Insurers weigh a simpler, cheaper treatment for artery disease: supervised workouts

When Char Zinda’s doctors discovered that she had had a couple of small, undiagnosed heart attacks, their instructions were to start walking.

She was game. She tried going to the local university’s indoor walking track near her house. But she couldn’t even walk two tenths of a mile before her legs began to hurt — a lot. Sometimes the pain was in her ankles, sometimes in her calves, sometimes in her thighs. “It made me cry,” said the 64-year-old, who lives in Morris, Minn.

That was a telltale sign of peripheral artery disease, which affects an estimated 8 million Americans. Zinda had a number of treatment possibilities, but the cheapest and least invasive has generally not been covered by insurance, despite years’ worth of evidence that it can be as effective as other options.

That is on the cusp of changing, experts say, because of a long-awaited proposal from the Centers for Medicare and Medicaid Services to cover what’s known as supervised exercise therapy — a program of graduated exercise with the help of an exercise physiologist, which is currently covered after certain kinds of cardiac events, but not for PAD.

The CMS proposal was triggered by an official request from the American Heart Association in September and is now open for public comment. So far, the input — mostly from specialists — has been overwhelmingly positive, making it likely that the change will take place on or before May 31. And if CMS decides to cover something, private insurers generally follow suit.

“I’m shocked it’s taken this long,” said Dr. Heather Gornik, the director of Cleveland Clinic Non-Invasive Vascular Laboratory. “It’s been a source of frustration for many of us. … We’re all collectively breathing a sigh of relief.”

Peripheral artery disease is caused by a buildup of plaque in the blood vessels that nourish the legs — and less commonly, the arms, stomach, and head. The reduced blood flow means that not much oxygen can get to the muscles, and that causes pain, sometimes so debilitating that it’s a struggle to get through everyday activities.

There are number of ways you can break up that blockage. A doctor can thread a tube into your artery and inflate a balloon to help move the plaque aside. Or a stent can be inserted, which will permanently prop the artery open. Or a surgeon can take a blood vessel from elsewhere in your body and create a little detour — a bypass — so that the blood can just flow around the blocked passage, like cars taking an alternate route to get around a pileup. Those three are all invasive, and often expensive, procedures.

But you can also improve leg pain and heart health without actually removing the blockage, studies have shown — all you need is exercise. Cardiologists think that the movement helps the muscles adapt to the amount of blood they are getting, and the vascular system grow more tiny, blood-carrying tendrils.

One paper published in 2015 showed that those patients who got supervised exercise therapy improved their ability to walk just as much as those who got a stent put in. And an article published by the same group in 2014 found that a stenting procedure generally cost some $5,000 more than supervised exercise.

Still, you might say there is one gaping problem with this idea. These patients’ primary symptom is pain during exercise. How could you possibly prescribe them yet more exercise?

That’s where the supervision comes in.

“Being told when you hurt that the answer is to go home and hurt alone is not therapeutic,” said Dr. Alan Hirsch, a professor of cardiovascular medicine at the University of Minnesota, who is part of the research group that compared supervised exercise to stent procedures.

Instead, in supervised exercise, an exercise physiologist helps determine just how much time you should spend on the treadmill, and at what level of difficulty it should be set.

“We try to work them up for eight minutes or so, work them to a level of pain that they almost cannot tolerate, and have them rest, and then put them back on the treadmill,” said Stephanie Zombeck, the chief exercise physiologist at Boston Medical Center.

“They do need to be able to push past the discomfort to get the most benefit. It’s hard to do that on your own. … It can be not only uncomfortable, but also frightening to experience symptoms and try to push themselves past it,” said Dr. Naomi Hamburg, a cardiology and vascular medicine physician who works with Zombeck at BMC. “Being in a monitored setting helps with that.”

If the CMS proposal goes through, three weekly sessions of 30 to 60 minutes would be covered for 12 weeks, with the possibility of extensions as needed. Supervised exercise therapy could be used in conjunction with other therapies, or tried before moving on to other more invasive options.

“Physicians and other providers and their professional societies have been able to align to present a uniform message … that coverage for supervised exercise was not only necessary because it would improve outcomes, but would also improve cost,” said Dr. Herbert Aronow, director of interventional cardiology at the Lifespan Cardiovascular Institute, who chairs the American College of Cardiology’s peripheral vascular disease council.

“It has been one of the greatest ironies — and almost, absurdities — in the field of PAD, that you could have a stent paid for, or a bypass surgery, but something as non-invasive or low-risk as exercise would not be covered,” said Gornik.

If the proposal goes through, that absurdity could soon be a thing of the past.

This story has been updated to reflect the symptoms of PAD.