Why Aren't Clinicians Referring Patients to Cardiac Rehab?

Cate Collings, MD

Heart disease is the leading cause of death for US men and women, but a powerful tool available to help treat and reverse the trajectory of cardiovascular disease remains significantly underutilized and might even be a model of care to treat other chronic diseases.

Traditional cardiac rehabilitation (TCR) and intensive cardiac rehabilitation (ICR) are physician-supervised, team-based, whole person approaches to post–coronary event care. TCR typically involves customized outpatient treatment plans. For a total of 36 sessions, patients participate in physical activity group sessions and education about other lifestyle behaviors, such as diet, stress management, or use of risky substances. ICR goes further by engaging patients for 72 sessions and providing more nutrition guidance, cooking instruction, stress management, and social support. Lifestyle medicine-trained clinicians may favor ICR as a model that aligns with their knowledge of the large role of nutrition and the other pillars of lifestyle medicine at the root of cardiovascular conditions.

Among the many benefits of cardiac rehabilitation are improved myocardial flow reserve, coronary endothelial function, and maximal oxygen uptake as well as reduced post–coronary event depression, weight, blood pressure, and all-cause mortality. It's possible to provide these benefits while also receiving a profitable payer reimbursement to help sustain a medical practice.

Both the American Heart Association and American College of Cardiology recommend cardiac rehabilitation programs for people with certain heart conditions. Qualifying events include coronary artery bypass surgery, heart valve repair or replacement, congestive heart failure, acute myocardial infarction, and chronic stable angina, among other heart conditions. Completing a cardiac rehabilitation program can reduce risk for rehospitalization or death by 25%-50%.

Despite the health benefits and research documenting increased quality of life, reduced healthcare costs, and coverage by Medicare and most commercial payers, utilization rates for cardiovascular rehabilitation are abysmal. As few as 14%-35% of heart attack survivors and about 31% of coronary artery bypass graft surgery patients utilize such programs. Many factors contribute to underutilization, but chief among them is a low referral rate.

Primary care physicians are often unaware of cardiovascular rehabilitation programs in their communities or consider referral to be solely at the discretion of the patient's cardiologist. However, that is not the case. In fact, there are examples of primary care physicians and physician groups establishing successful cardiac rehabilitation programs within their practices or health systems. One of my colleagues, Dr Padmaja Patel, an internal medicine physician and medical director of the Lifestyle Medicine Center at Midland Health in Texas, has done exactly that.

About 30-35 patients participate in Dr Patel's ICR program each day, creating substantial revenue for the practice, as Dr Patel recently shared in a webinar for the American College of Lifestyle Medicine (ACLM). Though obtaining a fair reimbursement for many lifestyle medicine interventions is an ongoing challenge, ICR is not one of them.

Since 2010, Medicare has covered both TCR and ICR, reimbursing 36 sessions per patient for TCR and 72 sessions for ICR. The reimbursement rate has grown from $36 per session in 2010 to $115 per session in 2023. That means that a clinician could be reimbursed $8350 for a patient who completes all 72 ICR sessions. Commercial insurance generally pays at a slightly higher rate.

In Dr Patel's program, patients attend sessions 3 days per week. For example, a patient may exercise and watch an education video on Mondays, exercise and attend a workshop on Wednesdays, and exercise and join a cooking class on Fridays. But this delivery model is flexible and can be tailored to meet the needs of patients and the program site. During COVID-19, Centers for Medicare & Medicaid Services approved virtual cardiac rehabilitation services for reimbursement, expanding patient access, and potentially strengthening program performance.

An important consideration in starting a TCR or ICR program is site neutrality. The Medicare reimbursement for outpatient office-based TCR is significantly lower than is the reimbursement for hospital-based TCR; however, reimbursement for office-based ICR is identical to the hospital-based programs. In this manner, ICR is the option more likely to provide a private physician practice the means to operate a financially sustainable program in an off-campus setting.

Resources exist for those interested in exploring TCR and ICR. The American Association of Cardiovascular and Pulmonary Rehabilitation certifies TCR programs and two turnkey programs, Dr Ornish's Program for Reversing Heart Disease and Pritikin Intensive Cardiac Rehab, provide information for ICR. ACLM has a member interest group dedicated to cardiology that would be a good resource for interested physicians.

Most patients with cardiovascular disease have one or more comorbidities, often leaving clinicians pressed to provide all the lifestyle support that their patients need. Cardiac rehabilitation can accomplish that through a scalable team-based model that can address a variety of other comorbid chronic conditions. ACLM has advocated for expanding ICR to cover two to three cardiac risk factors instead of requiring someone to first suffer a negative cardiac event. Eligible risk factors should include a diagnosis of type 2 diabetes, hypertension, and hyperlipidemia.

Through increased referrals or, better yet, creating financially sustainable ICR programs, primary care physicians can help patients build healthy heart habits to avoid future cardiovascular events as well as improve other diseases that they may have.

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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: Cate Collings. Why Aren't Clinicians Referring Patients to Cardiac Rehab? - Medscape - Mar 21, 2023.