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Heart disease is the most expensive condition in the U.S. According to the Agency for Healthcare Research and Quality, treating heart conditions cost $78 billion in 2006. Medicare paid close to half this total, while private payers (including employers and individuals) covered another 40%. These are only direct treatment dollars, and don’t include such costs as disability payments and lost productivity.

To effectively treat heart disease patients while controlling costs, Medicare has launched coverage for two innovative lifestyle programs. Both have impressive results in improving cardiac conditions. These two programs, the Ornish Program for Reversing Heart Disease and the Pritikin Program, are now approved treatment providers under Medicare’s new Intensive Cardiac Rehabilitation Program benefit. The implementation date of this groundbreaking change was October 25, 2010.

Medicare researchers rigorously analyzed studies in peer-reviewed journals before deciding to cover these two programs. Anecdotal evidence and unpublished data could not even be considered. Under Medicare regulations, the two programs were required to demonstrate the ability to:

1. Positively affect the progression of coronary artery disease
2. Reduce the need for coronary bypass surgery, and
3. Reduce the need for stents and angioplasty

But even more evidence was needed. The two programs also were required to demonstrate, through published studies, significant reductions in 5 or more risk factors related to heart disease:

1. Low density lipoprotein (also called “bad cholesterol”)
2. Triglycerides
3. Body mass index (this is a measure of weight)
4. Systolic blood pressure
5. Diastolic blood pressure
6. The need for cholesterol, blood pressure, and diabetes medications

Many of the studies Medicare cites as evidence to cover Ornish and Pritikin are multi-year trials that show long-term benefits. Often, patients graduating from these programs continue to improve over time, with less plaque clogging their arteries, shrinking waistlines, and other positive measures.

Dietary changes are fundamental to the Ornish and Pritikin Programs. Both use an eating plan based on whole plant foods: vegetables, fruits, beans, potatoes, whole grains, herbs, and spices. Patients are encouraged to eat all they want of these healthy foods, with no portion control. Nuts and other high-fat plant foods are limited in quantity, while low-fat animal foods, such as nonfat milk and egg whites, may be allowed on a very restricted basis.

Leaving out the animal foods altogether is allowed under the Ornish Program and encouraged by the Pritikin Program. Highly processed foods, especially oils, are excluded from both eating plans.

Exercise is a vital part of both approved programs. Patients learn the exercises tailored to their physical condition at the beginning of treatment. In addition, these programs train patients on effective stress reduction techniques and offer social support for lifestyle change.

Medicare covers only patients with established illness for Intensive Cardiac Rehabilitation. Beneficiaries must have experienced one or more of the following:

1. Heart attack within the prior 12 months
2. Coronary artery bypass surgery
3. Current stable angina pectoris
4. Heart valve repair or replacement
5. Angioplasty or stenting
6. A heart or heart-lung transplant

Medicare’s new coverage has important implications for group medical plans. Employers experience heart attacks, transplants, and bypass surgeries as large claims that do not occur with great frequency in an active population. However, related chronic conditions, such as high blood pressure, high cholesterol, and diabetes make up a high proportion of medical spend for most groups.

Rigorous studies show that significant lifestyle changes can prevent as well as reverse these kinds of chronic conditions. So insurers and self-funded employers can start taking advantage of effective lifestyle change programs to put a huge dent in their costs. While Ornish and Pritikin have limited geographic availability at this time, other programs that teach the diet and exercise essentials are available. Some can even be brought to the worksite. Plus Pritikin, at least, may expand to other locations.

In the 1980s, Medicare pioneered the use of Diagnosis-Related Groups (DRGs) to reimburse hospitals. Instead of reimbursing whatever services hospitals wanted to charge for, DRGs allowed Medicare to pay a fixed, predetermined amount based on a patient’s diagnosis. This was an incentive for the hospital to be efficient and render only necessary care.

DRGs blazed a trail for insurers interested in prospective payment systems. In this case, Medicare innovation opened new pathways for private insurance to effectively rein in hospital costs.

Intensive cardiac rehabilitation could well be a similar precedent – a Medicare innovation that will allow employers to save significant dollars on treating expensive chronic illness. While the process is just getting started, this is a development that employers may want to start exploring now. Significant employee lifestyle changes, especially dietary choices, can eliminate the roots of conditions such as heart disease and diabetes. Employers will benefit from both lower medical costs and a more productive workforce.