Cardiovascular Rounds

How intensive cardiac rehab can impact your patients—and your bottom line

by Marissa Schwartz and Jodi Askew

In our last post, we introduced intensive cardiac rehab (ICR), a more rigorous and frequent form of traditional cardiac rehab that must be proven effective in improving clinical measures and reducing costs to receive Medicare reimbursement. While our first post focused on reimbursement, in this post we’ll address the impact ICR could have both on your patient population and your CV service line.

What is the clinical case for ICR?

There is a large patient population that potentially qualifies for ICR. CMS beneficiaries are eligible for ICR if they have experienced a cardiac incident including a heart attack, CABG surgery, valve repair or replacement, or coronary stenting, and if their attending physician recommends them for a rehab program.

However, rehab opportunities are at present significantly underutilized: according to a 2009 study published in the Journal of the American College of Cardiology, of the more than 600,000 Medicare patients hospitalized for acute coronary syndrome, PCI, or CABG, just 12.2% participated in cardiac rehab. Of those who are referred to rehab, only 34% actually enroll. This low participation rate suggests the presence of a strong clinical demand for rehab programs like ICR.

What is the business case for ICR?

Traditional cardiac rehab has repeatedly demonstrated clinical effectiveness in the literature. As just one example, a 2013 presentation at the ACC’s annual scientific session showed that CR after AMI or PCI decreased cardiac morbidity and mortality. A meta-analysis of randomized controlled trials on exercise-based rehabilitation for patients with coronary heart disease found that CR was associated with reduced all-cause mortality, cardiac mortality, total cholesterol, triglycerides, and systolic blood pressure when compared with usual care.

Although there is a dearth of research on ICR, its proponents argue that it is a critical investment for hospitals and the health system at large. As Modern Healthcare reports, the director of the newly approved Benson-Henry Institute for Mind Body Medicine’s Cardiac Wellness Program anticipates their ICR program will provide a holistic cardiac rehab experience, reduce morbidity and mortality, and decrease Medicare costs long-term. Dr. Dennis Humen, a professor of medicine profiled in this 2013 article, has also called attention to this opportunity. Dr. Humen estimated the health care savings associated with administering intensive cardiac rehab for just 60,000 individuals who experienced heart attacks could save up to $8.6 million per year.

In fact, a group from Western University presented a study at the Canadian Cardiovascular Congress in 2013 demonstrating the business case for a program they called “intensive” cardiac rehab. They analyzed outcomes from 47 randomized trials and projected analysis over two years of follow up. Their study showed that costs for 3,500 patients enrolled in ICR and followed for two years would be about $5.4 million, compared to estimated treatment costs of $5.8 million due to cardiac events and hospital readmissions in the same population if not enrolled in ICR. Importantly, the Canadian program is not necessarily equivalent, in content or in cost, to American ICR, but the potential for long-term savings is apparent.

Commercial payers also seem to find value in ICR. Currently, Aetna covers the Ornish cardiac rehab program for eligible beneficiaries, and United Healthcare covers the three programs identified by Medicare.

How else might ICR affect your bottom line?

  • ICR can help brand your organization as a leader in health care transformation and innovation
  • Investing in the infrastructure necessary for an ICR program can position your program to lead in primary as well as secondary prevention, and thus continue to build alignment with community referrers
  • ICR may increase patient satisfaction and loyalty for consumers interested in disease reversal, prevention, and well being
  • ICR might improve your readmission rates, although the financial implications are difficult to calculate given today’s limited market information

What are some potential drawbacks of ICR?

Despite these potential benefits, the jury is still out on whether ICR can—and should—be widely utilized by programs. For example, a 2015 study in JACC noted that affordability and accessibility challenges may help explain low participation rates for traditional CR. If this is the case, will ICR—more expensive to run and requiring more time and energy from patients—really solve the problem? CV leaders have echoed this concern, noting several ICR closures despite overall cardiac rehab growth in some markets. ICR programs may also be limited by attracting a more “niche” patient population than the population drawn to traditional cardiac rehab.

Equally concerning, ICR programs may soon have to prove themselves against another standard: remotely cardiac rehab. Remote cardiac rehab was proposed by the JACC study as another alternative to traditional rehab, better positioned to address the need for patient-centered, easily accessible, and affordable care.

All this being said, the total and net cost and clinical outcomes associated with ICR are currently difficult to determine. A lack of controlled clinical trials and unavailability of data on cost savings could make evaluating the investment difficult. Either way, we will be keeping a close eye on the new developments in cardiac rehab and the increasingly critical field of prevention.

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