Disadvantages include lack of diagnostic and assessment equipment, and usually no emergency protocols for specific cardiac events, should they occur. Health clubs (who are seeing more and more special population groups join their ranks), are betting against the likelihood of adverse events by teaching only post-rehab programs, where symptomatic patients would usually not be a participant. By working with the phase III/IV client, their liability is reduced.

Louisiana Clinical Exercise Bill
There are two new "twists" in the prescription of exercise in the cardiac rehab setting. In July of 1995, the state of Louisiana passed a clinical exercise physiology licensure bill for those who primarily work in the cardiac rehab setting. This bill has had major ramifications in the sports medicine organizations, as other states (California in particular) are now organizing for the regulation of the profession state by state. This process may have an impact on who may supervise cardiac rehab programs, where this supervision may take place, and how much medical intervention (ie: cardiologist evaluation and prescription) may be included in the overall rehab process.

HMO wellness contracts
The second "twist" is the dramatic change seen in the HMO reimbursement process. Over the past year and a half, a small but significant number of health care agencies have formed to directly negotiate with HMO's for wellness contracts for health clubs. This shift in expenditure is a plus for those who have historically been involved in the wellness and health promotion arena, but its impact on traditional programs such as cardiac rehab remain unclear. In an interview with Dr. Barry Franklin, director of cardiac rehab and exercise science at William Beaumont Hospital in Royal Oak, MI, he states that even with the expansion of HMO services, there may be no real change in the upcoming years in the reimbursement for classic phase I and II programs. They will continue to receive payment for up to 18-36 sessions (depending on the geographic area). However the advent of HMO contracting will make phase III and IV programs more likely to be reimbursed depending on how the contract is formulated, where the service is taking place, and who is conducting the program (exercise specialist, cardiac nurse, etc.).

Conclusions
It is clear that cardiac rehab services are undergoing changes in terms of new information, insurance reimbursement, staffing, and long term applications for patients. Short term changes will occur in the type of programming, moving from traditional aerobic machines to complimentary forms of training, and the type of practitioner who is performing those services. Long term changes in cardiac rehab may entail contractual agreements with HMO's, health club programs, and reimbursements for home-based exercise. One realistic long term goal would be to have outcomes measures on persons who participate in multi-year exercise programs to see the benefits physiologically, socially, and from a cost-savings standpoint.

References
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