CMS has been busy. On July 25th they published their Notice of Proposed Rulemaking for Bundled Payment Models for High-Quality, Coordinated Cardiac and Hip Fracture Care. While the bulk of this document relates to the new bundled-payment model for heart attack and bypass surgery, there is an important ‒ and much appreciated ‒ new incentive program aimed at acknowledging the importance of cardiac rehabilitation programs to overall patient recovery.
Cardiac Rehabilitation’s Importance
To understand the scope of the issue, here are just three facts about referrals to cardiac rehabilitation from recent medical journals:
- Fewer than 25 percent of patients attend cardiac rehab following an acute MI (Journal of the American Medical Association, August 3, 2015)
- Only ten percent of patients with heart failure are referred to cardiac rehab (Journal of the American College of Cardiology, August 19, 2015)
- Only about 60 percent of patients receiving percutaneous coronary interventions are referred to cardiac rehab (Journal of the American College of Cardiology, May 19, 2015)
While not every patient is a candidate for, or can benefit from, cardiac rehab, a majority of cardiac (and vascular) patients can receive significant benefit from being referred to and attending such programs.
The New CMS Model Incentives
CMS’s announced model will test the effects of payments that encourage the use of cardiac rehabilitation services. Clinical studies have found that completing a rehabilitation program can lower a patient’s risk of heart attack or death. Increasing the use of cardiac rehabilitation services has the potential to improve patient outcomes and help keep patients healthy and out of the hospital.
The cardiac rehabilitation incentive payment model would examine the impact of providing an incentive payment to hospitals where beneficiaries are hospitalized for a heart attack or bypass surgery, which would be based on beneficiary utilization of cardiac rehabilitation and intensive cardiac rehabilitation services in the 90-day care period following hospital discharge. Hospitals may use this incentive payment to coordinate cardiac rehabilitation and support beneficiary adherence to the cardiac rehabilitation treatment plan to improve cardiovascular fitness. These payments would be available to hospital participants in 45 geographic Metropolitan Service Areas (MSA) that were not selected for the cardiac care bundled payment models, as well as 45 MSAs that were selected for the cardiac care bundled payment models (total 90 MSAs). This test will cover the same five-year period as the cardiac care bundled payment models. Standard Medicare payments for cardiac rehabilitation services to all providers of these services for model beneficiaries would continue to be made directly to those providers throughout the model.
CMS proposes establishing a two-part cardiac rehabilitation incentive payment that would be paid retrospectively based on the total cardiac rehabilitation use of beneficiaries attributable to participant hospitals:
- The initial payment would be $25 per cardiac rehabilitation service for each of the first 11 services paid for by Medicare during the care period for a heart attack or bypass surgery.
- After 11 services are paid for by Medicare for a beneficiary, the payment would increase to $175 per service paid for by Medicare during the care period for a heart attack or bypass surgery.
Based on Medicare coverage, the number of cardiac rehabilitation program sessions would be limited to a maximum of two one-hour sessions per day for up to 36 sessions over a maximum 36-week period, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare Administrative Contractor. Intensive cardiac rehabilitation program sessions would be limited to 72 one-hour sessions, up to six sessions per day, over a period of up to 18 weeks.
CFA has always believed that cardiac rehabilitation programs are underused and, frankly, underappreciated. After undergoing bypass surgery, my own father participated in cardiac rehab at his local hospital for many years. Both he and our family found it to be very beneficial, both physically and psychologically. It became his “club,” and the other participants, his good friends. Any incentives that can be included in the reimbursement for these services are welcome and should help to increase cardiac rehabilitation utilization and benefit to this important target population.
If you are interested in learning more about developing a successful cardiac and vascular rehabilitation program, please contact CFA at (949) 443-4005 or by e-mail at CFA@charlesfrancassociates.com