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Cardiac rehab gains more ground but cost and access issues remain



For Kaiser Health News


Mario Oikonomides credits a massive heart attack when he was 38 for sparking his love of exercise, which he says helped keep him out of the hospital for decades after.

While recovering, he did something that only a small percentage of patients do: He signed up for a medically supervised cardiac-rehabilitation program where he learned about exercise, diet and prescription drugs.

“I had never exercised before,” said Oikonomides, 69, who says he enjoyed it so much he stayed active after finishing the program.

Despite evidence showing such programs substantially cut the risk of dying from another cardiac problem, improve quality of life and lower costs, fewer than one-third of patients whose conditions qualify for the rehab actually participate. Various studies show women and minorities, especially African Americans, have the lowest participation rates.

“Frankly, I’m a little discouraged by the lack of attention,” said Brian Contos, who has studied the programs for the Advisory Board, a consulting firm used by hospitals and other medical providers.

Now, though, advocates say cardiac rehab may gain traction, partly because the federal health care law puts hospitals on a financial hook for penalties if patients are readmitted after cardiac problems. Studies have shown that patients’ participation in cardiac rehab cut hospital readmissions by nearly a third and saved money.

The law also creates incentives for hospitals, physicians and other medical providers to work together to better coordinate care.

Cost Undermines Participation

Oikonomides, who lives in Charlottesville, went for three decades without another heart attack after his first, but recently had bypass surgery because of blockages in his heart.

He is again rebuilding his strength at the University of Virginia Health System. “I attribute my 30 good years of life to cardiac rehab,” he said recently while pedaling on a stationary bike in a light-filled gym at one of the university’s outpatient medical centers, a heart monitor strapped to his chest.

But many patients still face hurdles.

Uninsured patients simply can’t afford cardiac rehab. And for those with some form of coverage, “the No. 1 barrier is the cost of the copayment, which is frustrating,” said Dr. Ellen Keeley, a cardiologist at UVA, who strongly encourages her patients to enroll.

Medicare and most private insurers generally cover cardiac rehab for patients who have had heart attacks, coronary bypass surgery, stents, heart failure and several other conditions. Most coverage is two or three hour-long visits per week, up to 36 sessions.

Insured patients usually must make a per visit co-pay to participate. For regular Medicare members, that runs about $20 a session, although many have private supplemental insurance that covers that cost. For patients with job-based insurance — and enrollees in the alternative to traditional Medicare called Medicare Advantage — out-of-pocket costs can range from nothing per session to more than $60 a pop.

“Some insurers say a copay for a specialty visit is $50, whether that means going to a neurosurgeon once in their life or whether that’s three times a week for cardiac rehab,” said Pat Comoss, a consultant in Harrisburg, Pa., who trains nurses to work in these programs.

More than a year ago, federal Medicare officials met with insurers after advocates voiced their concern that higher copays were keeping patients from cardiac rehab, said Karen Lui, a legislative analyst for the American Association of Cardiovascular and Pulmonary Rehabilitation, the profession’s trade group.

“To their credit, they dug in and talked with plans that had much higher copays, such as $100 per session,” said Lui. Medicare officials told insurers that a $50 copay per session is the upper limit a plan should charge,” he added.

UnitedHealth, with nearly 3 million members in Medicare Advantage plans, said patient payments for cardiac rehab vary widely. About 12 percent of members pay nothing, while 23 percent pay $50 a session. Another large insurer, Humana, has a similar range, with co-pays running up to $60 a session.

Nationally, the weighted average payment now for Medicare members in private plans is just a bit more than the $20 that patients in traditional Medicare pay, said Dale Summers, director of the Center for Medicare & Medicaid Services’ division of finance and benefits.

Preventing The Next Heart Attack

Aside from cost, another big reasons so few patients participate is many are never referred to a program. Some hospitals are addressing this disconnect by building automatic referrals into their discharge system.

Patients may be reluctant to attend cardiac rehab, especially if they had not been physically active before their heart problem.

To counter that, Gary Balady, director of preventive cardiology at Boston Medical Center, stresses its importance with his patients. He tells them that about 15 percent of heart-attack patients may experience another one within a year.

“One of first things we say [in cardiac rehab] is we are here today to work together to prevent the next heart attack,” he said.

At the University of Virginia medical center, heart-attack patients are given an appointment to come back to a special clinic within 10 days of discharge. Over the course of about an hour, patients meet with an exercise physiologist, a cardiologist, a nutritionist and a pharmacist — and all in the same exam room.

At the visit, the medical professionals answer questions, go over the patient’s medications, make diet tips and recommend cardiac rehab. Kathryn Ward, manager of UVA’s cardiology clinics, says up to 100 patients a month were referred to the clinic in its first year. Of those, 71 percent enroll, she said, well over the national average.

Other Barriers

Still, patients face other barriers to this kind of care, including time constraints, or having to travel long distances to the nearest program.

And existing programs aren’t enough to accommodate all patients who are eligible. A recent study in the Journal of Cardiopulmonary Rehabilitation and Prevention surveyed 812 existing cardiac rehab programs in the U.S., finding that even if they were expanded modestly and operated at capacity, they could still only serve 47 percent of qualifying patients.

“We have patients who are an hour away from any cardiac facility and they can’t afford the gas money or the time,” said UVA cardiologist Keeley.

Take Kathryn Shiflett of Culpeper, Va. At age 33, the last thing she expected was a heart attack.

But one night in late March, she felt pain in her arm — pain that spread to her jaw — and she felt nauseated. After tests at a local hospital, she was transferred by ambulance to UVA, where cardiologists opened a blocked artery in her heart.

Shiflett, a medical worker with two children, traveled back to UVA a week later for her clinic appointment, and was encouraged to participate in cardiac rehab.

Shiflett found the program appealing because she wants to be active and prevent a repeat of her heart attack. But she lives an hour away. In addition to the distance, she isn’t sure she can make any of the sessions. Cardiac rehab classes are during working hours. The latest starts at 3 p.m.

“I’m not sure I can get there by then,” Shiflett said.

One answer for patients like Shiflett could be a home-based program, which are less common, but drawing increased interest.

“There are a whole plethora of different ways to provide cardiac rehab outside traditional center model,” said Mark Vitcenda, senior clinical exercise physiologist at the University of Wisconsin Hospital and Clinics in Madison.

At his program, patients can start in a supervised program at a center for two or three sessions, then can choose whether to continue in a home-based model, with occasional visits to the center. About 30 to 40 percent of Wisconsin program patients choose the home-based option, he said, with most being younger, working patients with lower medical risk.

“If we can lower the barriers of transportation and cost, patients are able to be more involved,” he said.

Geisinger dramatically expanding geographical reach of its insurance


Danville, Pa.-based Geisinger Health System and Bethlehem, Pa.-based St. Luke’s University Health Network have agreed to extend Geisinger health plans to almost 50 Pennsylvania counties.

“The systems will share population and value-based payment model data and create a sponsored Medicare Advantage product to provide recipients access to services not covered under traditional Medicare and Medigap plans. In addition, more than 10,000 St. Luke’s employees will be placed on Geisinger’s health plan, effective Jan. 1,” reported Becker’s Hospital Review.

The development is one of the more dramatic demonstrations of hospital systems expanding insurance offerings to achieve the  cost efficiencies and customer loyalty that some systems see  as needed in the developing value-based world of healthcare.

“When you get to the heart of it, we are two organizations focused on taking the best care of patients and we’re excited to partner with a healthcare system that aligns with our vision and values,” said David Feinberg, M.D., Geisinger president and CEO. “Geisinger is thrilled to expand the scope of our relationship with St. Luke’s to advance population health, improve quality and provide better access to care.”


To read the whole story, please hit this link.

More sculpting of Medicare Advantage value-based program


Modern Healthcare reported:

“The federal government will expand a new Medicare Advantage program to three states in 2018, as part of an effort to change behaviors and cost-sharing for seniors who have chronic diseases.

“In addition, plans that want to join the Medicare Advantage Value-Based Insurance Design model can offer expanded benefits to two new types of chronically ill members {dementia and rheumatoid arthritis}.

“The concept behind VBID is to eliminate the financial barriers sick patients face when they are trying to get certain exams, prescriptions drugs and procedures. If patients with chronic conditions are able to obtain high-quality care that is recommended by doctors for free or at a reduced cost, in theory, they are more likely to get that care and avoid potentially more expensive care down the road. Cost-sharing likewise would increase for services that offer little to no value for patients.”

“Dr. Mark Fendrick, a physician at the University of Michigan and one of the original supporters of VBID, has championed a bill in Congress that would allow all private plans to provide first-dollar coverage for chronically ill people …in a high-deductible policy.

“Starting this January, interested Medicare Advantage insurers will be able to offer enhanced benefits in seven states: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania and Tennessee. In 2018, the project will expand to Alabama, Michigan and Texas.”

To read the whole article, please hit this link.

UHC pays $148 million to physicians in value-based program


HealthcareDive reports that giant UnitedHealthcare paid more than $148 million last year to primary-care physicians for improving  the medical outcomes for patients in Medicare Advantage plans. The insurer said that nearly 1,900 physicians received bonuses for achieving value-based goals in its PATH program, which encourages physicians to promote prevention, including  monitoring of chronic conditions.

Physicians in the program care for about a million Medicare Advantage members.

The Centers for Medicare & Medicaid Services  is trying to shift 50 percent of Medicare payments to value-based payment models by 2018.

To read the whole HealthcareDive story, please hit this link.

Medicare accepting applications from PCPs for monthly capitation payments

Medscape reports:

“Medicare is now accepting applications from primary-care physicians who want to receive monthly capitation payments for evaluation and management (E/M) services as well as care management apart from office visits — think phone calls, emails, and remote monitoring.

“Selected physicians will participate in a 5-year experimental payment model called Comprehensive Primary Care (CPC) Plus, which is designed for medical homes. The Centers for Medicare & Medicaid Services (CMS) wants to recruit as many as 5000 practices with upwards of 20,000 clinicians to treat 25 million patients, who will not be limited to beneficiaries of traditional Medicare. CMS is partnering with private insurers, state Medicaid programs, and Medicare Advantage plans that agree to adopt the same metrics for payment, data sharing, and quality. As a result, participating physicians won’t have to reorganize their practices just for the sake of patients in traditional Medicare.”

To read the entire article, please hit this link.

CHI getting out of scary insurance business


Englewood, Colo.-based Catholic Health Initiatives has decided to get out of the health-insurance business.

CHI’s insurance subsidiary, QualChoice Health, formerly known as Prominence Health,  has been offering Medicare Advantage and commercial insurance products to members in six states. But, Becker’s Hospital Review reports, the insurance business had a operating loss of almost $97 million in the first nine months of fiscal  2016, which ended March 31. In the like year-earlier period, QualChoice had a nearly $19 million operating loss.

CHI is one of many systems that have launched health plans in recent years, especially since the Affordable Care Act went into effect, but with often disheartening results.

McKinsey & Co.  found that of the 89 hospital-system insurance plans, more than 40 had negative margins in some or all of the past three years. To read the Becker’s story on this, please hit this link.


Coalition’s ideas for boosting care of patients with chronic conditions


The National Coalition on Health Care recommends that to  improve care of patients with chronic conditions in Medicare Advantage, Medicare ACOs and other plans:

  • Congress should pass legislation to encourage health plans and ACOs to invest program dollars in targeted social and long-term services and supports.
  • Integration of mental-health and primary-care settings should be promoted.
  • A Medicaid prospective payment system for community behavioral- health clinics should meet high standards of care and  coordinate and deliver both primary care and behavioral-health services to their patients.
  • That patient-centered care should especially be encouraged when chronic disease evolves into serious or advanced illness.
  • Palliative-care options should always be available  and made known to patients.

For the whole report, hit this link.

Feds fine insurance startup for misleading marketing


Barker at Vermont State Fair, 1941.

Federal regulators have fined Clover Health $106,095 for misleading consumers about their out-of-network benefits.

Clover Health sells Medicare Advantage products in New Jersey. The health- insurance startup provides enrollees with out-of-network benefits and lets them pay nothing for monthly premiums, co-payments and generic prescriptions.

Becker’s Hospital Review reported that CMS says that Clover’s  marketing misled potential enrollees about their ability “to always receive covered services from any out-of-network provider. The regulators said that the materials incorrectly stated that out-of-network providers participating in the Medicare program had  to accept Clover enrollees.”

For the full story from Becker’s Hospital Review, read this link.

The most alluring ACO model

In this HealthAffairs post, the authors argue that today’s most attractive national Accountable Care Organization model is offered by CMS.

They write:

“Fortunately, CMS heard the complaints about early MSSP  {Medicare Shared Savings Program} models and addressed the majority of them through the progressive structure of the Next Gen {of ACOs} model. In fact, the core difference between MSSP Track 1 and the current Next Gen model is that the latter is based upon extensive feedback from health systems regarding their concerns about MSSP Track 1.

“Next Gen is therefore a program that health systems have directly asked for. The model still has room for further improvement — for example, Next Gen ACOs should have access to the full toolkit of benefit- and network-design strategies found in Medicare Advantage and other provider-led offerings. But the CMMI {Center for Medicare & Medicaid Innovation} leadership has pledged to pursue additional features that could take effect in the later years of the Next Gen model, and will continue the virtuous cycle of improvements.”

Centene completes Health Net purchase


Centene has completed its  $6 billlion acquisition of Health Net, creating the largest Medicaid managed-care organization.  California regulators’ approval of the deal paved the way for the transaction to close.

The acquisition expands Centene’s government products to include Medicare Advantage and contracts with Department of Defense and the Veterans Administration,  as well as expanding its role in the health-insurance marketplaces. The integrated company will be insuring more than 10 million members.

The Department of Justice and some state insurance departments are still reviewing Aetna’s acquisition of Humana as well as  Anthem’s  purchase of Cigna.

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