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April 4, 2014

Why Medicare changed its policy for heart failure patients

Daily Briefing

After nearly a decade of debate, Medicare officials have decided to extend coverage for cardiac rehabilitation, removing a barrier for heart failure patients that has long barred them from exercise and counseling programs shown to vastly improve outcomes and prolong life, the Wall Street Journal's Ron Winslow reports.

About 6.5 million Americans live with heart failure, a chronic condition in which the heart cannot pump enough blood to meet the body's need for oxygen, and another 650,000 new cases are diagnosed each year, according to the American Heart Association (AHA).

The condition is among medicine's most debilitating and costly diseases, and although Medicare has long covered rehab for heart attack and heart surgery patients, the growing population of heart failure patients has largely been excluded from rehab programs. An estimated 17% of the 42 million Medicare beneficiaries have a heart failure diagnosis and account for about 800,000 hospital admissions annually.

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The turning point

Medicare was persuaded to reverse its policy after viewing the results of a 2,300-patient study called HF-Faction, published five years ago. The study found that three weekly exercise sessions over three months were associated with an 11% decline in mortality and hospitalizations among patients with heart failure.

According to Winslow, Medicare officials were swayed by the quality of the study, the benefit of a doctor-supervised exercise program, and patient counseling to guide lifestyle changes. "When you look at the big picture, it was a positive step forward" to extend coverage, says Tamara Syrek-Jensen, acting director for the coverage and analysis group at CMS.

Previously, patients and doctors were skeptical that it would be wise for patients with heart failure to engage in strenuous exercise. However, the "safety in the HF-Action trial was very significant," says Nancy Houston Miller, associate director of the Stanford Cardiac Rehabilitation Program and an investigator on the study.

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Will patients benefit?

The Medicare decision extends coverage to patients whose heart-pumping function has declined to a certain point and those who have certain symptoms despite receiving drug therapy for at least six weeks. The coverage pays for one course of 36 sessions for up to 36 weeks, with options for two- or three-per-week sessions. Patients may apply for a second course of rehab, but often this would be paid out of pocket.

Overall, about 50% of patients with chronic heart failure will be affected by the new policy, the Journal notes. Nonetheless, experts voiced concern that patients, many of whom are sicker and frailer than patients currently enrolled in cardiac-rehab programs, will be reluctant to sign on.

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"They have low confidence in what they can do physically," says Randal Thomas, preventive cardiologist at the Mayo Clinic, adding, "To convince people they can benefit is going to be a bit of a challenge."

Doctors say the trigger point for many patients likely will be their first hospital admissions for heart failure. The admission will open the door to a discussion about an exercise programs after six weeks on medication, they note.

The first episode "is your teachable moment," says AHA President Mariell Jessup, a heart failure physician at the University of Pennsylvania. At that time, most patients believe their diagnosis is an inevitable death sentence. "We say, 'you're not going to die. We're going to work on you living," Jessup says (Winslow, Wall Street Journal, 3/31).

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