November 17, 2023
6 min read
Table of Contents
- Two bipartisan bills would make authorization for virtual cardiac and pulmonary rehab services permanent.
- Hospital-based virtual cardiac rehab programs shut down when the public health emergency ended in May.
Among the many changes brought by the COVID-19 pandemic was an abrupt switch from in-person to virtual cardiac rehabilitation, a shift that allowed easier access to a service that patients typically struggled to attend, seemingly overnight.
During the COVID-19 public health emergency, CMS temporarily allowed certain cardiac and pulmonary rehab programs to be reimbursed under Medicare when provided or supervised virtually in a patient’s home. The switch was welcomed by patients and providers, but hospitals, which handle 95% of cardiac rehab patients, had to shut down virtual programs after the public health emergency ended in May.
“When CMS allowed for virtual cardiac and pulmonary rehab, that provided a lifeline, flexibility and access to hospitals to deliver this care,” Ed Wu, MD, co-founder and chief medical officer at Recora, a technology company providing virtual cardiac care services, told Healio. “This was a godsend to many recovering from a heart attack, a valve procedure, a bypass procedure. We had many patients tell us that without some other way to participate in cardiac rehab, they would have not done it.”
In October, the U.S. Senate introduced a bipartisan bill that aims to make the authorization for virtual cardiac and pulmonary rehab permanent for Medicare beneficiaries, after a similar bill was introduced in the House. The Sustainable Cardiopulmonary Rehabilitation Services in the Home Act would codify virtual cardiopulmonary rehab flexibilities that were established in response to COVID-19.
Healio spoke with Wu and Dhruv S. Kazi, MD, MSc, MS, associate director of the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, director of the cardiac critical care unit at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School, about how a shift to virtual cardiac rehab changed patient care, what a permanent fix could mean for access and health equity and how clinicians can get involved in supporting the new legislation.
Healio: What happened to cardiac rehab during the COVID-19 pandemic?
Kazi: The first few months of the pandemic were devastating for cardiovascular care in general. Patients were reluctant to seek care and hospitals were not prepared to provide nonurgent care in a safe environment. All of our energy was focused on keeping our ICUs going. There was a precipitous decline — almost to zero — in cardiac rehab during those early months. Then, there was a slow recovery, but it is incomplete. Data though the fall of 2021 show there are cardiac rehab centers that closed and did not reopen. The capacity for cardiac rehab, which was pretty limited before the pandemic, had been further constrained.
Healio: What are some of the inherent advantages of virtual cardiac rehab?
Kazi: With virtual cardiac rehab, eligible patients can complete their cardiac rehab at home with synchronous monitoring. Meaning, someone will dial in and watch the patient perform these exercises, with or without wearable devices. While this does not work for everyone, most patients can safely participate in virtual cardiac rehab or a model with some in-person mixed with some virtual visits.
The value of this is twofold. First, it addresses the supply-side issues. We can get around the constrained capacity for in-person cardiac rehab by means of novel technology to deliver cardiac rehab at home. Second, it addresses demand-side issues. Remember, we are asking patients who have in-person cardiac rehab to drive to your cardiac rehab center three times per week, for 12 weeks, battling traffic and parking. A virtual option makes it so much more convenient for the patient and lowers patient costs. The data suggest that a big part of why patients stopped attending their cardiac rehab appointments was the inconvenience and cost. Virtual cardiac rehab addresses many of these pain points. But it has historically not been supported by our public payors. We are at a crossroads. We have a once-in-a-generation opportunity to expand access to cardiac rehab.
Wu: Many patients do not have transportation. Some, to this day, fear being in congregate settings. Some patients are dependent on caregivers and there are people who may not speak English as their first language and fear going to a hospital. By doing cardiac rehab virtually, it is very easy, for example, for translation services to be patched in.
About 14% of the country is in a cardiac rehab desert and approximately 20% to 40% of people live in a cardiac rehab-challenged area. Studies have demonstrated that among patients who participated in cardiac rehab, there are decreased hospitalizations, decreased ED utilization and decreased mortality rates. Without cardiac rehab, patients may not get the exercise, training and education they need to turn their life around.
Healio: Why did CMS opt to not continue virtual cardiac rehab after the public health emergency ended?
Kazi: Our payors, particularly our public payors, have a huge role to play in influencing the ecosystem. Virtual rehab actually costs money to set up. You have to build a program that requires monitoring patients at home and that requires hospitals to make investments. That only happens when health systems see a long-term, sustainable model for this. Even though there have been really good data for about a decade saying that virtual cardiac rehab can be done and safely executed and it improves adherence, we have not had all the pieces fall into place.
If there is anything good that came out of the pandemic, it is that health care woke up to the fact that we have to provide virtual care and our patients are able to adapt to a virtual care model. A huge investment of time and money went into making virtual platforms possible. This was a bit of a natural experiment — there was a shock to the system and we had to go virtual. Then, in the first 18 to 24 months of the pandemic, we showed that it was possible. Now, we have the proof of concept to show the payors and say that there is no reason to pull the carpet out from under people’s feet when this program is working. We should be expanding it.
Healio: There is now legislation to try and address this. Where does that stand?
Kazi: As a clinician and a researcher, what jumps out to me is that, again, this is a rare historic opportunity to address a huge gap in our health care delivery and have real equity implications. There are bills in the House and the Senate. At some point, they will have to reconcile the two bills. There is bipartisan support for this. For cardiac rehab, what this would do is improve access to cardiac rehab for our Medicare population. That is the access that Congress controls. This is hugely important; at least half of people in cardiac rehab are Medicare beneficiaries, who frequently face access challenges and have unique social and health care needs.
I cannot emphasize enough: There is a difference between saying, “I will drive to Boston for my surgery” and “I will drive to cardiac rehab three times a week for 12 weeks.” For many of our patients with limited access to resources, even taking half a day off work is impossible. You may still have to take an hour off for a virtual session, but you are not layering on 2 hours or more to travel back and forth to a center.
My hope with improving access to virtual rehab is that, at the very least, we can backfill this huge gap we have created and solve this demand/supply problem in cardiac rehab for the long term.
Wu: HR1406 and Senate bill S3021 allow for a resumption of the virtual cardiac and pulmonary rehab that was available during the pandemic. We are not adding anything new; this is doing what we already did and protects that access going forward. Medicare has been all for cardiac rehab access. Their goal is 70% participation; we are currently at a paltry 24% participation rate. There has been momentum with 35 co-sponsors on the House bill. There continue to be positive discussions around the Senate bill. Beyond that, there are about seven or eight professional societies plus 15 to 20 different health systems supporting this legislation.
Healio: How can clinicians support these efforts?
Kazi: Clinicians, physicians and nurses have always seen themselves as advocates for patients within the health systems. This is a unique opportunity to advocate for an entire population of patients with CVD. Write to your representative, saying you support these two bills. Most of our cardiac and pulmonary professional associations have put their weight behind these initiatives, showing their support. There is no reason to underestimate the amount of work it will take to convert these to law, given how our systems work. But this is the farthest we have ever come in making virtual cardiac rehab positive. We must continue the momentum to bring about a positive change in our patients lives. This would be a small investment from public payors that would create a sustainable improvement in access.
Wu: There are three things. No. 1 is support this legislation by writing your representative. No. 2, part of this is an awareness issue. There is no major course on cardiac rehab in medical school. Create awareness for colleagues and when appropriate, order cardiac rehab for patients. No. 3, be prepared for patient questions on this topic. We are certainly seeing increased awareness among patients. With a shift to virtual, we really can’t put the toothpaste back into the tube. Now we are seeing many people trying to sort out the right things to do, virtually.
For more information:
Dhruv S. Kazi, MD, MSc, MS, can be reached at [email protected].
Kazi reports no relevant financial disclosures. Wu is co-founder and chief medical officer at Recora.