COVID-19 has thrown traditional cardiac rehabilitation programs a major curveball, but some experts say this crisis is also creating new opportunities to reimagine care delivery and payment for the long haul.
An October paper published in Archives of Physical Medicine and Rehabilitation by researchers at the Université de Montréal, zeroed in on cardiac rehabilitation and the challenges for traditional center-based programs in the wake of COVID-19. The pandemic, Florent Besnier, PhD, and colleagues explained, has created a sudden need to develop remote home-based programs. The prevalence of smartphones and high-speed internet should be viewed as “an opportunity to promote a major shift” using telemedicine to impact many people’s health.
Recent developments like virtual consultations, remote patient monitoring, smartphone apps, and eHealth platforms have all led to new strategies that supplement conventional services offered within the walls of rehabilitation centers. Digital tools and trackers enable individualized remote monitoring by nurses, exercise specialists, and cardiologists to promote healthy behavior like increased physical activity and good eating habits. Coaching over the telephone is an option for improving adherence. And home-based exercise workouts—many of which do not require any equipment—can be facilitated using live or online videos.
It is known that nonparticipation in cardiac rehabilitation increases cardiovascular mortality and hospital readmissions, Dr Besnier told First Report Managed Care. In the wake of this pandemic, cardiac operations have been delayed. In some instances, people who have had a heart attack have not been taken care of because cardiac rehab programs have been either canceled or postponed. Even if access to center-based rehab is limited during this crisis, he pointed out, home-based rehab is still possible for low to moderate risk patients. “So,” he asked, “What are we waiting for?”
Similarly, in a paper published November 4 in JAMA Health Forum, researchers revealed why they believe this is an opportune time to reinvent cardiac rehabilitation programs. “Although cardiovascular disease accounts for one-sixth of health care spending and affects half of American adults, cardiac rehabilitation—an effective prevention strategy with strong evidence of safety, efficacy, and cost savings—remains underused,” they wrote. “As the ongoing pandemic changes how cardiac care is delivered, it provides an unprecedented opportunity to reimagine how cardiac rehabilitation is prescribed, delivered, and financed.”
The pandemic has led to significant growth in home-based cardiology care, which has been facilitated by changes to both care delivery and financing. On October 14, for example, the Centers for Medicare & Medicaid Services initiated reimbursements for virtual cardiac rehabilitation. Any lessons learned from virtual delivery during the pandemic, the authors noted, ought to be used to inform delivery and payment reform moving forward.
“Cardiac rehab is one of these unique interventions that is effective, likely cost-effective, and yet has sat in the blind spot of both clinicians and policymakers for a long time,” Dhruv S Kazi, MD, MSc, MS, told First Report Managed Care. Over time, the evidence has suggested that it reduces hospitalizations and improves quality of life. “And yet, because it’s not a quick build that can be prescribed or a device that can be inserted…uptake has been slow,” added the associate director of the Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School.
Supply and Demand Issues at Play
Dr Kazi said supply has been bottlenecked, and there has not been a major move to increase demand until supply issues are figured out. Registered cardiac rehabilitation programs can serve less than half of the 1.25 million eligible US patients each year. And even for the subset of patients who are prescribed cardiac rehab, the delays are so substantial that by the time they can get in for their first appointment, the hospitalization that triggered the appointment was so long ago that there is less incentive to participate. “It’s almost like we don’t want patients to participate in cardiac rehab,” he said. “That’s what the system is signaling to patients.”
Increasing supply will hinge on finding more qualified health care professionals and facilities or coming up with new and novel delivery channels. Because of the shift to telemedicine this past year, there is an opportunity to deliver care in new ways. There are patients, particularly those who are older, “who we have for the longest time assumed would not be interested in participating in telehealth or would be unable to participate in telehealth,” he said, who have demonstrated that they are, indeed, willing, able, and interested. “And we’ve shown that they can be safely administered, particularly the clinical visits and remote monitoring.”
Demand will need to be addressed as well, he and colleagues explained in their paper, noting that increasing referral rates means dealing with barriers facing physicians and patients. Less than one-third of eligible patients are referred for cardiac rehab before being discharged, they noted, and those who are referred are met with other barriers, like transportation issues or the cost of copays. Physicians face challenges, too, such as a lack of awareness regarding cardiac rehab’s benefits. Educating doctors and initiating automatic referrals from electronic health records could grow the number of referrals, and educating patients about the benefits before discharge may improve engagement.
Home-Based Pilot Program Shows Promise
Some evaluations have led to encouraging results, Dr Kazi and colleagues pointed out. Last year, for instance, Kaiser Permanente piloted the practice of automatically referring eligible patients to home-based cardiac rehab using electronic health records. Participants received an in-person evaluation and were provided with exercise regimens, symptom journals, and a smartwatch. For nearly 2 months, these individuals exercised on their own, received coaching through a smartphone app, and communicated with case managers by telephone.
Compared with a center-based cardiac rehabilitation control program, this home-based program grew completion by 75%, trimmed readmissions by 30%, and cut cardiovascular mortality by nearly 30%. “Based on such studies,” the authors noted, “the American Heart Association and other societies endorsed home-based cardiac rehabilitation as an option for clinically stable patients at low to moderate risk. Scaling such models could expand capacity while reserving spots in facilities for patients at higher risk.”
There is a subset of high-risk patients who would likely need in-person monitoring and support, Dr Kazi added. Still, the vast majority of those who are eligible for cardiac rehab can be managed remotely. Ultimately, the researchers say home-based rehab can not only trim wait times but also enable flexible participation schedules and remove the need for travel to health care facilities.
Payment Model Reform Could Promote Long-term Success
The long-term success of the virtual delivery of cardiac rehab will depend upon a revised payment model, Dr Kazi and colleagues pointed out. Whereas the current fee-for-service model requires that cardiac rehab be carried out at an outpatient center with sessions lasting a minimum of 31 minutes, a payment model with increased flexibility (like a bundled prospective payment) could have several benefits.
Separating payments from session duration would make more frequent interactions possible. An hour-long exercise session, for instance, could be followed by a check-in later that week. Moving past the billing of individual sessions could also offer the flexibility needed to test strategies for improving cardiac rehabilitation uptake, like virtual group-exercise classes. Beyond that, a bundled payment covering inpatient and outpatient rehab would provide monetary incentives for care coordination to reduce the number of avoidable readmissions.
Among the conflict of interest disclosures listed in the JAMA Health Forum paper, Mr Vishwanath reported that he is the founder of a company that develops home-based technology solutions for older adults.
- Besnier F, Gayda M, Nigam A, Juneau M, Bherer L. Cardiac rehabilitation during quarantine in COVID-19 pandemic: challenges for center-based programs. Arch Phys Med Rehabil. 2020; 101(10): 1835-1838. doi:10.1016/j.apmr.2020.06.004
- Vishwanath V, Beckman AL, Kazi DS. Reimagining cardiac rehabilitation in the era of coronavirus disease 2019. JAMA Health Forum. Published online November 4, 2020. doi:10.1001/jamahealthforum.2020.1346