Cardiac Rehab Programs: Yet Another Evidence-Based Intervention That Isn’t Paid For

Evidence shows cardiac rehabilitation programs –which teach patients who have had a cardiac event about exercise, diet and prescription drugs – substantially cut the risk of dying from another cardiac problem; they also improve quality of life and lower costs. But as Kaiser Health News notes, fewer than one-third of patients whose conditions qualify for cardiac rehab actually participate.

One of the main reasons for the low participation rate is cost; patients must generally pay a co-pay to participate in such programs – about $20 per session for regular Medicare beneficiaries, and anywhere from zero to over $60 per session for Medicare Advantage enrollees and those who are privately insured.

Aside from cost, other barriers include distance/travel time to the facility, lack of referrals at the time of hospital discharge, and capacity of existing cardiac rehab programs. This is particularly troubling because in spite of the increased likelihood of death within five years of a first heart attack, certain populations are less likely to be referred for cardiac rehabilitation, including women, minority populations and patients of lower education levels of socioeconomic status.

[Note to readers: I am a bit obsessed about the evidence for cardiac rehab, as well as the social determinants of health that prevent it from being routinely recommended and included it as Case 17 in the textbook I co-edited, Essential Case Studies in Public Health: Putting Public Health into Practice, published by Jones and Bartlett.]

What do we pay for, and why?
In considering innovation and value, there are frequently situations in which patients are receiving a health care service that runs counter to recommendations based on the latest evidence- clearly a waste, but politically difficult to stop, especially if it runs counter to patient or provider preferences. However, this is an example of where the evidence clearly supports reimbursing for the intervention, but the service is underutilized considering its value to the patient and the system.

As noted, this low participation rate in cardiac rehab is due in part to patients’ reactions to time requirements, but can also be blamed on health insurer cost-sharing requirements that discourage use of a valuable intervention. To be clear, studies show 25% reduction in all-cause mortality rates and 31% reduction in hospital readmissions, translating into millions in annual savings.

Medicare is inching forward with its Cardiac Rehabilitation (CR) Incentive Payment Model which pays hospitals incentive payments based on total cardiac rehabilitation use for patients in their care after a heart attack or bypass surgery. Hospitals can receive $25 per cardiac rehabilitation service for the first 11 services they provide and the payment increases to $175 per service after those first 11 services.

If the evidence shows significant reductions in adverse events and cost of care for those who participate, is it time for payers to reflect that increased value in lower co-pays? And perhaps more importantly, is it time for payers to require providers to recommend cardiac rehab for everyone who could benefit, regardless of their gender, race or income?