Year of Publication



Public Health

Date Available


Degree Name

Dr. of Public Health (Dr.P.H.)

Committee Chair

Ty Borders

Committee Member

Glen Mays

Committee Member

Susan Smyth

Committee Member

Arny Stromberg


Cardiac rehabilitation (CR) represents a proven-effective intervention in secondary prevention that can stabilize, slow or reverse cardiovascular disease (CVD) progression, facilitate the ability of the patient to preserve or resume an active and functional contribution to the community, and reduce the risk of future cardiovascular events. Despite multiple guideline recommendations for CR and coverage by Medicare and most health plans, participation in CR remains low. Bundled payments are one of the suggested reforms designed to move health care providers toward to value-based care and is very applicable to the CR utilization in patients diagnosed with acute myocardial infarction (AMI) or have undergone through procedures of coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI), since it has the potential to catalyze and accelerate the establishment of innovative delivery models that could achieve greater communication and coordination among providers across the continuum of care and improve CR referral, enrollment and adherence.

This study examined the association of Center for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BCPI) initiative and CR uptake, patient outcomes and health care utilization among Medicare beneficiaries, as well as the potential collateral effect on health disparities in CR uptake and health outcomes in patients who are female, living in rural areas, are non-white, or are dual-eligible in Medicare and Medicaid, by conducting difference-in-difference analysis to a secondary data set.

In our analysis, we found that participation in the CMS BPCI initiative for cardiac episodes (AMI, CABG, PCI) was not associated with an increase in 3-month CR enrollment. The differential changes tended to be in both directions, though when we looked at hospitals by initiation of participation, the early-entrant cohort (i.e., Jan-BPCI) showed an observed improvement in 3-month CR enrollment rate. The disparities in CR enrollment regarding race, sex, socioeconomic status and rurality were demonstrated in our study. Though BPCI initiative has potential to reduce disparities in CR enrollment, our results did not show reduced disparities in CR enrollment among vulnerable groups regarding sex and SES, compared pre- and post- BPCI implementation.

Our study suggests: 1) it is imperative to describe the plans for integration of process and outcome data in design of model and advance understanding of how these models might be implemented to improve health for future policy changes and new initiatives; and 2) it is imperative to advance understanding of how these models might be designed and implemented to reduce health disparities. The new bundled payments policy needs to be sufficiently flexible to allow and encourage health systems to determine and implement the best approaches to reduce disparities in their settings and populations.