Fall 2012 Newsletter

Montana Association of Cardiovascular and Pulmonary Rehabilitation
Members Only:

Letter from the President

Greetings Everyone!
I hope you are enjoying the beautiful fall weather. We have had a very mild autumn and are so grateful the smoke has cleared from the area at last.
The MACVPR board is busy preparing for our spring conference. It will be held in Billings again this year and be the day before the Cardiovascular Health Summit. Our conference last April had a wonderful turnout. It is so nice to be able to see everyone.
At the last conference there was a discussion regarding group verses individual membership dues. This is still a topic of discussion and MACVPR is open to feedback. In the mean time dues will remain as a group membership.
Take Care,

Outcomes Committee Report

The Montana Outcomes Project continues to hum along. We have not seen a lot of programs quitting due to the July launch of AACVPR’s National Registry Project. I suspect we will see our numbers decrease as programs change over. I have stopped accepting new programs at this point as we are big enough. Currently we have about 150 programs that submit data. These 150 programs represent 22 states across the US.
I recently sent out a new reporting spreadsheet that you are to start using on October 1st. However it is important to remember that you will not submit this spreadsheet to me until April 2013. We have one more reporting period using the old spreadsheet (Jan 2013). There are minimal changes to the spreadsheet most notably related to the sodium screener. When you enter the pre and post sodium screener score the spreadsheet will calculate the sodium intake in mgs. This will be useful when counseling your patients.
A big push by the CDC (my primary funder) is related to the ABCS. The A stands for the appropriate use of ASA, the BP stands for BP control, the C stands for cholesterol control and the S stands for smoking cessation. We continue to do very well as a state with the A (last quarter 94% of patients met the criteria), the B (last quarter 93% of patients were at goal), and the C (95% were on lipid lowering medications and 72% had a LDL >100). The problem that we struggle with is the S – smoking cessation referral. We only referred 65% of our smokers to a cessation program. This is actually the easiest one that you can impact. Please refer all patients that answer yes to the pre smoking question – even if they are not currently smoking – to the state’s Quit Line. I sent you all Quit Line materials in the past — if you need more let me know.

Thanks and please contact me if you have any questions.
Mike McNamara, MS, FAACVPR
[email protected]


Treasurer Report

Submitted by: Shannon Isakson

Currently have 10,669.04 in our MACVPR account. The total revenue for conference was 6395.00 and total expense was 2917.83.


St. James Motivates with Smiles

Submitted by: Shannon Isakson, RN and Malorie Hildreth, CES

St. James Cardiac Rehabilitation believes laughter and happiness are the keys to becoming heart healthy. Patients require motivation to stick with their exercise programs. Employees in Cardiac Rehab do our best to supply them the motivation and smiles they need to succeed.
At the beginning of September, Cardiac Rehab sponsored an end of summer barbeque for all Medical Exercise patients. Patients enjoyed a day out in the sun with refreshments, food, and good company. Many stories were shared about historical Butte, MT and the great experiences of each patient’s life. The Medical Exercise patients worked hard all summer and were rewarded for all of their personal efforts and goals achieved!
We look forward to our future Halloween party, Thanksgiving feast, and Christmas celebration and the opportunity to add joy to our patients’ lives.


Clinical Exercise Physiologist Licensure

Submitted by: Ashley Wishman MS CES CSCS PES HFS CSSE

The fight for licensure for Clinical Exercise Physiologists’ continues in multiple states across the country. Massachusetts and Utah have come close in the past 2 years, but Louisiana is still the only state to have licensure as an option for the Exercise Physiology profession. The Clinical Exercise Physiologist Association, CEPA (a branch of ACSM) has a state licensure committee that meets to discuss ideas to overcome opposition, changes in language of the bill and advancement for licensure.
As one of the Montana representatives, I have contacted programs through MACVPR to begin building a list of supporters for licensure in our state. We are still in the beginning stages of obtaining licensure, but all your support is greatly appreciated. If you would like to assist or would like to be added to the list of supporters, please contact me at [email protected].
Six practice areas are included in legislation for licensure (e.g., cardiovascular, pulmonary, metabolic, orthopedic/musculoskeletal, neuromuscular, neoplastic-immunologic-hematologic [NIH]). Wording for these areas becomes difficult and needs to be perfected to eliminate opposition from physical therapists throughout the country. An example from Massachusetts bill reads: “The CEP formulates, develops and implements exercise protocols and programs, administers graded exercise tests, and provides education regarding such exercise programs and tests and risk factor modification in a rehabilitation or diagnostic setting to individuals with cardiovascular, pulmonary, and metabolic diseases. The CEP uses exercise as a therapeutic tool to maximize health in individuals with stable diseases and conditions in other practice areas (neoplastic (oncology)/immunologic/hematologic conditions, chronic orthopedic and neuromuscular diseases and disabilities).”
The committee has agreed that “physician –referred” is acceptable language, but that “physician-supervised” or “physician-directed” or “medically-supervised” or “under supervision of other health care professionals” is not acceptable.
Minimum education requirements for licensure will be a master’s degree in Exercise Science, Exercise Physiology, or Kinesiology PLUS an ACSM Clinical Exercise Specialist (CES) or RCEP certification. However, there would be a one year grandfather clause that stipulates a minimum of a bachelor’s degree and 10,000 hours in the past 10 years. Each state differs slightly in this area, as some require certification and/or recommendations from physicians to qualify for licensure under the grandfather clause.
Finally, the committee agreed that licensure should protect the terms LCEP and CEP, but not RCEP, CES or Exercise Physiologist (EP), because someone can clearly be an RCEP, CES, or EP even if they are not licensed.
One of the major efforts of the legislative committee is to provide a forum for ideas and collaboration on state licensure attempts across the country. This forum can be found at:
More information on state by state efforts can be found at:

Congratulations to Mike McNamara on His Distinguished Service Award

2012 Distinguished Service Award winners – American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) National Conference, Orlando, FL. Left to right, Anne Gavic, AACVPR President, Randy Thomas, MD Mayo Clinic, Richard Josephson, MD, Case Medical Center, Michael McNamara, MS, Montana Department of Public Health and Human Service, Steve Lichtman, AACVPR Past President.

The Distinguished Service Award is presented to an individual whose leadership, ideas, and committee work have significantly benefited the AACVPR as an organization. Mike McNamara has been instrumental in developing the National Cardiac and Pulmonary Registry Project. The Registry project collects outcomes data and establishes national benchmarking information. The benchmarking information is used to facilitate quality improvement activities with the overall goal of improving patient care. McNamara has also been an active participant in various AACVPR Task Forces and Committees and is currently on the Executive Board of Directors. He is also the Past President of the Montana Association of Cardiac and Pulmonary Rehabilitation. McNamara works for the Cardiovascular Health Program within the Montana Department of Public Health and Human Services.
McNamara lives in Montana City with his wife Beth and kids Ryan (14) and Tatum (10).

Legislative Information:

Submitted by Cathy Lisowski, MA, ACSM CES

• Do you want more flexibility in meeting physician supervision requirements for your pulmonary and cardiac rehabilitation program?
• Could you reduce the expense of delivering your program if you were allowed to utilize a non-physician practitioner (NPP) in place of the current Medicare requirement that mandates a physician be immediately available per the Medicare direct physician supervision requirements we now live with?
• Is your Critical Access Hospital (CAH) rehab program at risk of closure because you are unable to comply with the Medicare requirement that a physician be immediately physically available at all times your program is in operation? Would the use of a non-physician practitioner for MD supervision in your critical access hospital allow you to keep your program doors open for patients who benefit from our services?
Help AACVPR correct unnecessarily restrictive Medicare regulations for cardiac and pulmonary rehabilitation.
CMS’ restrictive interpretation of the authorizing statute precludes non physician practitioners from supervising pulmonary and cardiac rehabilitation programs. The bureaucratic barriers hospitals face, particularly CAHs, are hindering access to pulmonary and cardiac rehabilitation. In fact, CMS currently allows NPPs to provide aspects of direct physician supervision for all other hospital outpatient services except cardiac and pulmonary rehabilitation.
Senators Schumer (D-NY) and Crapo (R-ID) have introduced S.2057, a technical correction that will clarify Congressional intent and allow hospitals to provide and supervise pulmonary and cardiac rehabilitation services the same way that hospitals provide all other hospital outpatient services.
This is a non-partisan, non-controversial, NO-COST technical correction that will solve the issue by clearly signaling to CMS the actual Congressional intent of the cardiac and pulmonary rehabilitation Medicare legislation. AACVPR is asking that this bill be included as part of an appropriate legislative vehicle that arises later this year. S2057 must have majority support before it will be considered for inclusion in an appropriate legislative vehicle (a larger bill dealing with Medicare) that arises later this year.

As we know ~ due to the nature of the bill, it will likely be rolled into the Doc fix at the end of year. Both Tester and Baucus have supported this over the last 3 years and are likely to continue to support.
PLEASE! contact your two U.S. Senators and ask for their support of S.0257. Get S2057 rolled into the doc fix ~ let them know it is important! Call/email Senators in Late October & November:
Senator Tester’s office: Phone: (202) 224-2644
Contact Name: Alpha Lillstrom ([email protected])
Senator Baucus Office: Phone: (202) 224-2651
Contact Name: Callan Smith ([email protected])

Reimbursement Information:

Proposed 2013 Medicare Regulations:
Most significant are the 2013 projected reimbursement rates for both services.
Cardiac Rehabilitation Payment:
In the hospital outpatient (hospital-owned) setting, the cardiac rehabilitation reimbursement rate for both CPT 93797 and 93798 is slated for $80.06 payment. This is a national average and will vary based on geographic location due to adjustments related to labor costs. The co-payment amount (secondary insurance or patient portion) is $16.02.
The higher cardiac rehabilitation reimbursement rate may be due in part to the increased use by hospitals of the cardiac rehabilitation nonstandard cost center on the Medicare Cost Report Form 2552-10. This option was implemented in October, 2009.
Pulmonary Rehabilitation Payment:
Pulmonary rehabilitation received a modest increase to $39.58 for HCPCS code G0424. Co-payment amount is $7.92.
Respiratory services (what those in the field refer to as “pulmonary rehab” for patients with a non-COPD respiratory disease) also received an increase to $35.12 per 15 minutes for the timed procedure codes, G0237 and G0238 and the un-timed group exercise therapy code, G0239. The co-payment is proposed to be $7.03.

There is an upcoming AACVPR Webcast that may help clarify some of the reimbursement issues:
Tuesday, November 13, 2012
12:00pm Central (10:00am Pacific, 11:00am Mountain, 1:00pm Eastern)
Medicare Rules and Important Regulatory Issues for 2013
Presented by:
Karen Lui, RN, MS, MAACVPR, GRQ, LLC & Phil Porte, MS, Legislative Analyst, GRQ, LLC
Attendees earn 1.0 AACVPR Continuing Education Credit

Exercise Training Improves Diastolic Function in Heart Failure Patients

Submitted by: Casey Harrod, EP

In the May 2012 number 5 edition of the ACSM Medicine & Science in Sports & Exercise Journal there is an interesting study on exercise training improving diastolic function in heart failure patients. The main purpose of the study was to analyze the effects of exercise training on exercise tolerance and left ventricular systolic function and structure in heart failure patients with preserved, mild, and moderate to severe reduction of left ventricular ejection fraction (LVEF). Ninety-eight patients were categorized with moderate (n=34), mild (n=33), and preserved (n=31) with LVEF’s ranging between 37-56%. These patients were randomly assigned to exercise training plus usual care (n=65) or usual care alone (n=33) in a randomized ratio of 2:1. Left ventrical function, left ventrical dimensions, and exercise tolerance were assessed before and after each intervention.
The Results of the study showed exercise tolerance and LVEF increased with exercise training in all patient groups, where as they remained unchanged after usual care alone. Exercise training increased the mean ratio of early to late mitral inflow velocity (E/A ratio) and decreased deceleration time (DT) of early filling in patients with mild and preserved LVEF. In patients with moderate to severe systolic dysfunction and advanced diastolic dysfunction (DT160ms), exercise training also improved mitral inflow patterns. Exercise training decreased left ventricular dimensions in patients with mild moderate to severe reduction of LVEF but not in patients with preserved LVEF. These results indicate that exercise training can improve the course of heart failure independent of the degree of baseline left ventricular dysfunction1. For more information on this study please see reference source.


1Alberto Jorge Alves, Fernando Ribeiro, Ehud Goldhammer, Yelena Rivlin, Uri Rosenschein, Joao Luis Viana, Jose Alberto Duarte, Michael Sagiv, Jose Oliveira. Exercise Training Improves Diastolic Function in Heart Failure Patients. Medicine & Science in Sports & Exercise ACMS May 2012;5: 776-785

A Book Review

Submitted by: Erika Schreibeis

“Prevent a Second Heart Attack”

By Janet Bond Brill , Ph.D., R.D., LDN

At last year’s Cardiovascular Health Summit, one of the speakers—Dr. Annaelle Volgman, highly recommended a book and actually said it was a “must read”. Dr. Vogman presented a very informative lecture on “How to be a Superior Clinician by Preventing Heart Disease and Strokes”. This is a pertinent topic for those of us who work in outpatient cardiac rehabs and beat the secondary prevention drum. I ordered the book from the amazing and found it very informative and since have incorporated much of the information into our patient education classes.

In this review, I just want to highlight what I found to be the most informative. (Strongly resisting using Oprah Winfrey’s “Ah—haa” verbiage, but I did learn a lot from reading this book and strongly encourage you to read it).

1. The Mediterranean Diet. Dr. Brill states that this is superior to any low fat diet and quotes many research studies to validate. This diet consists of “cardioprotective” foods such as olive oil, greens, figs, omega three fish, walnuts, flaxseeds, lentils, oatmeal, red wine (with meals) and a small amount of dark chocolate. These foods are cardioprotective in that they work to stabilize vulnerable plaque, reduce inflammation, stabilize the electrical conductivity of the heart muscle and change the composition of the blood.
2. Olive Oil – is actually a fruit juice because it is made from crushing and pressing a whole fruit (olive pits and all) as opposed to a seed (rapeseed, which is the source of canola oil) and vegetables (corn, which is the source of corn oil). Health benefits are derived from three key compounds: monosaturated fat (oleic acid), polyphenol antioxidant compounds, and the antioxidant vitamin E. Dr. Brill recommends two tablespoons of extra virgin oil every day. This should preferable be the main, if not sole added fat in your diet.
3. Dark Chocolate – Did you know that dark chocolate has a higher antioxidant quality/quantity than red wind, black tea and green tea? The benefits include anti-inflammatory and anti-clotting effects on the blood, lowers blood pressure, reverse endothelial dysfunction and lowers inflammation in the arteries. The recommended amount is two tablespoons of natural, unsweetened cocoa powder or one or two squares (up to one ounce) of dark chocolate daily. The chocolate should be at least 70% cocoa. Read the nutrition label carefully and make sure the first ingredient is cocoa and not sugar. Also, watch the serving size and keep under 20 grams or 2 small squares. Avoid any chocolate bar that has alkali in it which robs the chocolate of the flavonoid benefits.
4. Saturated Fat…why does it cause an increase in LDL? Here is the answer. Saturated fatty acids raise LDL because they slow the activity of cholesterol receptors on liver cells. LDL liver receptors are the clearing house for LDL cholesterol. Less LDL receptor activity means less LDL cleared form the bloodstream causing increase LDL blood levels which fuels atherosclerosis. Saturated fat can also hinder good HDL cholesterols ability to control blood vessel inflammation thus promoting endothelia dysfunction and triggering plaque formation. An overdose of saturated fat, even if just once during the day, works to increase LDL, decrease the benefit of HDL in reducing inflammation and triggers plaque formation. Scary stuff for us butter lovers.
5. Exercise really does work. Here is an interesting fact to share with your cardiac rehab patients. In a study “Corpus Christi Heart Project”, seven years after having a heart attack, 78% of the patients had a lower risk of having another heart attack and 89% a lower risk of death compared to those who remained sedentary. Unfortunately , this benefit is lost within a month if exercise is halted. Exercise, much like prescribed medicine, cannot be stopped on a whim and hope that you are “fixed” for life.
6. At this point, if you have read this far, would you drop me an email at [email protected]. I have long wondered if newsletters actually get read and am actually doing my own little study.

In summary, the book is good for everyone. Which one of us does not want to have valuable information to share with our cardiac patients? And, one thing for certain, this disease is prevalent and may affect us personally in the years to come. The best way to have affordable healthcare is to stay healthy, right? This book presented a lot of good information in an understandable way.