Karen Lui, RN, MS, FAACVPRGRQ Consulting, LLC

karen@GRQConsulting.com770-531-9298

OSCVPROctober, 24 2009

I have nothing profound to say.

Many ideas grow better when transplanted into another mind than in the one where they sprang up.

Oliver Wendell Holmes, Jr.

Is our program “safe”?◦ Politically◦ Cost efficiency◦ Efficacy

Is our program all that it can be?◦ Bottom line◦ Service to other patient populations

Is our program ready for 2010? 2015? 2020?◦ Or is it circa 1990?

1970’s Patients 80 Payroll RNs(2)$35,000 Sessions 72 Equipment $

3,000 Reim$ 50 Misc. $ 8,000 Sessions/yr=4350 Rent 0 Total Revenue Expenses

$ 235,000 $ 86,000*Profitability encouraged program

proliferation.-CTC, Prime Medical

2000’s• Patients 300 Payroll

RN,PT,EP $ 110,000• Sessions 24 Equipment $ 9,000• Reim $35 Misc. (MD, RD) $ 10,000• Sessions/yr=7500 Rent $ 40,000

• Total Revenue Expenses$ 150,000 $ 150,000

*HMOs=limited sessions & higher co-payments

1981-HCFA (now CMS) “PR is a covered benefit.”

This opened the door for Local Medicare Contractors to write local coverage policies.

PT codes for PR services were available to all PR practitioners.

1990’s-CMS created G Codes to replace PT codes for non-PTs (end of bundled PR codes).

2006-CMS “lacks authority” to cover PR. Some local contractor policies were consequently retired.

Medicare HMO co-payments Private Payer co-payments Private payer limits on # of sessions due to

our testing protocols and our risk stratification

Increased Phase III/IV/Maintenance clients Hospitals freezing or downsizing staffing Cost of physician coverage for “off campus”

hospital CR and PR program locations Underutilization of CR/PR services

9Suaya et al. Circulation 2007; 116(15): 1653-62

Use of CR by State

Suaya JA, Shepard DS, Normand ST, Ades PA, et al. “Use of cardiac rehabilitation by Medicare beneficiaries After myocardial infarction or coronary bypass surgery”. Circulation 2007;116;1653-1662.

Suaya et al, JACC, 2009; 54:25-33. Gurewich D, Prottas J, et al. “System-level

factors and use of cardiac rehabilitation”. JCRP 2008;28:380-385.

National goal for CR participation=60% (Dr. Phil Ades)

◦ 10% ineligible due to medical conditions◦ 30% behavioral barriers

GWTG (72,000 patients)=56% referral rate◦ Increased program availability leads to increased

utilization◦ Waiting list is not an option

CMS: “typically 1-3 weeks after discharge”◦ Don’t wait for patients to come to you-seek

referrals

Patient barriers◦ Unaware of benefits◦ Perceive as “gym”◦ Unsure about insurance coverage◦ Perceived complexity of enrollment◦ Not motivated to chance behavior◦ Lack of transportation or social support◦ Financial constraints

Provider barriers◦ Referral contingent on providers◦ Confusion about eligibility◦ Perception of no added benefits

Thomas. Circulation 2007;116:1644-1646

• Community barriers– Lack of positive media messaging– Transportation barriers

• System barriers– Competing demands for resources– Lack of integration into spectrum of

cardiovascular care– Inadequate reimbursement– Cost of programs– Lack of automatic systems for referral

Thomas. Circulation 2007;116:1644-1646

System level barriers to CR participation• Degree of automation and

assertiveness around securing CR referrals

• Level of integration of CR within the hospital setting and physician community

• Relationship to other CR facilities• Capacity restraints

• Improve your system of physician referral to CR/PR to increase ratio of eligible to enrolled patients

• Automate in preparation for EMR– Automatic referral can increase referral rate 20%– One study: 52% of eligible CR patient enrollment

with automated system vs. 32% without automation

• Referral to CR is part of ACC IC3 Registry (GWTG)

Re-design your program to be ready for 20% increase in referral rate◦ Add exercise equipment (more pts/class)◦ Eliminate waiting list◦ Grace SL et al. York University, Toronto (n=668):

Median delay from CR referral to start of 43 days Most frequent causes were system related

1. Program capacity issues2. Awaiting test results or MD response

◦ If Phase III/IV limits Phase II #s, move your maintenance (or raise price)

◦ Consider use of CPT 93797 for: Non-exercise sessions (Education) Non-ECG monitored exercise sessions (more

pts/class)◦ Consider paradigm that allows more patients/day

Stagger lunch breaks to keep facility open Open gym concept rather than classes Less time between classes (overlap with weight

training) Patient convenience over staff convenience

◦Remove modifiable patient barriers to participation Restrictive or rigid scheduling options

Improve patient perception of need for CR by endorsing importance of 2ndary prevention to referring physicians & patients

Increase program visibility within your institution◦ Data you already collect (program effectiveness):

Report to staff Report to your director Report to your VP/admin Report to your QA dept Present at MD Grand Rounds

• Keep your folder of evidence-based research that demonstrates value of cardiac and pulmonary rehabilitation updated.

• Share that data.– Scientific Statements, Guidelines, & important

research publications are posted on AACVPR web page for members.

– Grand Rounds• Hospital CEO in CA after seeing data: “I don’t know

why we don’t use cardiac rehab more!”

Seek revenue-generating services◦ PAD rehab (self-pay)◦ “Safe Start” Phase III ◦ Education and/or exercise “package” for chronic

disease management populations: DM Asthma Obesity Depression Arthritis HTN Lipid abnormalities

◦ Education and/or exercise “package” for chronic disease management populations: Heart Failure Clinic AED Support Clinic Post-Bariatric Surgery Clinic Physical Therapy Transition Pre/post Natal Clinic Sport Specific Training Clinic

Seek to do something that others

can’t do,won’t do,

or haven’t even thought of doing!

Barb Fagan, FAACVPR

Work with your hospital’s “Insurance Contracts Negotiator” to promote/expand your services◦ Hospital is the insurance company’s customer◦ Who are the major insurance companies in your

area?◦ What are their “Under 65” CR/PR policies?◦ If unacceptable (high co-pays, restrictive

qualifying dx, etc), use hospital to help bring about policy change

◦ Challenge Medicare HMO co-payments

• Be on a first-name basis with whomever does your billing (monthly “Bagels for billers” day)

• AACVPR Tool Kit for CR available to members– Budget worksheet– Sample referral orders, assessment tools, referral to

enrollment tracking excel spreadsheet– Marketing tools

• CR ppt for community use– Medical Director resources

• Sample letters• Roles/Job description• AACVPR Position Paper on Medical Direction (King et al,

2005)• Medical Directors Newsletter-CR & PR

• A1 & A2: Referral from hospital & from Dr office• B1: Emergency policies

– Medical Director– Emergency Response Team– BLS/ACLS

• B2: Risk stratification for risk of event during exercise– Ongoing assessment (years of scientific data)

• B3: Risk stratification for disease progression• B4: Tracking

– Enrollment (barriers beyond referral barriers)– Individual patient outcomes– Program outcomes (program effectiveness)

JACC 2007;50:1400-33.38

JACC 2007;50:1400-33.39

◦ PR Performance Measures are in early stages of development

◦ CR Performance Measures to improve MD referral rates have been endorsed by National Quality Forum (NQF)

◦ Goal is for inclusion by CMS as quality indicator◦ So what?

Physician Quality Reporting Initiative (Congress)

Physician Voluntary Reporting Program (CMS)

Pay for Performance (P4P)

Value-Based Purchasing (VBP)

• 2007-73 measures selected• 2009- expanded to 153 measures • Measures are developed by

professional organizations (AMA, SVS, etc) based on practice guidelines (which are generally based on evidence of improved patient outcomes)

• Only route to become part of CMS measure set is through NQF

• So what?

Examples of CMS Quality Measures CAD

Lipid profile doneAntiplatelet tx

MIAsa within 24 hours of ER arrival

DMLDL in controlHTN in control

CABGLipid mngmnt & counseling @ hosp DCBB

COPDSpirometry doneBronchodilator for FEV1 < 70%

CMS Focus on “Care Coordination”◦ 14 Quality Improvement Organizations (state

“QIOs”) awarded grants to study care gap◦ Currently gaps in care from hospital DC to home 1 in 5 Medicare pts re-admitted in 30

days Half of these in 1st week Half had no MD/clinician follow-up Availability of DC summary @ 1st post-

DC visit=12-34% affecting care in 25% of follow-up visits (JAMA 2007)

So what?

CMS Focus on “Care Coordination”◦Indicators of success in improving pt

outcomes that reduce unnecessary re-admissions Reduction in adverse medication reactions Improved patient understanding of and

adherence to treatment plan◦CR/PR can serve important role in closing

care gap

Care Coordination Study Goal: to improve patient adherence and ability to

communicate with MDs◦ Author:

“…most effective is identifying problems before they became severe and responding quickly, through care coordinators having standing orders to…,through telling patients they needed to get to their MD, and through trusted relationships with the patients’ MDs, who took it seriously when notified that one of their patients as having worsening symptoms that required their prompt attention.”

“Effects of Care Coordination on hospitalization, quality of care, & health care expenditures among Medicare beneficiaries”, Peikes D, Chen A, Schore J, Brown R., JAMA, Feb 11, 2009, Vol 301, No. 6, 603-618.

Long-term medication adherence after MI Followed 3 yrs: 45% medication

continuation rate(BB, statins, ace inhibitors)

CR associated with 34% decrease in likelihood of non-adherence to statin 3 years out (similar for ACE inhibitors & BB)◦ Not dependent on # of sessions attendedShah ND, Dunlay SM, Thomas, RJ et al. “Long term medication adherence after myocardial infarction: experience of a community”, American Journal of Medicine, Oct; 122 (10)961.e7-13.

Stratification of risk for events during exercise

vsStratification of risk for progression of disease

Per CMS:◦Assessment/re-assessments based on patient-centered outcomes (goal setting with patient)

◦Measurable and expected outcomes

◦Estimated timetable to achieve these outcomes

AACVPR Guidelines, 4th Edition, 2004, 56-67

Entry Stress Test Bruce protocol with estimated VO2 (not

direct measurement) Handrail support used by > 90% of

hospitalized pts (includes even two fingers on front bar)

Average resting metabolic rate for CAD pts is 23-36% lower than widely accepted 3.5 ml O2/kg/min

Berling J, Foster C, et al, “Effect of handrail support on Oxygen uptake during steady state treadmill exercise”, JCR, 2006;26:391-394.

Savage PD, Toth MJ et al, “Re-examination of metabolic equivalent concept in individuals with CHD”, JCR

Result: Overestimation of functional capacity Consequent Private Payer “risk

stratification”

Patient-Centered OutcomesAdes PA, Savage PD, et al, “High-calorie-

expenditure exercise: a new approach to cardiac rehabilitation for overweight coronary patients”, Circulation, 2009:119

Current CR exercise protocols developed in 1970’s (profound deconditioning due to lengthy hospital stays )

CR exercise protocols result in little weight loss and minimal changes in cardiac risk factors

>80% CR pts are overweight & >50% have metabolic syndrome

CR exercise protocols unchanged despite focus on risk reduction and 2ndary prevention◦ CR-related energy expenditure 7-800kcals/wk

Study design: Longer duration (45-60 min vs 25-40) and

more frequent (5-7x/wk vs 3) compared to standard CR

“Walk often and walk far”: goal of >3000-3500 kcals/wk (onsite for 1st 2 weeks before expanded to home setting)

Study Findings: Double the weight loss (P<0.001) @ 5 mths

(maintained @ 1 yr) Double the fat mass loss (P<0.001) @ 5

mths Reduced insulin resistance Reduced ratio of total to HDL, increased

HDL, decreased trigs, reduced BP Prevalence of metabolic syndrome

decreased from 59% to 31%

Before you ask…Not associated with increased rate of overuse injuries

Not described as more unpleasant to accomplish, in fact, was well-accepted by patients

Conclusions: High calorie-expenditure exercise substantially more effective than standard CR ex for wt loss and risk factor change in overweight CHD pts

Doesn’t preclude established benefits of standard CR, rather optimizes exercise intervention

ACSM Position Paper-Goal should be 200 minutes/week for wt loss

Scientific evidence continues to demonstrate strong patient benefits of these services.

We are each responsible for educating the medical community and the patient community on the value of CR and PR.

Be part of health care reform by transforming your CR/PR Program into a Disease Management Program

As Jody’s CEO said, “Why didn’t I know about these CR outcomes before now?”

Lastly, get ready for 2 big events…

6th Annual DOTH March 3-4, 2010Washington, DC

ACSM WORLD HEART GAMESMay 14-15, 2010

Agnes Scott College-Decatur, GA