At the end of a recent phone conversation with a female patient in her 70s, she told me how grateful she was for my advice. When I first saw her several months ago after a serious heart attack, I had encouraged her to complete a cardiac rehabilitation program.

Why was she so grateful that she had gone to the rehabilitation program? She now felt much stronger and understood her heart condition better. Cardiac rehabilitation programs are designed to help patients recover from heart attacks and other cardiac events, to improve their overall understanding of their condition, and to encourage behavior that will keep them healthy.

These programs have many different components, including baseline patient assessment, dietary counseling, risk factor management (blood pressure, etc.), psychosocial and vocational counseling, and encouragement in physical activity.

Cardiac rehabilitation programs are of proven value. Research shows that patients who complete 30 to 36 cardiac rehabilitation sessions over 10 to 12 weeks after a heart attack are more likely to take lifesaving medications over the following three years, less likely to be hospitalized within the next year, and more likely to survive for the next one, five and 10 years.

Cardiac rehabilitation programs are generally recommended for patients after heart attacks, coronary artery stenting, and coronary artery bypass grafting.

The Centers for Medicare and Medicaid Services (CMS) recognizes the value of these programs and previously reimbursed for them. Unfortunately, on Oct. 1, CMS began a bundled payment program that will reduce the availability of these programs, and thereby cost thousands of lives. As a practicing cardiologist for the past 37 years, I am trying to draw attention to this serious mistake.

Cardiac rehabilitation programs are already underutilized. Participation rates are as low as 10 to 20 percent in some states. In December 2016, CMS announced an incentive program to encourage the enrollment of Medicare patients in cardiac rehabilitation programs, but then canceled it in August 2017.

In January 2018, CMS announced a new advanced program of bundled payments, which includes the inpatient diagnoses of heart attack, coronary stenting and coronary artery bypass surgery. The program includes several quality measures that will be used to adjust hospital payment. These measures do not include cardiac rehabilitation programs.

The last quality measure in the incentive program ends 30 days after a heart event (such as a heart attack), when cardiac rehabilitation programs will usually be underway but less than 50 percent complete. There is no measurement of quality beyond 30 days after a heart event. In contrast, the bundled payment program measures costs for 90 days and rewards hospitals that reduce costs.

Cardiac rehabilitation programs will contribute to 90-day costs, but their value will not be measured.

The 832 acute care hospitals participating in the program will now have a financial incentive to reduce costs by scaling back, or closing, cardiac rehabilitation programs. This new bundled payment program will reduce access to, and participation in, cardiac rehabilitation programs, and thereby cost many lives.

CMS is trying to reform the payment system to pay for value, but will decrease the use of high-value cardiac rehabilitation programs. Many lives are at stake. Using national survey data that estimated the previous use of lifesaving medications in patients with coronary artery disease at only 25 to 30 percent, the Centers for Disease Control and Prevention reported that these medications saved 35,900 lives per year in 2000. Cardiac rehabilitation programs can increase the usage of lifesaving medications to 50 percent, and thereby save another 20,000 to 30,000 lives per year.An even greater number of hospitalizations can be prevented every year.

I urge Health and Human Services Secretary Alex Azar and CMS Director Seema Verma to correct this error as soon as possible.


Raymond J. Gibbons is a staff cardiologist at the Mayo Clinic in Rochester, past president of the American Heart Association and past member of the board of trustees of the American College of Cardiology. The opinions expressed here are solely his own.