Cardiac rehab emerges as readmission reduction solution as Medicare targets hospital readmissions with payment policies

 For Medicare, congestive heart failure is the most common reason for hospital admissions and readmissions and it is among the most costly diseases to treat.  The Care Continuum Alliance estimates that CHF patients' medical costs are $2,684 per member per month.  Medicare has created a broad array of financial payment incentives and penalties to minimize costly CHF hospital stays, including cardiac rehabilitation.

In February of 2014, CMS issued a formal decision to begin covering 36 hours of cardiac rehabilitation for eligible CHF patients whose disease cannot adequately be controlled with medication alone.  Medicare's coverage decision for CHF is not surprising considering this is one of many payment policies it has recently implemented to reduce hospital readmissions. The Hospital Readmission Reduction Program, the Bundled Payment for Care Improvement initiative and accountable care organizations all create financial penalties for hospitals with excessive readmissions, while Medicare's Hospital Value-Based Purchasing program specifically requires discharge instructions for CHF patients and has also added a performance metric for CHF mortality for 2014. 

Even for a hospital not participating in BPCI or an ACO, too many emergency department frequent flyers with CHF diagnoses can still create payment penalties under Medicare's HRRP and VBP programs.  Commercial insurers, such as UnitedHealthcare and WellPoint, are duplicating many attributes of Medicare's pay-for-performance payment models in their contracts.

Using cardiac rehab to reduce readmissions
CR is a medically supervised program designed to optimize a cardiac patient's physical, psychological and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerosis. Before CHF was added to the eligibility criteria, CR was already a covered Medicare benefit for patients experiencing six types of cardiovascular disease events, including heart attack, bypass graft surgery, angioplasty or stent, angina, valve replacement or heart transplant.

South Denver Cardiology Associates in Littleton, Colo., has operated its own CR program for decades. 

SDCA's director of preventive medicine and CR, Richard Collins, M.D., says that when President Dwight Eisenhower had a heart attack in 1955, the mortality rate at the time was 50 percent and such patients were laid up for four weeks. Now with stenting technology, patients often return to work within a week.  Dr. Collins says sending a hospital patient home after a heart attack or stent placement is like wrecking a new boat on a rock.

"If someone wrecks a great boat, they can take it in and get the damage repaired," say Dr. Collins. "But if you don't address the behavior that caused the wreck, they will do the same thing again."

"Cardiac rehab prevents a recurring event," say SDCA's CR supervisor Anna Norlin, a clinical exercise physiologist. "CR is an education and lifestyle process to prevent another event."

Anna says the core of their program is teaching patients exercise monitoring, blood pressure monitoring, nutrition, psychosocial assessments and monitoring how each patient tolerates his or her medications.

"The interval time after first month is pretty important." says Dr. Collins. "If you get a stent, you are automatically on five medications.  Explaining medication functions is part of program.  It is figuring out what education is right for each patient."

Several studies conducted between 2009 and 2011 of CR-eligible Medicare patients found that CR was correlated with compelling reductions in mortality rates and subsequent heart attacks. Despite high effectiveness in preventing death and hospital readmissions, CR enrollment and adherence is very poor.  Of eligible patients, only 14 to 35 percent of heart attack survivors and approximately 31 percent of bypass graft patients participate in CR. Participation is lowest in women, minorities, impoverished patients and the elderly.

Anna says cost can be a major barrier for some patients.  While Medicare beneficiaries have no out-of-pocket costs, commercially insured patients typically have a $50 copay each of their 36 total visits.

Anna says this is a real shame because their CR program is very effective in preventing costly emergency department visits (ED). For example, SDCA's CR program can help manage patients who become "hyper-chest aware" after a heart attack and prevent them from unnecessarily flocking to the ED for a battery of diagnostic tests.

Cardiovascular disease is the No. 1 cause of death for women in the United States, yet most of SDCA's CR patients are men because women are disinclined to participate.  Dr. Collins says this is an interesting psychosocial phenomenon.

"I just had an elderly patient today who didn't want to burden her granddaughter with driving her to cardiac rehab," Dr. Collins says. Anna and Dr. Collins both say that becoming a burden to their families is a major reason that women don't adhere to the program.

In response, SDCA has started a women's support group that meets on a monthly basis. This support group has thrived. Women have different symptoms than men and the group has greatly improved patients' confidence. 

 "We also monitor for depression," says Dr. Collins.  "You'd be surprised how often patients slip into depression."

SDCA's stress psychologist, Dr. Larry Bloom, has been with program from beginning. Every patient is assessed on a depression scale, quality of life, and nutrition to develop individualized plans.

SDCA has dedicated approximately half of the space in its 65,000 square foot South Denver Heart Center to CR and other wellness promotion activities. Dr. Collins gives regular nutrition lectures and cooking classes.

Our CEO had a vision, knew how to manage CR, and kept the place living and liable," says Dr. Collins, "It is very unusual for cardiologists to invest part of their earnings in wellness.  CR centers struggle to make money."

Dr. Collins advises patients whose elderly parents are eligible for CR, "Take advantage of it.  Do everything possible to keep dad or mom in the program."

"You're not able to take care of anyone else if you're not around.  After the one hour with us, you can take care of everyone else," says Anna.  "We just take an hour of your time.  We say this is the only place within the medical field where you will actually have fun."

Sidebar: CR and ICR reimbursement
In addition to traditional CR, Medicare has issued three special national coverage determinations for intensive cardiac rehabilitation programs. To gain approval, candidate ICR programs must demonstrate, through peer-reviewed published scientific research, that they either (1) positively affected the progression of coronary heart disease, (2) reduced the need for coronary bypass surgery or (3) reduced the need for cardiac catheterization interventions (i.e., angioplasty and stents).  This research must also demonstrate statistically significant reductions for five or more risk factors for heart disease (i.e., cholesterol, weight, blood pressure).

ICR programs are reimbursed at the hospital rate for traditional CR, which is much higher than the rate for physician office settings. Additionally, ICR programs are eligible for 72 hours of billable treatment, whereas traditional ICR is only eligible for 36 hours of billable treatment.

Nicholas Newsad, MHSA, is a co-founder of Healthcare Transaction Advisors. HCTA provides healthcare-focused provider alignment programs that foster collaboration between physicians, hospitals, health systems and other healthcare organizations. nnewsad@hctadvisor.com