WHY SETTLE FOR SURVIVAL WHEN YOU CAN SOAR!

1. WHY SETTLE FOR SURVIVAL WHEN YOU CAN SOAR! Karen Lui, RN, MS, FAACVPR GRQ Consulting, LLC karen@GRQConsulting.com 770-531-9298 OSCVPR October, 24 2009

2. DISCLAIMER I have nothing profound to say.

3. SUBTITLE:“NUGGETS AND DUDS” Many ideas grow better when transplanted into another mind than in the one where they sprang up. Oliver Wendell Holmes, Jr.

4. Introspective Questions to Ask Your Staff and Yourself • 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?

5. CR Budget-Historical Glance 1970’s • Patients 80 Payroll RNs(2)$35,000 • Sessions72 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

6. CR Budget-Historical Glance 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

7. PR-Historical Glance • 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.

8. Budget Today • 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

9. Use of CR by State Suaya et al. Circulation 2007; 116(15): 1653-62

10. Underutilization of Cardiac Rehabilitation • 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.

11. Underutilization of Cardiac Rehabilitation 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

12. Why is Cardiac Rehabilitation Underused? • 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

13. Why is Cardiac Rehabilitation Underused? • 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

14. Why is Cardiac Rehabilitation Underused? 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

15. Strategies • 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)

16. Strategies • 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 issues 2. Awaiting test results or MD response

17. Strategies • 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

18. Strategies • 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

19. Strategies • 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

20. Strategies • 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!”

21. Strategies • 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

22. Strategies • 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

23. Strategies Seek to do something that others can’t do, won’t do, or haven’t even thought of doing! Barb Fagan, FAACVPR

24. Strategies • 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

25. Strategies • 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

28. CR Performance Measures • 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)

29. 38 JACC 2007;50:1400-33.

30. 39 JACC 2007;50:1400-33.

32. Performance Measures • 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?

33. Performance Measures Physician Quality Reporting Initiative (Congress) Physician Voluntary Reporting Program (CMS) Pay for Performance (P4P) Value-Based Purchasing (VBP)

34. Performance Measures • 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?

35. Performance Measures Examples of CMS Quality Measures • CAD • Lipid profile done • Antiplatelettx • MI • Asa within 24 hours of ER arrival • DM • LDL in control • HTN in control • CABG • Lipid mngmnt & counseling @ hosp DC • BB • COPD • Spirometry done • Bronchodilator for FEV1 < 70%

36. Focus on Care Transitions 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?

37. Focus on Care Transitions 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

38. Focus on Care Transitions 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.

39. Focus on Care Transitions 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 attended Shah 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.

40. Risk Stratification Stratification of risk for events during exercise vs Stratification of risk for progression of disease

41. Risk Stratification 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

42. Risk Stratification 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

43. Risk Stratification Result: • Overestimation of functional capacity • Consequent Private Payer “risk stratification”

44. New Approach-Better Outcomes Patient-Centered Outcomes Ades 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

45. New Approach-Better Outcomes 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)

46. New Approach-Better Outcomes 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%

47. New Approach-Better Outcomes 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

48. New Approach-Better Outcomes 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

49. In Summary • 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.

50. Preparing for Your Program’s Future • 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…