In June, Stanford Health Care announced a partnership with Kivo Health to deliver “virtual first,” “AI powered” pulmonary rehabilitation (PR) to their patients with COPD. Stanford Health Care closed its “brick and mortar” PR program.
On the surface, this partnership has all the glitz of scientific progress—artificial intelligence, virtual technology—and embraces many valued healthcare system goals: equitable delivery of care, improved access, and improved patient outcomes. However, this partnership reflects another more nuanced U.S. story about how a perfect storm of the Covid-19 pandemic, changing Medicare reimbursement rules, and healthcare systems’ pressures to cut costs has allowed commercial entities to emerge with virtual products that do not have fidelity to PR jeopardizing the biggest stakeholder—millions of patients with chronic respiratory disease—who stand to lose out with substandard care.
Center-based PR (i.e., PR delivered in-person at a medical facility) is standard of care for patients with chronic lung disease. The Covid-19 pandemic forced social distancing, reduced personnel, and put healthcare systems “in the red.” Tele-PR models emerged to deliver PR to patients in their homes. Initially, many were based at academic medical centers with existing center-based PR programs and the necessary multidisciplinary expertise. These programs were collecting important data to determine safety, patient selection criteria, and quality metrics. With the end of the public health emergency in 2023, Medicare stopped reimbursement for tele-PR delivered from hospital-based sites. Academic centers with expertise and research capabilities had to close their tele-PR programs. The hub (academic center) and spoke (community centers) model for tele-PR never materialized. Hampered by reimbursement barriers, the relatively young field of tele PR could not mount coordinated efforts to determine its effectiveness. Head-to-head data on the impact of center-based versus tele-PR on hospitalizations, time to exacerbation, and mortality are lacking.
For unclear reasons, Medicare continued to reimburse for tele-PR through the Physician Fee Schedule. Far fewer center-based PR programs are located in physician offices. However, this change in Medicare reimbursement rules allowed commercial entities with no relationship to hospitals to emerge. Their websites describe education and physical activity promotion. There is little evidence of exercise training and exercise progression which are the cornerstones of PR. There are currently limited data on their safety and actual reach to rural patients. Commercial entities, with unclear PR expertise, are trying to fill the void since hospital-based PR programs cannot create virtual programs and many center-based PR programs are closing their doors.
There is an urgent need to change Medicare reimbursement rules. There also needs to be greater collaboration between commercial entities and experienced center-based PR
providers. All programs calling themselves PR need to deliver the essential components of PR with the expected outcomes. It is problematic for patients to dedicate their time to and for insurance companies to reimburse for services that are not PR. Health care systems need to support their center-based PR programs and critically evaluate virtual products before partnering with contract providers.
The views presented in this Editorial are solely those of the author. They do not represent the official views of the American Thoracic Society or Harvard Medical School.
