Pumping up the heart: Medicare now covering cardiac rehab

Jay Siegfried, Lankenau cardiac rehab director, with nurse Linda Don and patient Frank ONeill. He says, "The goal is for patients to take information on how to exercise and use it for the rest of their lives."
Jay Siegfried, Lankenau cardiac rehab director, with nurse Linda Don and patient Frank ONeill. He says, "The goal is for patients to take information on how to exercise and use it for the rest of their lives." (COURTNEY MARABELLA / Staff Photographer)
Posted: May 18, 2014

When Frank ONeill's heart was failing, what saved his life was a heart transplant.

But what improved his quality of life and the strength of his peripheral muscles before his transplant was an individually tailored exercise program that he paid for out of pocket - $300 for six sessions - at Lankenau Heart Institute, part of Main Line Health.

Now, for the first time, Medicare will cover cardiac rehabilitation programs for patients suffering from "stable, chronic heart failure," according to a February decision memo from the Centers for Medicare and Medicaid Services.

Cardiologists who treat heart failure and physical therapists have applauded the decision, which acknowledged after a decade of study that exercise for heart-failure patients could be safe and beneficial.

"Heart failure can be very frustrating," said Jay Siegfried, director of the Cardiac Rehabilitation Center at Lankenau. "You go into the hospital, have fluid drained off your lungs, then return home. Six to eight weeks later you drift back to where you were, with fluid in the lungs and shortness of breath, and you're back in the hospital."

"This is a chance to directly impact the problem and break that cycle," Siegfried said. "It's a gift."

For patients, it's often a case of "use it or lose it," said Behnam Bozorgnia, lead physician for the Cardiac Heart Failure Program at Einstein Medical Center. Heart-failure patients often end up losing muscle mass and developing secondary problems, including bedsores, malnutrition, lack of energy, and depression, "all of which can be addressed by someone who has a minimum amount of activity and exercise."

"I like this kind of research and this kind of funding: it's simple and it makes sense," Bozorgnia said. "It gives leeway to a clinician to advise a patient to get into the gym, but also to have some authority and funding for it."

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 650,000 new cases are diagnosed each year, according to the American Heart Association.

"Stable" heart failure is defined as not having had recent or planned major interventions for at least six weeks. Patients also must have less than a 35 percent ejection fraction - a measurement of the percentage of blood leaving the heart each time it contracts - and meet specific symptoms within the New York Heart Association functional classification system.

Cardiac rehab sessions covered by Medicare are initially limited to 36 sessions, with another 36 sessions subject to approval by a Medicare contractor.

Until now, some private insurers covered cardiac rehab for heart failure, or patients paid out of pocket.

Several groups "had lobbied for cardiac rehab for heart-failure patients," Siegfried said. But the Centers for Medicare and Medicaid Services remained unconvinced that patients could withstand the stress of exercise.

What changed the agency's position were the results of the HF-Action study, published in the Journal of the American Medical Association. It examined the effects of cardiac rehabilitation on nearly 2,300 patients and showed that aerobic exercise is safe and effective for heart-failure patients.

"Many of the patients in the study didn't exercise very much over the two years," said Lee Goldberg, medical director of Penn Medicine's Heart Failure and Transplantation program, who was involved in the study. "But the people who exercised did significantly better, with better mortality and fewer hospitalizations."

Cardiac rehab is less about the mechanism of the heart and "more about the mechanisms of other muscles of the body," Goldberg said. "Programs help to train peripheral muscles to work much more efficiently, so with the same amount of heart pumping, those muscles are more efficient."

The psychological benefits of rehab are also important. "Exercise can jump-start confidence," Bozorgnia said. "Patients realize, 'I can get on a treadmill and nothing bad happens to me.' "

Two years ago, ONeill, 68, of Manayunk, had a left ventricular assist device implanted at the bottom of his failing heart to help pump blood to his vital organs. Six months later, he told his doctors that he needed to exercise, and started a program at Lankenau.

Despite his device, ONeill's condition continued to worsen. Last August he was put on a heart-transplant list, and in early October, he was taken to Thomas Jefferson University Hospital to receive a new heart. Unfortunately, that heart was not viable, but two weeks later, on October 20, he got the call once more. Waking from anesthesia, his doctor told him, "You got a good one."

Recounting that moment, ONeill's eyes filled with tears. "It was overwhelming," he said. "I mean, I should be dead."

By mid-December, ONeill returned to cardiac rehab at Lankenau for one-hour sessions. He started out slowly - working out for 6, 7 or 8 minutes at a time on the treadmill or recumbent bike. Based on his stamina and performance, therapists gradually added more resistance over longer periods.

"People are under the impression you need to do the gold standard of 20 to 30 minutes of exercise at your target heart rate," Siegfried said. "But if you have a person with a 25 percent ejection fraction who can barely walk a half a block, that might not be possible."

"When you go to cardiac rehab, the point is not to graduate," he added. "The goal is for patients to take information on how to exercise and use it for the rest of their lives."

ONeill has taken that message to heart. Finished with cardiac rehab, he now hits a Planet Fitness gym in Manayunk for an hour a day, lifting weights and performing aerobic exercise. Benefits have included more energy and stronger muscles. Once in a while he catches a glimpse of himself in a gym mirror and "it's like, 'Wow, how can I be doing this?' "

And there's another message. Twenty-five years ago, ONeill's sister Jacqueline was killed while riding her bicycle in Colorado. Only 40, she was an organ donor, whose heart and corneas went to needy recipients.

"At the time I was sad about my sister," ONeill said, "I never thought about how many people - like me - might benefit. It never crossed my mind."



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