The Role of Cardiac Rehab in Bundled Payment Models
The shift from fee for service to value-based care by Medicare has sparked a renewed interest in the role and importance of cardiac rehabilitation (CR) in the secondary prevention of heart disease. CR is a comprehensive secondary prevention and lifestyle management program that consists of supervised exercise, risk factor management, education and psychosocial support to help patients with heart disease recover from their cardiac procedure, improve their health outcomes, quality of life and reduce their risk for another cardiac event.
Today, 20% of AMI patients (nationally) are readmitted within 30 days of leaving the hospital. Now, extrapolate the timeframe to 90 days, can you guess how many patients will be readmitted in 90 days? Maybe 40-50%? The average AMI admission costs $14,000 to a hospital. Under those assumptions, it is very clear that hospitals must reduce their readmission rates, else the cardiac bundle will be a financial disaster.
The cardiac bundle and incentive payments provide strong financial and clinical incentives for hospitals to innovate in secondary prevention programs. To reduce readmissions, hospitals must build strong post-acute care relationships to ensure patients are doing the right things and following the latest guidelines to keep them out of the hospital. Depending on the patient’s risk level, there are different post-acute destinations. High-risk patients could be sent to either a skilled nursing home or receive care directly at home from a home-care team. Low to medium risk patients should be sent to a CR program. Of all the three options, CR is the cheapest and has the best evidence for reducing readmissions.
Studies show that CR can reduce 90-day readmissions by up to 30%. CR’s success in reducing readmissions can be attributed to improvements in the patient’s health from exercise, healthy diets and medication adherence but also “surveillance” through frequent contact between the patients and staff. By interacting with patients frequently and assessing their risk factors, CR programs can prevent readmissions by catching abnormalities early and resolving them before they lead to an acute event. Medicare has recognized this fact and has placed a clear emphasis on the importance of CR by introducing the incentive payment model to encourage more CR participation. The Incentive payments will more than double CR reimbursements from a maximum of $3600 to $8,250 per patient. This increase in revenue coupled with the potential for hospitals to use CR as a cost reduction tool means that hospitals should invest more resources into CR.
However, despite referral to CR being a class 1 recommendation for patients with acute myocardial infarction (AMI), percutaneous interventions (PCI) and certain forms of congestive heart failure (CHF) and the strong evidence behind its impact on improving patient outcomes and preventing future cardiac events, less than 20% of eligible patients participate. The reasons for lack of participation stem from the current delivery model of CR being inaccessible and inconvenient for patients. To participate in CR a patient is expected to attend 3 classes a week for 12 weeks. Most times, the classes are located far away from home and work. The classes are also offered mostly during business hours which makes it impossible for working people to attend. In addition, the out of pocket cost to patients could be as high as $1,800 and many CR programs have limited physical space and capacity resulting in long-waitlists.
In the earlier fee-for-service payment model, the low patient participation meant many CR programs were unprofitable and underfunded. With the transition to value-based care, CR’s success is more critical to a hospital’s bottom line from a cost reduction perspective vs. revenue generation. Despite their well-documented benefits, CR programs may not be able to impact readmissions in a significant way due to low patient participation. For CR programs to to be successful in realizing their revenue and cost saving potential with the new payment models, hospitals must evolve the delivery model of CR to be more patient centered and accessible.
Studies have shown that home-based CR programs have equivalent outcomes with much higher participation rates than center based CR. Studies have also shown that the use of telehealth in the delivery of home CR yields better patient accountability, compliance and outcomes. Home-based CR delivered through telehealth allow care teams to do “more with less” by extending their reach beyond the walls of the hospital. To improve CR participation hospitals should consider using home CR programs and telehealth tools to deliver hybrid programs that reduce the number of classes a patient attends but augments them with a home-based program.
Despite advances in patient-centered CR models such as home or hybrid programs, hospitals haven’t adopted or invested these models due to the lack of a financial incentive to do so (home CR is not reimbursed by Medicare). The two new alternative payment models represent a historic opportunity for hospitals and CR programs to adopt these models, expand the scope of their practice, increase the volume of patients they serve and strengthen their financial standing. Securing these programmatic and financial benefits will require augmentation and refinement in the traditional methods of care delivery.