The health care costs associated with this condition totaled an estimated $475.3 billion in 2009 (American Heart Association). Reducing atherosclerosis — a buildup of fat deposits, cholesterol, and other substances in the arteries that can block blood flow and lead to heart attacks and strokes — is the objective of treatment, which can be accomplished via medication, diet and exercise and interventional technologies such as coronary stenting or coronary bypass surgery.
Several studies by Philip Ades, M.D., University of Vermont professor of medicine and director of cardiac rehabilitation and prevention, and colleagues demonstrate that future cardiac events, as well as costs, can be greatly reduced if a patient participates in a rehabilitation program. Cardiac rehabilitation programs teach patients how to make lifestyle changes, including physical activity, diet, and exercise training, under the supervision of cardiac exercise specialists. However, there are potential obstacles to ensuring that a cardiac patient has access to this type of preventive care. Among them is insurance reimbursement.
“We are in the midst of an obesity epidemic due in part to extremely low physical activity levels, which has resulted in an epidemic of type 2 diabetes and higher rates of coronary heart disease,” says Ades. “While we can treat high cholesterol, diabetes and high blood pressure with pills, a lifestyle disease demands a lifestyle solution and benefits of diet and exercise are well demonstrated. Some medical insurance companies have recognized the importance of lifestyle and are pushing prevention not only with their words, but with their pocketbooks.”
In 2006, Medicare expanded coverage for preventive cardiac rehabilitation programs to include coronary stent recipients in addition to heart attack patients. Currently, Medicare Part B covers 80 percent of outpatient cardiac rehabilitation programs for older cardiac patients. Nearly a year ago, BlueCross BlueShield of Vermont announced it was doubling coverage for cardiac rehabilitation sessions — from 18 to 36 — and instituting a new program to educate patients and encourage participation. The company’s decision was based on a three-year analysis of internal data, which found that 87 percent of members with heart disease who completed the recommended number of cardiac rehab sessions did not suffer another cardiac event.
The coronary stent device industry has experienced a real financial boon in the past decade. While many lives have been saved by these devices, the costs are high and the success of these stents has overshadowed the value of the lower-tech cardiac rehabilitation program and can deter patients from making necessary lifestyle changes to prevent another cardiac event. Whereas UVM/Fletcher Allen Health Care cardiologists regularly refer most patients to Ades’ cardiac rehab program, Ades’ colleague Daniel Forman, M.D., director of cardiac rehabilitation at the Brigham and Women’s Hospital in nearby Boston finds that his area hospitals are less likely to refer patients to cardiac rehab and tend to prefer what he and Ades describe as “expensive, high-tech procedures that garner prestige and immediate profit in a fee-for-service healthcare model.”
“With the coming national focus on health care costs and an emphasis on prevention over expensive medical procedures, I feel that cardiac rehab programs are optimally positioned for a steady growth spurt,” says Ades. In the future, adds Ades, he hopes and expects referring appropriate patients to cardiac rehabilitation will be considered as a “quality indicator,” where medical centers will be graded on their cardiac rehab referral rates . This is currently the case for preventive medication use and smoking cessation efforts in patients with coronary heart disease.
Ades and Forman co-wrote a post on this topic for WBUR public radio’s “Commonhealth” blog3 last fall. The January 11, 2010 issue of the Boston Globe features an article4 on the benefits of cardiac rehabilitation, with quotes from Ades and Forman, as well.