Welcome, everyone, and thank you for joining this Quality Summit Hot Topic session focused on cardiac rehabilitation. I'm so thrilled to welcome Dr. Jerry Blackwell, the President and CEO of MedAxiom. Dr. Blackwell has a deep passion for encouraging physician leadership, teaching, and inspiring team-based care and organizational performance improvement. I'm confident that his passion for this particular topic will be immediately evident to you, and I hope you take a few moments to become better acquainted with him by reading his impressive bio. Now let's get started. Dr. Blackwell? Hi, folks. Jerry Blackwell from MedAxiom. It's a pleasure to be here at the Quality Summit, and I'm going to be talking about cardiac rehab. The title talks about rehab in the inpatient setting and bridging the gap, but I'm going to be talking about the whole spectrum of cardiac rehab. I'm the President and CEO of MedAxiom, an ACC company, and my main disclosure is that MedAxiom has a corporate partnership with Pritikin Intensive Cardiac Rehab. We also have a variety of other industry relationships that could be viewed as tangentially related to this talk. While I have a clear passion that you'll see, it is important that you know MedAxiom has this corporate partnership. So my goal here will be to just give you an overview of cardiac rehab, because it's just so important for our entire community. I'm also going to be talking about indications, who will benefit from participation, what are the major barriers to participation, and then ultimately, hopefully, give us all some strategies for success. I think it's very important that I give you my interface with the cardiac rehab space, and as Connie mentioned in the introduction, I think you'll see my passion for this is obvious, and it comes from seeing cardiac rehab from multiple different perspectives. First of all, I've been a practicing cardiologist for over 30 years, continue to practice, and I've been involved with rehab from a utilitarian point of view. I've also been the practice leader of a large single specialty cardiovascular group, cardiologists, cardiac surgeons, vascular surgeons, where I actually was part of the group that introduced cardiac rehab into our system, and I'll tell you a little bit about that, where we talked about quality and value metrics would be a nice interface for this particular discussion. I have also spent some time in the executive suite of a large health system, our system here, Ballard Health System, where I got to hear and see about cardiac rehab from the executive suite of a health system. I think that's relevant. Then, I think most importantly, here recently, as the president and CEO of Medi-Axiom, I've been able to see cardiac rehab from a business perspective and also the national perspective, because all of this is local and regional, and I'll tell you a little bit more about that. So, here's what cardiac rehab looks like in the hills of Tennessee, where I practice. I live in northeast Tennessee, in Kingsport, the Tri-Cities region. Our practice serves an area of about 9,000 square miles, but a population of only a million, so it's very, very rural here in northeast Tennessee, southwest Virginia, but we've been in the cardiac rehab business for quite some time, and for the last few years, in intensive cardiac rehab, which I'm going to discuss. This is a standard cardiac rehab setup with exercise. There's an educational component that we'll talk about, and then I know you can't see this clearly on this slide, but what this shows is actually a kitchen with a large monitor and a dietary component to rehab. This is cardiac rehab, again, where I practice every day. So, as I go through this talk, sort of following the old Stephen Covey model here, to begin with the end in mind, I want to focus you on what I really would like for you to take away from this. I'll come back to this. I'll keep saying it more than once, but first and foremost, cardiac rehabilitation is a class one indication for specific groups of patients. You need to be aware that class one indication means it's the most important thing that we can do for patients are class one indications. For instance, aspirin following an MI would be an example of a class one indication. So cardiac rehab is a class one indication for specific groups of patients. Next, the benefits of cardiac rehabilitation approach or exceed those of many standard therapies. So what I'm going to be talking with you about here is clear science. This is not something that's experimental or just up and going. There's very clear science around this. The third thing that I want you to take home from this is cardiac rehabilitation is under subscribed. And if you go back to the first about it being class one indication, if it's under subscribed, what I would contend here, not trying to be dramatic, but I want to be very direct. I would say there's a moral imperative for us as a cardiovascular community to improve subscription to cardiac rehabilitation. There are legitimate resources available. So in other words, you're not in this alone. Many folks can help. There are many resources, but we do need to be creative and disruptive from a business point of view. And I'll talk a little bit about that. And then finally, momentum is developing from multiple sources. The American Heart Association, American College of Cardiology, specialty societies, insurers, industry. There's a confluence of things that are occurring that I think will make rehab easier and better to subscribe to. So those are the things that I want you to take away from this. I think it's important for those, many of you are just getting exposed to this topic for you to hear a little bit about the history of cardiac rehab. And I decided to do it because it's so very brief. This is very simple slide. Early cardiology textbooks don't even mention cardiac rehabilitation. So don't be harsh. At that time, we were still learning what we were treating. So there's not even a mention of rehabilitation. And cardiac rehab really began sort of in the 1950s and 60s. Dwight D. Eisenhower is sort of a poster child in some ways for this, where he had an MI and he was just put to rest, basically. So the initiation of cardiac rehab was originally for the purpose of restoring strength after being sedentary following an MI. So think about that. Cardiac rehab was started for the way we treated the disease, not for the disease itself. In other words, we made folks sedentary. So we said, we need to rehab them for this. It wasn't for the disease itself. So we've come a long way. And the cardiac rehab, even in the most recent edition of one of our Sentinel texts, Brodenwald's Heart Disease, talks about exercise-based comprehensive cardiac rehab, exercise being the focus. Now going from history to evolution, that's the only history side, the evolution is actually quite exciting because we've increased our understanding of cardiovascular pathophysiology. So therefore, there's been an evolution of rehab strategies. Exercise remains key, but what I'm going to be focusing on or spending a lot of time helping to convince you is that it's therapeutic lifestyle changes that now dominate the current approaches, not simply the rehab itself, but the, excuse me, exercise itself, but the therapeutic lifestyle changes. So let's talk about the nomenclature. We have to get on the same page to do this correctly. There are two distinct programs. So when you hear cardiac rehab, there's traditional cardiac rehab, but there's also intensive cardiac rehab. I'll say this over several times. Intensive cardiac rehab is not just cardiac rehab on steroids. It's a completely separate Medicare-approved program that has a focus not only on exercise, but even more of a focus on the therapeutic lifestyle changes. So CR and ICR are two distinct programs. And in addition, there is two other things that you need to know in the nomenclature. First is virtual cardiac rehab, and the next is home-based cardiac rehab. Those actually refer not to the program itself, but to the program delivery and location. So the first two are the distinct programs. The others refer to program delivery and location. So traditional cardiac rehab, called CR here, phase one cardiac rehab occurs in the hospital. Insurance pays for this. Phase two cardiac rehab, which is where the bulk of cardiac rehab occurs, is an outpatient continuation. Insurance likewise pays for that. Lots of variability there, but insurance does pay for it. And then the phase three, which is the maintenance, is a self-pay program. We'll talk briefly about that. And you'll hear this several times. Cardiac rehab traditionally has 36 monitored sessions that occur over the course of a couple of months. This was in the Journal of the American Medical Association a couple of months ago, a patient page about cardiac rehab. Talks about phase one, where they talk about range of motion exercises and just basically getting folks up and about in the hospital setting. The phase two, which is where most of the rehab occurs, is in the early outpatient, low-impact aerobics, and just, again, strength training. And then finally, the late outpatient phase three. My point about this is that there are resources available for patients as well, so that folks can get very comfortable with the nomenclature of cardiac rehab. So it's actually a nice jam of patient page from a couple of months ago. What is cardiac rehab, on the other hand, is this distinct and separate entity from cardiac rehab. It's about 10 years old, roughly, since Medicare approved this program. I'm very interested in this because, actually, our particular institution was, I think, the seventh to adopt a pretty good program nationwide, so I've been involved with this from early in its inception. But there are 72 monitored sessions, and the focus, as I said, is on education and therapeutic lifestyle changes, but very importantly, the intensive cardiac rehab programs tend to focus or include, I should say, family members, significant others, which is very important. So it's not just simply, as they say, giving a man a fish, but teaching a man to fish. So it's about the entire family and education. There's only two programs. You have to be in... There's actually a third one, but these are the two dominant by a very wide margin. The first is the Pritikin program, the other is the Dean Ornish program. Both are outstanding programs, and if you're in intensive cardiac rehab, you must be in one of these two programs. It's not an option to just expand your current cardiac rehab. You have to have the prescribed program or course of cardiac rehab through Pritikin or Ornish, both fantastic. So here, graphically, you see the traditional cardiac rehab, 36 reimbursable sessions. Intensive cardiac rehab has 72 reimbursable sessions. Cardiac rehab is predominantly exercise-based, although education is important, there's no doubt about it. On the intensive cardiac rehab, I would advert that and say exercise is important, but the central component is the education and diet and the involvement of family. So it's a more broad-based exposure. So what are the indications? The indications for cardiac rehab, you can go to the Medicare website and find these out here. The standard ones, MI in the last 12 months, percutaneous intervention, revascularization via surgery, Stabilangina is a legitimate indication for cardiac rehab. If you've had a heart valve repair or replacement, you qualify. The niche group of heart or heart-lung transplant, and importantly, recently approved, is stable chronic heart failure. Now you'll also hear about peripheral arterial disease and exercise, but that is not cardiac rehab. It's a branch of it, if you will. This is supervised exercise therapy, the so-called SET or SET program for PAD. And as I told you, there are class 1 indications for cardiac rehab. These are class 1A indications or 1B indications for those things that I just told you about. I'll keep coming back to that over and over. So it's very important. And you need to know what's the big deal. So why do we talk about it? Well, first of all, it's widely applicable to folks that have cardiovascular disease, been shown to decrease mortality. It reduces symptoms, so it helps from the point of view of quality of life. It reduces nonfatal recurrent myocardial infarction, increases overall exercise capacity, and very important, as I said, this sense of well-being. It does that in a very cost-effective way, and germane to this quality talk, NCDR accreditation, as you guys know, everybody, this is the choir on this particular presentation, quality matters. So it's a quality issue, and what I hope to convince you, it's in a value-based world, this is actually can be something that is revenue positive, which is important to keep programs sustained. So here is one of these slides that I'd like for you to take home. This is a slide that was put together, and Frank Smith and the group at Michigan Heart allowed me to steal this, but this is just a compilation of things, of treatment benefits after a cardiac event, whether it's an MI, STAT, bypass, angina, and if you look at the first four indications there, look on the right-hand side of the slide, you have aspirin, you have beta blockers, you have statin therapy, ACE inhibitor, everybody on this call understands how important aspirin use after these events is, 95% plus, every single person on this presentation in their program has some sort of performance measurement and way to prove that patients are getting aspirin after discharge, beta blockers, statins, ACE inhibitors. But I want you to go down to the fifth one, letter E here, and that is cardiac rehab. What you'll see is that the relative risk reduction is actually greater than all of these other things that none of us would for a second consider not using. The side effect profile is basically zero, just the inconvenience of getting there, yet it's used in somewhere in the range of 20% or less of folks at discharge. So cardiac rehab is both highly effective and under-prescribed, that's a problem. And another way to look at this is treatment benefits after a cardiac event, again, everybody gets anti-platelets, ACE inhibitors, statins, beta blockers, yet if you look at this, actually on the bottom of the slide, the number there, that's the so-called NNT or number needed to treat, you only have to treat 37 patients with cardiac rehab to prevent an event. That's a far better profile than we see with all of these other indications. So cardiac rehab, as I said earlier, I believe it's a moral imperative that we improve the subscription to cardiac rehab. So what would be the elements of a good program? Well, as in everything that is related to good medicine, from my point of view, it has to be patient-centric. It has to be something that can be accessed conveniently, the environment needs to be friendly, and at the center of whatever you do in your program, the patient should be at the center if you want it to be an elite program. There need to be physician champions, without physician champions, it doesn't happen. It also has to have non-physician champions, we'll come back to that. It needs to be data-driven, so that you can support the program and prove, show its effectiveness, which will cause increased subscription, again, administration needs to be involved, the team-based dietitians, exercise, social components, advanced practice providers, and then finally, there needs to be expert coding and billing, because there's some nuance to this that can help make your program financially viable. So those are the general elements of a good program. You don't have to memorize them, you'll have the slides here to take a look at. So if it's so good, what's the problem? What are the barriers? I'm going to spend some time talking about those, but the most important barrier in many ways is lack of provider referral. In other words, there's not enough passion inside the cardiovascular community for the providers to say, hey, you got to get going on this, and there are several reasons why that's the case, but absent a physician champion, it doesn't happen. That's just all there is to it. Weak endorsement by the provider, even if they refer, if it's a weak endorsement, patients pick up on that very quickly. The third bullet here on the availability of rehab programs is very important for folks to think about because there's been some data that says that if every person that was eligible were all of a sudden sent to cardiac rehab, that we wouldn't have nearly enough rehab space to accommodate them. Well, I believe that's something that we can correct. But the bottom line is we need to further increase the number of programs and the subscription to them. The fourth thing is important for patients that are actively working. It can be very difficult to go. I'll come back to that in a little bit. But we need to again get back to patient centricity. We need to set up these programs so that accommodates patients that are actually working or that would need to come at different times. Perhaps copayments insurers pay for this, but copayments are highly variable and those could be a big disincentive to patients, particularly when there's variability from insurer to insurer. It can be hard for programs to understand who's paying for what. And there are a variety of others, but those are the biggies and I'll show you some more firm data on those. So here's a little bit of the science behind it. In 2018, the ECCA clinical performance and quality measures for cardiac rehab were published. So again, relevant to this talk with NCDR and accreditation and quality in general, there are very specific performance and quality measures. And there were nine total. At the top are the so-called performance measures. These are things that have been shown to be effective and actually can be part of pay for performance programs and actually are known to be things that improve both quality and the outcome for patients. And you see the list here, there's six different things that relate to referral and inpatient setting for several indications, including heart failure. And then we go to the quality measures. And the quality measures are those things that can be viewed as part of a quality program and getting up and going, but they haven't yet ascended to being appropriate for pay for performance or sort of the more sophisticated subscription. But the point that I'm making in this slide, again, I know it's a busy slide, but for your reference is that you know that for programs across the country, there are specific endorsed quality measures and performance measures that matter in cardiac rehab. The references listed here on the slide. And then as we transition to a little more clinical part of the talk, I want you to be very familiar, again, most folks on this presentation will know, but I want to remind folks of the Million Hearts program and specifically the Million Hearts Cardiac Rehab Collaborative. And my view of this is it's turning talk into action. The Million Hearts has a specific goal of reducing cardiovascular morbidity and mortality with specific timelines related to it. And cardiac rehab has been taken on as one of those things that's very important, truly turning talk into action. There are resources related to this. Again, this slide is busy, but it talks about benefits and referral. And I'm going to give you several things that you can consider from the Million Hearts, but they've just done a beautiful job from my point of view. If you're going to read one article, this is the one that I would point you to from Mayo Clinic Proceedings. I couldn't stop from the great philosopher Yogi Berra having a quote there that many of you will have heard. And that is, if you don't know where you're going, you'll end up someplace else. Well, the Million Hearts Collaborative has come up with a roadmap and the roadmap has a very specific goal in mind. And that is to take cardiac rehab participation from the dismal, roughly 20%, all the way up to 70%. Now this was published in 2017. So we're getting close to the five-year mark and we're not there yet, that's for sure. But if you were going to read one article, this is the one that I would encourage you to do because they do a beautiful job of both outlining the problem and importantly, talking about specific solutions. And they have a beautiful graphic that goes along with that that's on this slide here, which is the Million Hearts Initiative, the roadmap here, I think it's very cute. But there are three things to think about. The first is cardiac rehab referral. If you don't refer patients, the global view, if you don't refer folks to cardiac rehab, it ain't going to happen. That's for sure. So there are many things that we can do related to the electronic health record, other ways to grease that pathway. So it starts, the road starts with cardiac rehab referral for appropriate patients. But the referral isn't what actually helps folks, it's actually the enrollment. So after you refer folks, there has to be a very intentional mechanism to get the folks actually enrolled for their participation. And there are a variety of techniques that we can use for this. This article highlights several of them. But there has to be staff liaisons. And there have to be ways to actually engage folks in the enrollment. And then further along the pathway, the most important thing is not referral. Second most important is enrollment. But the key is participation, because there's good data that says that the further you get along the program, if you actually complete the program, you get maximum benefit. So we need to get folks referred, we need to get them enrolled, and then we need to get them to adhere to the program. And the adherence actually becomes good if you have solid programs staffed appropriately, and physician and non-physician champions. I'll give you some examples. Here's another important reference, I think this comes from circulation cardiovascular quality and outcomes just published actually, in the last year. And it talks about participation rates to, again, go back to what we talked about on this roadmap, referral and enrollment being important, but the participation key. If you go back five years ago in 2016, only one fourth, that number keeps coming up sort of roughly 20%. And this is only Medicare fee for service beneficiaries that were eligible for outpatient cardiac rehab participate. Think about that one in four. But of those participants, only one in four of them were initiated early, the earlier you do it, the more important, and less than or again, about a quarter completed a full course of sessions. So it's a very small number of folks that actually maximally benefit. They estimate over 7 million missed opportunities. This has huge financial implications. My point is there's lots of work to do. This is another very important article for folks to take a look at. This slide actually is a graphic from that article. And the breakpoint here is at 50%. Nowhere do we get up to 50%. And the vast majority of folks, whether it's men or women, non whites, Hispanics, Asians, actually even do worse. So there's very important work for us to do for inclusion in cardiac rehab, but nobody does well. A good thing, though, is the specialty societies are starting to join the fray. Cardiac rehab for patients with heart failure has now been fully endorsed exercise used has always been recommended. Now, full cardiac rehab is recommended as a class two a indication for patients with heart failure. And I think the involvement and engagement of special specialty societies may help us. Again, my point here is just for you to review these, perhaps after the talk for those of you that are particularly interested. This is a cardiac rehab for patients with heart failure, the article I just showed you. And it goes through the various ways that cardiac rehab helps from the point of view of exercises we talk about. It talks about peripheral adaptation, where cardiac rehab can help neuro humoral improvements, psychosocial improvements, there's a whole litany of things that benefit patients with heart failure. And again, from this article, the it goes through the patient and family, the team based aspect of this, the cardiac rehab team and healthcare team, and then for transitions of care, all of those relevant. My point is not to baffle you with these slides, but for you to understand there's very clear ways for you to get up to speed in the cardiac rehab process through these various resources. And then finally, on the technical aspect, coding and billing cardiac rehab has to be implemented strategically, the location where cardiac rehab occurs matters, I'll talk to you about that cardiac rehab and intensive cardiac rehab are billed differently. And there's important nuance, you need to have somebody that knows what they're doing so that you can support your cardiac rehab program. This is from our MedAxiom coding and billing team led by Nicole Knight. And there's two variables. First is the service location is in the hospital outpatient department, or the physician office. And then how is it paid? Is it paid through the outpatient perspective, payment system or physician fee schedule. My goal here is not to, to baffle you with all the finance of this. But the colloquialism of no margin, no mission, if you have cardiac rehab, that is not billed appropriately. It can be a loss leader, and it shouldn't be that. Here's a key take home from this, though, to tell you the big difference. If you look at just traditional cardiac rehab, that's done if it's done in a physician office, get paid about 20-25 bucks maximum per session. Many programs can't break even with that. If you do this in an outpatient department and bill this to the outpatient perspective payment system, there's a fivefold increase per session. So there's nuance to this. And there are people that can help you to understand you see that's a huge difference between those two. There's a big difference between cardiac rehab and intensive cardiac rehab. But the payment for ICR is comparable in both locations, the physician office and the hospital outpatient department. And there's, as you know, the public health emergency, there are waivers in place for this. This is not the purpose of this talk, but I wanted you to know those resources are available for you. So I'm going to wind this up with just a whirlwind of not just the national data, but some data that literally that we're just getting into into people's hands right now for some cardiac rehab data from our MedAxium community. It has about 450 organizations across the country, roughly 12,000 members and mostly, again, large, sophisticated organizations, academic, non-academic, and also many small organizations. So we actually touch the nation in multiple different spots. Ginger Beesbrock, our Executive Vice President of Care Transformations led this initiative, but there have been many other folks involved, Sean Smith from IT, Taylor Jessinger has helped, there are a variety of folks that folks that have helped. And I want to show you what it looks like inside our MedAxium database. So very quickly, my goal here, again, is not for you to get every detail of this, but to see there are data available. We had 72 programs that responded, about 90 plus, 93% were hospital based, 7% were office based. All across the country, the demographics, the number of physicians that you can see here, most of the programs had one to 10 docs involved, 86% were employed, 14% were independent. Again, folks, you don't need to study these, I just want to give you a flavor for what we see here. As we look across the country, at cardiac rehab, not just the inpatient setting, but the phase two cardiac rehab where most of this work takes place. If you look across the country, 90% of programs offer traditional cardiac rehab and only 10% offer intensive cardiac rehab. I will tell you, I think that's likely to change going forward. And I think that it would be a good thing if it could change because of the focus on therapeutic lifestyle and longer term improvement, as I told you, both for the patient and involving the family. The other side of the slide shows what is the average number of sessions completed and unfortunately, whether it's ICR or CR, cardiac rehab or intensive cardiac rehab, most of the time, it's less than 50%. Oftentimes, I shouldn't say most, oftentimes, it's less than 50% or less completion. This is just a slide that talks about full time equivalent positions in programs across the country. Almost everybody has a nurse, 90%. There's respiratory therapists, dietitians, exercise physiologists, life coaches are employed in some large, sophisticated organizations, the clinical and office staff, and then the catch all term of other. So there are staff very differently across the country. And I think we need to try to see if we can come up with ways to make this more standardized. Again, you don't need to memorize this, but what you'll see, or what we're showing here is that in our MedAxium database, the traditional cardiac rehabilitation visits with a denominator of full time equivalents in the organization. So these are the annual visits based or compared to staffing. And likewise, for ICR, the absolute numbers are not as important as the concept here. What about the administrative oversight, the executive position? Who is responsible for the program? What our database shows is that about a third of the time, a little bit more than that, the executive position, who is the executive responsible for the program is in operations. It can be nursing, it can be CV leadership, clinical leadership, but it's usually an operational person. And then how much time do they spend as part of the program? What our data shows is that it ranges from roughly 40 hours per month, down to, excuse me, I'm sorry, 43% here, less than 10 hours per month for program medical directors, and a small number of programs, the medical director commits over 30 hours per month to this. So you see, there's a wide splay. And I would say that we need to narrow that gap. What about virtual cardiac rehab in the area of COVID? That's starting to increase. 87% offer virtual cardiac rehab now that would have been a much lower number before COVID. And of those that aren't doing it, over half really hope to, or excuse me, roughly half hope to have virtual cardiac rehab going forward. So it's catching on across the country for the virtual sessions. And then inside the cardiac rehab, there are some cousins to cardiac rehab. Pulmonary rehab is an important component in many programs, supervised exercise therapy, the SET program we talked about for peripheral artery disease, PAD, both pulmonary and SET. The folks that run cardiac rehab can often do this best, cardio-oncology, telehealth. So there's a variety of services that can be lumped together with cardiac rehab to benefit patients and to make it a better business proposition. And then the American Association of Cardiovascular and Pulmonary Rehab, AACVPR, has certification that's available. So you can know if you're doing the right thing. AACVPR is a wonderful organization. About three-fourths of programs are certified. Unfortunately, that should be 100%, roughly three-fourths, 75%. And then inside those, do the programs collect performance measures? Almost everybody does. We need to increase this further, but I think we're on the right road. And getting to the meat of the revenue part of this, we asked our members, does your cardiac rehab program have a positive net revenue and most do but a shockingly high number either say no or they don't know that that's that's just remarkable for this class one indication uh that there's a significant portion that are either losing money or don't know about it so there there's a better way guys we can do this in the barriers we've talked about uh the most important unfortunately is insurance and co-payment and the the setting and making it available for folks uh the covid restrictions of course are relevant right now but a barrier is physician referral the patient barriers we talked about limited space um the distance to the facility in other words folks that have to drive a long way are less likely to come staffing again you see all of these the um technology care coordination leadership support there are a variety of barriers but the most important ones unfortunately relate to payment for this and the physician uh and provider referral and commitment passion and i couldn't give this talk in uh at this time without at least referring to cardiac rehab in the covid era there's actually data on this this is from the canadian journal of cardiology no real surprises here but it it talks on uh it gives some guidance on implementing in virtual care i wanted you to just have that for your reference so i'll wind this up here in the next couple slides and what what i wanted to say broadly you're being philosophical again i'm passionate about this topic and if we think about one of the things that attracted most of us to cardiovascular care and the specialty is that cardiovascular disease affects everybody and it's a cradle-to-grave proposition but the fact of the matter is is as we go through our life cycle from the cradle to the to the rest in peace this portion of the journey the vast majority of the person uh the journey is in primary prevention when folks don't really have manifest disease yet yet secondary prevention is where we spend all of our time and resources and so if you look at cardiac rehab and insurance payments for this it only happens once patients have been diagnosed and have underlying disease well the fact of the matter is the biggest opportunities are in primary prevention so we need to get upstream and the therapeutic lifestyle changes that go along with cardiac rehab these things can all be translated into folks that don't have manifest disease so i believe we make our society healthier actually healthier by the the lessons that we learn from cardiac rehab and involving other folks we simply have to get upstream and not spend all of our time down here in the secondary prevention world so i'll end up right back where we started cardiac rehab is a class one indication for patients and the benefits approach or exceed many standard therapies aspirins beta blocker statins as we've seen yet the undersubscription from my point of view really could be thought to represent a moral imperative i'm not trying to shame any of us except we need to do better the resources are available and momentum is developing just as i mentioned early on and you need to help the folks the choir that's participating in this conference for they're committed to uh ncdr accreditation quality issues i can tell you this there's no other class one indication where you today can have an influence on making this radically better not just a little bit better but radically better there's no parallel in cardiovascular medicine for ignoring this you can help and need to help it's low tech and doable that's very very important and i know this is not the time for the details of this but let me tell you now it lends itself to philanthropy you know most of the time when we're actually looking for philanthropy it's for fancy equipment cath labs advanced imaging physical facilities etc for a very small investment philanthropic investment you can get your cardiac rehab up and going that's exactly what we did here in northeast tennessee we had a person that was looking to provide some philanthropic support they'd been touched by cardiovascular disease personally and family-wise and for a low bar they were it's very easy to explain to folks so it lends itself to philanthropy and the resources are available so i'm going to encourage you to do that and make cardiac rehab everywhere usa it doesn't have to you don't need big fancy buildings it can occur everywhere and there are many folks that can help you aacvpr is a great place to start me and hearts what a beautiful job they've done the aha of course with the acc ncdr many many ways to to help folks that want to be helped and i'll stop thank you very much this is my contact information with my email and cell phone again i'm passionate about this topic and would be glad to help any of you inside of med-ax and we'd be happy to help you as well so thanks and have a great day thanks for your attention dr blackwell thank you so much for that informative and energizing discussion about cardiac rehab so there's so much there we're probably all going to have to re-watch this recording on in slo-mo to take all our notes um so the first question i have for you is uh you mentioned that physicians prescribing or giving the referral for cardiac rehab is one of the or the lack thereof i should say is one of the top three reasons why cardiac rehabilitation doesn't take place so is there anything that hospitals can do to get the doctor out of the way and perhaps move the referral process to different team members or empower the clinical team to carry it out yeah connie what what a great question and that just uh shows me your nursing and care background because you're exactly right uh the best way to do this and the way that most elite programs do this actually is by doing just what you say that is taking the doctor out of the actual technical aspect of this it needs to fall to other team members it's a beautiful example of where electronic health record should help us uh the uh nursing staff that is involved with the the care of the patient uh discharge planning sort of work so in other words it lends itself to a performance measure and something that can actually be codified as part of the late hospital stay or discharge work it really lends itself to do that and you don't want the doctor to be the person that has that as their top choice not because they don't want to but they're just not as good at that and we have many examples in medicine where that's the case if you take this measure out of the doctor's hands but actually codify the what what's intended to occur it tends to do better so um and also one of the top three um uh sort of barriers to cardiac rehab from insurance um so there's so many different insurance plans i'm just curious if you know of any um sort of shift within the insurance um payment system that will see a change there or how can hospitals work around that yeah kind of this is one that's going to require a lot of work because uh as the as the old saying in politics of you know all politics is local well the same general colloquialism could apply to cardiac rehab and insurance work there's an important local and regional component to it so you have to actually get involved with your local and regional carriers to explain to them the importance of this and the importance to remove barriers now in addition there's a huge national component okay in other words this is something where the acc i think shines and has become involved in this um from a regulatory point of view and from an advocacy point of view where we can help at a national level to understand that this actually should be available everywhere and should be highly standardized so the bottom line is it's going to require both uh reach local regional work on one hand and national work on the other hand unfortunately there's even further nuance on this related to cardiac rehab versus intensive cardiac rehab so intensive cardiac rehab as i made a point here is a specific medicare approved program the pritikin or the orner's program it's not just cardiac rehab in an intensive fashion it's a very different prescribed course of a program i should say but it's amazing how the many carriers only clearly acknowledge the cardiac rehab not the intensive cardiac rehab so programs that want to do intensive cardiac rehab are really going to have to work with their carriers to help my approach to this though and my advice to those that are listening and watching is be diligent about this this is why you need passionate folks and committed folks and educated folks every single denial every single time we get pushed back we actually fight it and i think that's what has to happen unfortunately uh to to understand and my final comment i'm sorry i'm a little long-winded on this but it's important cardiac rehab historically in many programs is viewed as a loss leader as i mentioned in other words it's hard for it to be something where programs whether it's not only just lucrative it's not even breakeven in many programs we should change that but that is if you view cardiac rehab intensive cardiac rehab as a cost center in a value-based world cardiac rehab intensive cardiac rehab actually becomes a clear revenue center because it's low cost and it improves long-term outcomes so in a value-based world which we're all transitioning to i think there's great hope and we must drag the insurance companies with us now final comment uh there are many insurers that are agreeing and getting up to speed on this we need to get them off so jerry one of the things you mentioned was the philanthropic opportunities and it seems as though every hospital has a foundation or is raising money for those big ticket beautiful items but maybe there's an opportunity for cardiac rehab to to get in their line of sight katie uh there are many things on this talk that i want folks to take home some of which they're going to have to think about long and hard this is actually a really simple one yet most folks don't think about it and that is how accessible cardiac rehab is the philanthropic uh improvement in other words this is a topic that you can talk to the average person on the street about and they can understand what cardiac rehab is you mean you're going to help me to learn how to live a healthier lifestyle you mean my significant other and family can be involved in this you mean this is long-term stuff you can explain this to folks without having to go through complex science or show them the physics of instrumentation or things that are really high tech that many of us in cardiology most of us in cardiology love so the the easy uh excuse me the ease with which you can explain this to folks is a blessing number one number two the amount of money that takes to really push uh high quality cardiac rehab is extraordinarily low compared to these other things so for fifty thousand a hundred thousand a million and obviously there's big amounts of money but in the world of philanthropy there are way more folks that would be willing to give smaller amounts to help as opposed to five million ten million uh you know these these very large things so i can tell you i give you a personal anecdote here in our program on day one as we were taking this from our practice to the executive leadership of the health care system on day one we identified uh a philanthropist a potential donor we spent about a little hyperbole but you know spent a half an hour or an hour with them and said my goodness i've never been approached from the health system with something this easy here you go and so that that really it's important guys uh have the courage of your convictions so um you mentioned one of the opportunities um was to increase referrals we talked some about the intensive uh cardiac rehabilitation process and involving families and all of that um what about primary prevention you touched on this just a little bit and our focus in health care is often on the secondary prevention and making sure the referral process gets out but um where do you see hospitals and health care systems sort of um helping to educate their communities about primary prevent prevention is or is there a spot so there's the dirty excuse me there's the dirty little secret right uh and that is the reason folks focus on secondary prevention is that's where they can get paid uh in very few situations can we get paid for preventing disease in the primary prevention this is where i believe the national advocacy and our communication directly with highly informed insurance carriers can help where we can say look if we can get upstream in the primary prevention world you got to help brother out here you got to give us a little money on the front end for primary prevention we can actually improve the long-term outcome and make it financially valuable for these places that are in it for the long haul like medicare or insurers that have to think about longitudinal payments if we can get further upstream at a low low cost we can reduce the very high cost secondary prevention uh and and so there's a there's a compelling story to be made it's in the value based world look in my opinion what i'd love for this to occur i would like for the primary prevention and this story to get told all the way back into the secondary school systems right in other words get the young folks uh and i'm literally in the secondary school systems where we can help them about dietary choices healthy living etc that's when we'll make a true difference jerry thanks so much for everything that you've shared with us just before we go could you share with us one success story of a patient from your practice and and tell us how cardiac rehabilitation helped them thanks connie because in the final analysis it is an individual issue right i can give you many examples young folks that had no idea about the therapeutic lifestyle issues um folks that have had specific events and that it's uh sort of wake them up if you will and change your life but there's one patient in particular that i can uh think of um i'd love to tell you his name but it's somebody he's somebody i've taken care of for many years i actually took care of his wife for many years as well and his cardiac rehab journey um has involved the whole span from uh secondary prevention therapeutic lifestyle changes um a coronary revascularization procedure that really got his attention um and he really committed to to making changes in his overall profile but the story i want to tell you actually is not even one um that i've really focused on in this talk and that is that as he transitioned from phase one cardiac rehab to phase two cardiac rehab he then became a passionate player in our phase three cardiac rehab which is the maintenance program and this is something that's crucial to cardiac rehab to to that be understood that it becomes a form a healthy form of group therapy in other words this gentleman has made uh educationally tremendous strides but he's made connections in his life with other folks that have been on a similar journey with him and longitudinally honestly i don't know what his life would look like right now without the support of the phase three cardiac rehab again i wish i could have him with you uh for you guys to see his face on this talk because he has really i think embodied as much as anybody i've ever seen the long-term journey and commitment that is what i think of when i think of cardiac rehab well thank you so much again dr blackwell for joining us and um if anyone who listened to our presentation today has any questions feel free to email ncdr at acc.org and thanks again for joining us

cardiac rehabilitation

types of cardiac rehab programs

benefits of cardiac rehab

physician referral

barriers to participation

insurance and payment

advocacy

philanthropy

long-term outcomes