CMS will pay hos­pi­tals to push car­diac re­hab. Is that enough?

Modern Healthcare - - NEWS - By El­iz­a­beth Whit­man

After pa­tients have a heart at­tack or heart surgery, in­ter­ven­tional car­di­ol­o­gist Dr. Amit Keswani urges them to go to car­diac re­ha­bil­i­ta­tion. The pro­gram of su­per­vised ex­er­cise and coun­sel­ing helps car­diac pa­tients re­cover and low­ers their risk of fu­ture heart at­tacks, chest pain, hospi­tal ad­mis­sion and a slew of other med­i­cal prob­lems.

But at most, only about half ac­tu­ally do it. “I wish that it would be more,” Keswani said. “I tell my pa­tients: It’s bet­ter than any medicine.”

Some pa­tients can’t af­ford the co­pays. Oth­ers live too far from the car­diac re­hab fa­cil­ity that’s part of Van­der­bilt Univer­sity Med­i­cal Cen­ter in Nashville, where Keswani works.

The prob­lem is not unique to Keswani or to Nashville. Na­tion­wide, fewer than 20% of pa­tients who are el­i­gi­ble for car­diac re­hab pro­grams par­tic­i­pate in them. The gov­ern­ment is plan­ning to test whether pay­ing hos­pi­tals to put el­i­gi­ble pa­tients in car­diac re­hab or in­ten­sive car­diac re­hab will boost par­tic­i­pa­tion and save both lives and health­care dol­lars.

Car­di­ol­o­gists and other ad­vo­cates of car­diac re­hab de­scribe the ex­per­i­ment as a step in the right di­rec­tion. But they doubt it’s enough to address the most se­ri­ous bar­ri­ers—out-of-pocket costs and lack of trans­porta­tion—stop­ping pa­tients from en­rolling in or com­plet­ing car­diac re­ha­bil­i­ta­tion pro­grams. Those are chal­lenges that won’t be solved by fi­nan­cial in­cen­tives, they said.

The ex­per­i­ment, the Car­diac Re­ha­bil­i­ta­tion In­cen­tive Pay­ment Model, was fi­nal­ized in late De­cem­ber. It is part of a pack­age of ex­per­i­men­tal pay­ment mod­els aimed at re­duc­ing health­care spend­ing while im­prov­ing out­comes, in­clud­ing the ex­pan­sion of CMS’ manda­tory bun- dled-pay­ment pro­gram to in­clude all care as­so­ci­ated with by­pass surgery and heart at­tacks.

Un­der the car­diac re­hab pay­ment model, Medi­care will pay par­tic­i­pat­ing hos­pi­tals $25 per ses­sion of car­diac re­ha­bil­i­ta­tion or in­ten­sive car­diac re­ha­bil­i­ta­tion for the first 11 ses­sions. And it will pay $175 per ad­di­tional ses­sion, for a max­i­mum of 36 to­tal ses­sions. Those pay­ments would ap­ply only to Medi­care ben­e­fi­cia­ries with heart at­tacks and coro­nary artery by­pass surgery.

The money could off­set the costs of re­fer­ral or co­or­di­na­tion, such as trans­porta­tion. It could also go to “ben­e­fi­ciary en­gage­ment in­cen­tives,” which are sup­posed to be “rea­son­ably con­nected to med­i­cal care,” such as tech­nol­ogy that mon­i­tors a pa­tient’s weight or vital signs, ac­cord­ing to the fi­nal rule. (Hos­pi­tals “could not pro­vide the­ater tick­ets, which would bear no rea­son­able con-

The gov­ern­ment’s five-year test to get more car­diac pa­tients into re­hab pro­grams is slated to be­gin July 1, in 90 geo­graphic re­gions en­com­pass­ing ap­prox­i­mately 1,320 hos­pi­tals.

nec­tion to the pa­tient’s care,” the CMS noted.) Ev­ery year, 735,000 peo­ple in the U.S. have a heart at­tack. For 210,000 of them, it’s not the first time.

Med­i­cal ev­i­dence strongly sug­gests that car­diac re­hab re­duces the risk of death and fu­ture heart at­tacks, and im­proves qual­ity of life. A re­view pub­lished in Jan­uary that ex­am­ined 63 ran­dom­ized con­trolled tri­als in­volv­ing nearly 14,500 pa­tients found that ex­er­cise-based car­diac re­ha­bil­i­ta­tion ser­vices re­duced car­dio­vas­cu­lar mor­tal­ity

and im­proved pa­tients’ health-re­lated qual­ity of life, as well as their risk of hospi­tal ad­mis­sion.

The gov­ern­ment’s five-year test to get more car­diac pa­tients into these pro­grams is slated to be­gin July 1, 2017, in 90 geo­graphic re­gions en­com­pass­ing ap­prox­i­mately 1,320 hos­pi­tals. Half of those re­gions are also par­tic­i­pat­ing in Medi­care’s bun­dled-pay- ment pro­gram for car­diac care be­cause the CMS wants to gauge whether the car­diac re­hab pay­ments have dif­fer­ent ef­fects on uti­liza­tion in fee-for-ser­vice ver­sus episodic pay­ment mod­els.

The beauty of the in­cen­tive pay­ments is that hos­pi­tals can spend the money ac­cord­ing to their needs and to address the unique ob­sta­cles that their own pa­tients face, pro­po­nents of the model said.

“This es­sen­tially en­cour­ages hos­pi­tals to have some in­ter­est in get­ting their pa­tients to re­hab,” said Dr. Nanette Wenger, a car­di­ol­o­gist and a pro­fes­sor of medicine at Emory Univer­sity’s School of Medicine in At­lanta. “It will vary very, very much with the hospi­tal, the lo­ca­tion and the prob­lem,” she added. “But ev­ery hospi­tal, look­ing at this in­cen­tive pay, will say, ‘What can we do to over­come this bar­rier?’ ”

A pa­tient’s lack of par­tic­i­pa­tion could be a mat­ter of where they live, their age, their fi­nan­cial re­sources or a num­ber of other fac­tors, said Sue Nel­son, the vice pres­i­dent of fed­eral ad­vo­cacy for the Amer­i­can Heart As­so­ci­a­tion. “What we think is so creative about this ap­proach is it gives pro­grams ad­di­tional re­sources, and they can fig­ure out how to solve the prob­lem their pa­tient pop­u­la­tion is fac­ing,” Nel­son said.

But that ap­proach is also un­likely to re­move some of the big­gest bar­ri­ers to re­hab.

Medi­care Part B gen­er­ally al­ready cov­ers car­diac re­hab and in­ten­sive car­diac re­hab for all Medi­care ben­e­fi­cia­ries who have had a heart at­tack or un­der­gone coro­nary artery by­pass surgery. But co-pays for those ser­vices can be pro­hib­i­tive for pa­tients, es­pe­cially over dozens of ses­sions.

“The last pa­tient I re­mem­ber is some­one who called and said, ‘I have to pay $50 per ses­sion. I’m not go­ing,’ ” said Dr. Brent Muh­lestein, an in­ter­ven­tional car­di­ol­o­gist at In­ter­moun­tain Med­i­cal Cen­ter in Mur­ray, Utah. Even among his pa­tients who are Medi­care ben­e­fi­cia­ries, co-pays vary sig­nif­i­cantly, he said.

Over the 36 ses­sions in a stan­dard course of car­diac re­hab, a rel­a­tively mod­est co-pay of $20 would add up to $720.

Medi­care’s in­cen­tive pay­ment model would not change co-pays for car­diac ser­vices. The agency said in its fi­nal rule that most par­tic­i­pat­ing ben­e­fi­cia­ries would not ex­pe­ri­ence sig­nif­i­cant out-of-pocket costs, cit­ing the statis­tic that in 2011, just 19% of tra­di­tional Medi­care ben­e­fi­cia­ries lacked sup­ple­men­tal cov­er­age, which meant that the ma­jor­ity of ben­e­fi­cia­ries have ex­tra cov­er­age to off­set outof-pocket ex­penses.

A lack of trans­porta­tion is the other ma­jor rea­son Muh­lestein’s pa­tients don’t en­roll in re­hab or stick with it, and the prob­lem is par­tic­u­larly no­tice­able among Medi­care pa­tients.

“They have to drive to the hospi­tal all the time, and it may not be con­ve­nient for them to drive to the hospi­tal,” he said. “They may not have a driver’s li­cense. They have to get some­one to take them, and they don’t like get­ting peo­ple to take them, be­cause that’s an im­po­si­tion.”

In these cir­cum­stances, dis­tance mat­ters less than lo­gis­tics, Muh­lestein said. “It’s al­most as hard to get some­body to take you three blocks as it is to take you 10 miles.”

That’s why some car­di­ol­o­gists say it’s time to think be­yond fi­nan­cial in­cen­tives to put more pa­tients in car­diac re­hab ser­vices, such as find­ing ways for them to do re­hab at home. Sev­eral stud­ies have shown home-based re­hab, su­per­vised re­motely us­ing smart­phones or other tech­nol­ogy, to be equally ef­fec­tive for pa­tients, said Wenger, the Emory car­di­ol­o­gist. But Medi­care doesn’t cover home­based car­diac re­hab.

One rea­son pay­ers re­sist cov­er­ing such ser­vices is that it’s eas­ier to con­trol and as­sess the qual­ity of care at a re­hab fa­cil­ity. Judg­ing the qual­ity of re­hab ser­vices at home is “more of a learn­ing curve,” Wenger said. Nev­er­the­less, she de­scribed such ser­vices as “the fu­ture of re­hab.”

A self-guided ver­sion of home­based re­hab is along the lines of what Keswani, the Nashville car­di­ol­o­gist, pre­scribes for pa­tients who can’t make it to the hospi­tal for re­hab for lo­gis­ti­cal, fi­nan­cial or other rea­sons. He sug­gests they join the lo­cal Planet Fit­ness for $9.99 a month and walk on the tread­mill, at their own pace, for 30 min­utes a day.

If join­ing a gym is not pos­si­ble, he di­rects them to lo­cal parks or high school tracks. And he de­flects protests about rain and the el­e­ments by urg­ing pa­tients to go to a Wal­Mart or the lo­cal mall to walk around for half an hour.

It’s not the same as the su­per­vised ex­er­cise and sup­port for be­hav­ioral change of­fered in car­diac re­hab, such as im­prov­ing diet or quit­ting smok­ing. But, Keswani said, “at least they’re out and do­ing some­thing.”

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