American Heart Association President Steven Houser, Ph.D., FAHA issued the following comments on the Centers for Medicare and Medicaid Services’ (CMS) Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) final rule:

“Cardiac rehabilitation (CR) can greatly improve the health outcomes and lives of patients suffering from cardiovascular disease, but it’s benefits are largely untapped. That’s why we are extremely pleased that this final rule will help more Americans attain the high quality, evidence-based care they deserve. We urge the new administration to move forward with this demonstration program to help identify and remove barriers to this life-saving service. 

The treatment gap for CR and Intensive Cardiac Rehabilitation (ICR) is enormous. In 2013, only 20 percent of Medicare beneficiaries initiated cardiac rehabilitation. Rates were even lower for women and minorities. Barriers that stand in the way of CR utilization typically include low referral rates, financial burdens due to co-insurance and lost work, lack of accessible sites and the Medicare requirement for physician supervision of CR. Fortunately, an incentive for CR programs to remove many of these barriers and improve coordination across care settings is provided by the demonstration program. The savings associated with reduced rates of readmissions related to subsequent cardiac events may even offset the costs of these incentives, which makes the demo a win-win for patients and taxpayers.

We are disappointed, however, that the waiver of the Medicare requirement for physician supervision was not site specific. Requiring a physician to be immediately available at all times can create unnecessary costs and severely limit the program expansion into rural and underserved areas where there is often a shortage of physicians. We understand that by law, waivers could only be applied to patients participating in the demo program. Therefore, we will continue to advocate for legislation that would allow physician assistants, nurse practitioners and clinical nurse specialist to supervise cardiac rehabilitation on a daily basis – provided that the requirement for medical direction of these programs is preserved. 

The AHA is pleased that the final rule broadened the incentives programs. Thanks to this, beneficiaries in fee-for-service Medicare could have more incentives to participate beyond help with transportation. In particular, we support items or services involving technology, which can track and motivate patients when they are not at a CR Center.   

The AHA recognizes and supports the movement towards value‐based payment and the role models, such as care bundles, can play in achieving our ultimate goals for health care. We appreciate the attention CMS paid to the concerns of patient groups, like ours, and its commitment in the final rule to put in place heightened monitoring and evaluation, as well as explore additional risk adjustment methods to protect patients from potential unintended consequences.”