Financial Impact of COVID-19 on phase 2 cardiac rehabilitation service delivery

Introduction: Provision of phase 2 cardiac rehabilitation (CR) has been directly impacted by the coronavirus disease 19 (COVID-19). After a 3-month COVID-19 shutdown, the CR program at the University of Vermont Medical Center (Burlington, VT) reopened, adhering to state and CDC-related guidelines including: COVID-19 screening, lowering participant density, extending program hours, frequent cleaning, and suspending educational classes, likely increasing costs and lowering revenues. Economic analyses to date have not identified the financial implications of pandemic-related changes to CR. Purpose: Compare the costs and reimbursements of CR between two time periods: (1) pre-COVID-19 and (2) post-COVID-19 shutdown. Design: Observational, Retrospective. Methods: Healthcare costs of providing CR were calculated via a micro-costing approach, combining participant and program data for two time periods: 07/2019-01/2020 (pre- COVID-19) and 07/2020-01/2021 (post-COVID-19 shutdown). CR services unit costs were based on staff time, consumables, durable equipment, and overhead costs. Reimbursement rates were derived from commercial and public health insurance. The mean cross-sectional cost and reimbursement per participant by month was calculated as the product of the mean service utilization multiplied by the corresponding unit cost or reimbursement;changes for each of the 7 months (July through January) between the two time periods were calculated. Results are presented as mean±S.E. and compare time periods with paired t-tests. Staff and participant COVID-19 infections were also examined. Results: Between the two time periods, the mean number of new CR participants enrolled per month declined insignificantly post-shutdown (15%;35.1±2.1 vs. 29.7±3.1, respectively, p=0.14). The mean number of exercise sessions per month also fell insignificantly (11%;787.3±34.9 vs. 697.3±57.9, p=0.20). The mean number of initial in-person consultations (including baseline stress tests) per month decreased significantly (36%;35.1±2.1 vs. 22.3±2.1, p<0.01), while the mean number of telehealth initial consultations increased substantially (0.0±0.0 vs. 7.4±0.7, p<0.001). The mean cost per participant increased marginally (7%;$2,581±$99 vs. $2,767±$94, p=0.10). The mean reimbursement per participant fell 6% ($158±0.0, p<0.001) post-shutdown ($2,759±$194 vs. $2,601±$194). As a result, the pre-COVID mean operating surplus per participant of $178±$106 (p=0.14) eroded into a post-shutdown deficit of $166±146 (p=0.30) per participant, a significant net deterioration of $344±$95 (p<0.05) per participant, or 12% of pre-COVID-19 reimbursements. No known COVID-19 infections occurred among the 208 participants and 14 on-site staff members during the post-shutdown time period. Conclusions: COVID-19 related protocols required CR programs to reduce participant density and other modifications in order to safely continue this important secondary prevention program. Recognizing the importance of CR, these results demonstrate that it was possible to maintain this critically important service in a safe and economically feasible manner despite financial headwinds.