Impact
of health care reform on the management of cardiac rehabilitation programs
CHARLES W. CORTES1
and TOMMY BOONE2
1Program
Administrator, Clinical & Research Programs, Neuromusculoskeletal Institute
& Department of Rehabilitation Medicine, University of Medicine and
Dentistry of New Jersey, School of Osteopathic Medicine, Stratford,
NJ
2Professor
and Chair, Department of Exercise Physiology, The College of St. Scholastica,
Duluth, MN
Introduction
Cardiac rehabilitation professionals
find themselves increasingly drawn into discussions about healthcare reform,
particularly it relates to cost-containment. Driven by dizzying mutations
in medical costs, program directors and staff ponder the disruptive dynamism
of these new reforms. In a short time, the reforms might well be a dynamic
instability in the care and networking of patients with cardiovascular
diseases.
In the United States, cardiovascular
diseases remain the number one cause of death. The reality of these diseases
cannot be ignored. They represent a terrifying and destructive force that
kills more than two out of every five Americans. Seventy million Americans
each year are affected by these diseases, and nearly 1 million Americans
die each year; all at a cost of nearly $120 billion annually (1).
At no time has this enormous growth
of medical costs loomed larger as a social question than now. While healthcare
strategies abound from diverse viewpoints and divergent professional groups,
no one strategy has all the answers to reform the medical-healthcare enterprise.
Yet, total healthcare expenditures have risen from $41 billion in 1965
to $750 billion in 1991
(2) and approximately $800 billion
in 1992 (3). While these data are at best rough estimates
(4),
there is one certainty -- we spent only a tiny percentage of the $800 billion
on prevention (5).
Observers of modern healthcare policy
and management have repeatedly pointed out that we are headed into a major
crisis in healthcare. Not infrequently, these professionals indicate that
the crisis will become apparent during the second half of this decade
(2).
It is a complex story within the healthcare scheme of technological modernization
that has one profound and simple reality! There will not be enough money
to pay for the healthcare costs of this country.
The costs of advances in modern medical
technology and services have been projected between $1.5 to $2.3 trillion
by the year 2000. Despite this increase, is it appropriate within the context
of the declared good by the engaged professionals? Can the leadership in
medicine justify, for example, the spending of $1.7 trillion (not $2.3
trillion) by year 2000 when, in reality, it would mean an increase in healthcare
costs by $1 trillion over a period of 8 years? One can only imagine the
financial burden if the healthcare costs are closer to $2 trillion or some
16% of the Gross National Product by year 2002 (3).
This article is a critical reflection
and exploration of the healthcare industry's commitment to technology and
services that, while having an obvious social importance, have raised some
questions pertaining to cost-effectiveness. Naturally, any discussion of
this topic would result in considerable debate and varied viewpoints. At
its worst, it could cause the reader to disagree with the totality of the
comments. At its best, however, it could cause the reader to reflect and
take responsibility through one's work.
The American Lifestyle, Medical
Cost-Containment Crisis, and Cardiac Rehabilitation
Although the United States is experiencing
a medical care cost crisis, it is the patient who is the significant center
piece of this problem. But, "What can the patient do?" Patients are not
able to pay the costs of medical technology care out-of-pocket even if
they believed that it was worth the expense. Instead, they expect their
insurance to pay for medical care. When it does not, they must reach deeper
in their own pockets.
Understandably, there are no magic
steps to take in simplifying this problem. But, what about the notion that
the individual per se unaided by medicine assumes responsibility for lifestyle
choices? The impetus of which has not been fully realized or clearly understood
even after decades of public consumption, both within the public and medical
sectors.
In a timely article in the BMJ (reference),
Public panels were sequestered to assist government agencies to assign
priorities and dollar limits to a given service. Participants were asked,
"Should CABG be denied to smokers or should smokers be given a lower priority
for CABG versus non-smokers?" The panels concluded that treatment of patients
outside their local county should be strictly limited. The primary concern
was to avoid wasting local resources!
These clinical and moral issues of
whether the patient did it to him- or herself because of a questionable
lifestyle is far from resolved. The medical profession itself is replete
with differing views on many subjects. As an example, the question as to
whether high or low cholesterol is related to the development of coronary
artery disease is met with considerable controversy (6,7).
Barratt and Irwig
(8) concluded "...that cholesterol
testing/treatment as a primary prevention strategy is not justified on
current evidence." Similarly, Ravnskov (9) concludes
that "Lowering serum cholesterol concentrations does not reduce mortality
and is unlikely to prevent coronary heart disease." The author also stated
that "Claims of the opposite are based on preferential citation of supportive
trials."
In light of good common sense, practical
reasoning, and the necessity of professional articulation, it is the responsibility
of all professions not to victimize their clients. So, while most in the
field of healthcare would agree that the practice of moderation is imperative
in all aspects of one's lifestyle, the unanswered questions in medical
science and healthcare leave everyone poised to do a little good and bad.
Rather than disappointing the patient by preaching and/or the presentation
of half-formed answers as to how the one should have lived, a restoration
of trust is necessary and possible by sharing with the patient the challenges
before medicine to find solutions to the nation's healthcare problems.
These problems are part of America's affluence, but not limited to it.
Theoretically, there are simply too
many confounders for a specific disease regardless of the role of negative
behaviors. Obesity, alcoholism, hypertension, inactivity, and lipid disorders
(to mention a few) are a consequence of not one but many factors, some
known and, perhaps, an equal number unknown. Reconceiving lifestyle change
to prevent ill health and disease reveals the importance of multi-variate
thinking. It also expands the idea of a partnership between the patient
and h/her doctor versus victimizing the patient for getting sick
So, when the question is asked, "Who should pay for abuses in one's lifestyle?"
A more logical extension of the earlier statements is everyone should pay,
but why not pay reasonable costs for medical services? Real growth in technologic
advances has raised both quantity and quality of services. Inefficiency,
waste, and inflation have, however, sacrificed these advances in healthcare
for increased doubt and disappointments. Patients are becoming increasingly
detached from the historically embraced patient-doctor relationship.
Maximizing preventative strategies
and visits to the doctor may help avoid undercutting the medical community's
efforts in "marketing" more favorable lifestyles. But where is the incentive
for the patient when their checking accounts have been economized to the
bottom line? Inflation is eating away take-home pay, and they live under
increased pressure to endure the financial costs of day-to-day existence.
House payments, children in college, insurance of all kinds, and the unfortunate
variety of financial accidents; all create an almost unconscious living
with unanswered needs, fears, and problems.
Of course, the aggregate feeling
and/or response of hospital administrators may be summed up in the question,
"Do you know what it cost to run a hospital?" The answer for a significant
portion of society is "no." They do not know, but another question might
be (from the patients' perspective) -- "What about the problems subsumed
within inefficiency?" Quality medical care, technology, and rehabilitation
do not have to be reduced to the economic imbalance that is presently the
case. In short, there is a need: (a) to reorganize basic approaches
to cardiac rehabilitation away from ECG dependent exercise protocols; (b)
to reduce low adherent rates and duplication of services; (c) to allow
and encourage other college educated graduates in less traditional fields
of study (such as exercise physiologists vs. nurses and physical therapists)
to care for patients in the hospital phases of postmyocardial infarction
(Phase I), to supervise low-level treadmill test and exercise rehabilitation
(Phase II), and to oversee reevaluations of patients during maximal symptom-limited
exercise tests and rehabilitation (Phase III); and (d) to optimize the
utilization of technology and rehabilitation equipment (new or otherwise).
Because medical cost is never entirely
separable from having more of the same (i.e., the bigger the better idea),
it is never fully understood. Yet the need faced by cardiac patients is
not more money, a bigger exercise area, or new instrumentation, but rather
a better rehabilitation system. The rehabilitation system for cardiac
patients should have less open-ended funding through indemnity insurance
and fee-for-service reimbursement of doctors and hospitals, and more balance
between actual medical needs and prudent medical practices. There should
be less emphasis on cardiac surgery, and more attention to preventive medicine
and patient education without victimization. There should be less competition
for patients with hospitals promoting their services as a pure business,
and more hospital administrators with their attention focused on patient
needs.
Imagine a system with less advertising
and marketing as standard practice, and more medical personnel who feel
the hurt and pain their patients live with. A system with less need to
build upon itself and less pressure to increase volume of services, and
more CEOs, physicians, and rehabilitative specialists who go to work for
reasons other than the bottom line. A system with less competitive entrepreneurialism
and overexpansion of medical personnel and facilities, and more CEOs, physicians,
and rehabilitative specialists with high ethical standards (10).
In a nation reduced to almost inconceivably
high medical costs, cardiac rehabilitation has just maintained itself.
The original infrastructure has changed from a medically supervised, multidisciplinary
healthcare team of unified professionals consisting of a cardiologist or
other physicians, nurses, psychologists, nutritionists, exercise physiologists,
vocational counselors, and health educators to unsupervised home-based
exercise (not rehabilitation). Thus, in order to "get more for the dollar
invested" -- cardiac rehabilitation directors and others have substituted
an agenda that supports their interests (i.e., the bottom line) while conceivably
offering fewer psychophysiologic and cardiovascular benefits to the patients.
This is not a reflex answer, it is reality. Indeed, this is also the view
stated by Arnold S. Relman, a physician, and a former editor-in-chief of
The New England Journal of Medicine. He fears that the medical profession,
in general, has lost its ethical way with deleterious consequences for
patients and for society as a whole (11).
The most likely trigger for change
will be the erosion of trust in the medical system, in general, and physicians,
in particular. This forecast is reasonably reliable, and who is running
head-on into this system -- the elderly. With increased life expectancy,
there will be changes both in quality of healthcare and costs. First, on
a per capita basis, the elderly average thousands of dollars more of personal
health care expenditures than the younger age groups. Second, the increase
in elderly persons (many of whom are cardiac patients) in the United States
will become the focus for change both ethically (regarding costs) and via
policy (as healthcare balances affluence, poverty, technology, and cost-containment).
Under the present analysis, while
HMOs are justified for the healthy older person, they do little for encouraging
the sick to regain their independence. Physician capitation schedules,
which seems to encourage frugality, may result in the elderly patient being
denied appropriate care. Also, under capitated arrangements or other financial
constraints, the physicians' income will suffer unless reimbursed by fee-for-service
(which may place an excessive burden on the patient). Then, too, implicit
macro budgetary constraints with physicians at the wheel shifts their role
from advocacy to allocation. This shift may create serious philosophical
problems for the healthcare professional.
Thus far the suggestion is that not
everyone receives the same quality of care. Attempts to modify this outcome
or fix blame are obvious, but generally complicated by the inertia of the
healthcare system and decades of increases in cost of hospital care as
a direct function of unnecessary use of medical technology.
The Delivering of Cardiac Rehabilitation
Services
Although cardiac rehabilitation services
are typically defined as comprehensive and long-term programs
(12),
the description does not recognize the limitations inherent in minimally
supervised or unsupervised settings. First of all, the home program (which
may use transtelephonic technology) is not comprehensive or long-term.
Whether this delivery model lessens the risk of future coronary events,
controls coronary artery disease symptoms, or optimizes long-term compliance
is not known. For certain, if the well-known combination of multi-intervention
strategies as previously conceived and used by rehabilitative specialists
are not put into practice in a disciplined and requisite manner, then the
home program can not be considered (by definition) cardiac rehabilitation.
The service is, therefore, a very expensive series of exercise sessions
that happen to be covered for a brief period by insurance!
On the other hand, the non-equipment
based, medically supervised cardiac rehabilitation model (such as Phases
III or IV) is not covered by many third-party carriers. The resulting effect
is that many physicians appear disinterested and do not refer their patients
to formal supervised programs in the post-hospital phase either because
of the economic dis-incentive or because they are not a pivotal part of
the rehabilitative process. Moreover, this delivery model is labor intensive
as witnessed by the lower ratio of patients to staff. Without a large pool
of patients, program administrators and others are forced to consider alternative
rehabilitative models.
The third alternate approach is the
exercise rehabilitation program with continuous ECG monitoring. Currently,
ECG monitoring is recommended for high-risk patients and any patient who
has problems during exercise. The duration of the exercise sessions is
usually 12 weeks or 36 sessions. These cardiac patients undergo a systematic
evaluation including a history and a physical examination, an entry stress
test, and frequently an exit stress test. The patients' insurance is billed
for each service including the 12 weeks of monitoring and for all visits
by and to physicians associated with the program for assessment of change
in symptomatology.
While cardiac rehabilitation intervention
is covered by some HMOs, the financial administrator in clinics not covered
must determine what is paid per individual per insurance company. The obvious
problem and cry for help, from a program director's viewpoint, is the challenge
to recover hospital and/or program expenses for patient education and counseling.
Unfortunately, though, the use of biobehavioral interventions extract a
toll. Insurance companies do not generally reimburse the program for education
services rendered to their patients. Hence the reason for increased emphasis
on exercise rehabilitation, and particularly exercise in the unsupervised
setting. Of equal significance, again, is the attention given to less than
the desired total rehabilitation of the cardiac patient.
Cardiac Rehabilitation and Future
Options?
What lies ahead for cardiac rehabilitation
is admittedly anyone's guess. It seems clear that it has reached some level
of significance within the healthcare system. Whether this means that it
will continue to take shape for a better footing and that these shapes
and adjustments will benefit the cardiac patient remains uncertain. What
is apparent to many cardiac rehabilitation specialists is that the present
delivery services are less than desirable. There is a negative side to
implementing exercise rehabilitative sessions without medical supervision.
If coronary artery disease is not cured by exercise, which it is not, then
exercise with this disease can certainly predispose the patient to a life-threatening
crisis. This logic, although not agreed upon by many contemporary specialist
in the field, extends across the spectrum of cardiac patients (whether
low, moderate, or high risk for cardiovascular complications).
There is also a negative side to
paying the high charges for exercise sessions (either with or without ECG
monitoring). These rising costs represent the most logical means by which
program directors waste little time in increasing their revenue. However,
if the charges continue to rise without serious documentation of need or
the likelihood of meeting the program outcomes, one could expect these
services to be gradually reduced in the years to come.
In summary, we are convinced that
it is not right to put the cardiac patient at risk (however slight, such
as during unsupervised exercise) just because insurance carriers will pay
for the sessions. We also disagree with the notion that any health professional
is adequately educated to provide care during the design and implementation
of the exercise prescription (as exercise physiologists are trained). Clearly,
while some gains in cardiac rehabilitation are obvious, the subtle but
definite changes from proven standards and protocols appear to put the
welfare of the patients at risk. In light of these remarks, it seems apparent
that cardiac rehabilitation specialists should re-evaluate the concept
of "quality care." These specialists should also collect and analyze data
of all unsupervised patients and correlate risks against costs. Above all,
new developments in cardiac rehabilitation, particularly exercise rehabilitation,
must be adequately and scientifically researched before financial incentives
takes precedent over patients' safety.
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American
Society of Exercise Physiologists
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