their arms around what [the incentive model] means for their service lines.”

“The more time we can give them to connect and plan for the impacts on the cardiac rehab programs and the service line, the better,” Draper says. He is concerned that the mandatory aspect of the EPM could be eliminated, as has been suggested in light of past opposition by Department of Health and Human Services Secretary Thomas Price, MD, to requiring providers to participate in bundled payment programs.  

What’s important, Draper emphasizes, is that hospitals receive incentives for upping cardiac rehab use.

Incentivizing enrollment

There’s no shortage of data supporting the role that cardiac rehab can play in improving outcomes for heart patients. Studies have shown that CR attendance reduces cardiovascular mortality by up to 31 percent; cuts hospital readmissions; enhances exercise capacity, mood and quality of life; and improves adherence to medication regimens and diet recommendations. American College of Cardiology/American Heart Association guidelines include a class I, level of evidence B recommendation that “exercise-based cardiac rehabilitation/secondary prevention” should be part of an AMI patient’s posthospitalization plan of care (Circulation 2013;127[4]:e362-e425).

Despite impressive outcomes, the guideline notes, “cardiac rehabilitation services remain vastly underutilized.” Reports suggest that only 10 to 20 percent of eligible AMI patients in the U.S. participate in a structured CR program, and that some clinicians are referring patients to CR at rates as low as 20 percent. Part of the reason for these discouraging data, CR proponents say, is that reimbursements for CR have been small compared to payments for cardiologists’ more technical and procedural work.

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“Cardiac rehabilitation … is really a critically important part of the total care of patients who have heart problems,” says Laurence Sperling, MD, director of the Emory Heart Prevention Center in Atlanta. “Right now, cardiac rehab is structured, unfortunately, in a model that was developed in the 1960s and ’70s in this country and we’re still stuck in this model because [it] is tied to reimbursement.

”The new incentive payment model would mean “the pyramid of cardiovascular economics turns upside down,” Sperling says. It signals that CMS is rethinking how cardiac rehab is reimbursed and aiming to link it to metrics, which could lead to “more investment in cardiac rehab and better care of patients.”

The AACVPR was—and continues to be—optimistic about the program, according to Draper, because CMS outlined the model as “almost a controlled study,” with hospitals in 45 of the MSAs also participating in the AMI and CABG bundled payments program and hospitals in the other 45 enrolled in only the cardiac rehab EPM. Both groups would be paid incentives of $25 for each of the first 11 CR services a patient receives and $175 each for services 12 through 36. The two-cohort format signals “that CMS is very serious about understanding the importance of cardiac rehab,” Draper says. By setting up the model to generate data and dollars, the model might also provide programs with fuel to make the case for CR to their hospitals’ decision-makers, he adds.

But, for that to happen, CR programs need to prepare their programs to succeed during the incentive payment model.

Boosting referrals

Clinicians over-taxed with the demands of providing day-to-day care don’t always have an appreciation for cardiac rehab services, so they may not refer patients or encourage them to attend, Sperling says. At the system level, he says, barriers to CR include the need for space and resources, certification requirements for some staff and low reimbursement. 

Financial incentive turned out to be an answer to the referral problem for the cardiac rehab program at Beaumont Hospital in Royal Oak, Mich. When the CR program was launched three decades ago, it consisted of a handful of patients meeting at a local YMCA. Now, more than 300 patients participate every year, says Barry Franklin, PhD, Beaumont’s director of preventive cardiology and cardiac rehabilitation.

The program got a lift a year ago, when the local Blue Cross and Blue Shield insurance provider offered remuneration if Beaumont referred at least three-quarters of its percutaneous coronary intervention (PCI) patients to CR. With this incentive, the hospital set up automatic referrals and allowed referring physicians to sign off electronically. Success occurred because physicians were challenged to improve the performance metric and given means to complete the task in seconds, Franklin says.

It didn’t take long for the challenge to have an impact. Last year, 93 percent of all Beaumont Royal Oak PCI patients were referred to cardiac rehab before hospital discharge, an increase from 10 to 15 percent in the years prior. This resulted in a short-term increase of about 45 percent to the already busy program, which is what “got the administration’s attention,” Franklin says.

Dedicating staff to the effort also helps increase CR referrals, according to Chris Rosser, MSEd, who manages the cardiopulmonary rehabilitation and wellness center at Baylor Scott & White in Waco, Texas. He had seen minimal upticks in CR referrals until a part-time nurse was dedicated to navigating cardiac patients to the next step after discharge, which in many cases included cardiac rehab.

“We [had] tried getting everybody as a team to jump in and go,” Rosser says, “but until you have somebody who owns it, it’s not going to take you there.” Since the nurse’s position became full-time in January 2016, referrals have climbed from capturing only 40 percent of candidates to getting referrals for 80 to 90 percent of them.

The AACVPR is working on turnkey strategies to combat barriers. They are developing scholarship programs to help with CR costs and teaching CR staff how to market to the physicians and administrators whose buy-in is necessary for referrals to increase and for programs to be allotted more resources. Referring physicians must understand the benefits of cardiac rehab, Draper says, because research shows that the strength of a physician’s referral—how strongly he or she encourages the patient to participate in CR—has a major impact on attendance (Heart 2005;91[1]:10-14).

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Hooking patients

Even after a patient gets to cardiac rehab, it’s not always easy to keep them coming back. After finding its structured CR schedule didn’t work for everyone, Rosser’s center at Baylor & White made scheduling more flexible and saw attendance increase by 10 to 15 percent. Now, some patients come just once a week and continue their exercise program at home or the gym.

At the end of each session, center staff ask patients if they’ll be attending their next appointment. If patients seem unsure, staff work with them to try to solve issues on the spot, whether it’s arranging for transportation or getting a family member on board. “Once they miss that first one,” Rosser says, “it’s easier to miss the second.” If a patient doesn’t show up, CR staff call to find out why.

When co-pays were preventing patients from attending cardiac rehab, staff invited them to a “super wellness program” instead. “It’s not the full cardiac rehab, but it’s the nuts and bolts,” Rosser says. “They can get some monitoring and some education, so they aren’t completely on their own.” A $50 joining fee covers a clinical assessment, and patients can pay $66 a month to continue visiting the center.

The impact of Medicare’s incentive payment model could be significant for CR programs, Rosser says. “With the extra money potentially behind it, I think more programs [would] have a little something more to stand on when they talk to physicians and administrators,” he says. “And not only [would it] help the patients, but [we’d be] getting extra reimbursement for doing it.”