Melissa Walton-Shirley


March 17, 2015

Dr Rajeev Pathak (University of Adelaide, Australia) started his talk on the 5-year follow-up data from the LEGACY trial by stating, "One in three Americans is fat." He demonstrated that "fatness" is associated with a higher burden of atrial fibrillation. He flashed a damning slide of predicted obesity rates across four countries with the red curve looming above the other countries, labeled "US," declaring that 70% of Americans will be overweight by the year 2022. We will be the "fattest" of all nations. In fact, we already are. But then, his later slides demonstrate that "at final follow-up, 46% of patients who lost >10% weight remained free from AF without any rhythm-control strategies."

And these were patients who had already demonstrated paroxysmal atrial fibrillation!

The correlation between being overweight and the development of atrial fibrillation should have garnered the attention of accountants at the offices of the Centers for Medicare & Medicaid Services (CMS) long ago, but it doesn't seem to have rattled any windows. The best they've done is to have generated a CPT code, G0447, for primary-care physicians (only) to counsel patients with obesity. It's a code that few know how to use and on which even fewer are willing to gamble. Adding insult to injury, cardiologists weren't even considered for reimbursement for obesity intervention, yet we are the "keepers" of the diagnosis of atrial fibrillation.

It was diet, weight loss, and exercise that ablated atrial fibrillation in LEGACY.

My friend, fellow blogger and electrophysiologist extraordinaire Dr John Mandrola, would be quick to tell you that when he uses catheters to ablate afib, it comes with a much higher price tag. It would dwarf the cost of a few face-to-face encounters. Throw in the cost of devices, hospital admissions, bleeding from anticoagulants, antiarrhythmics, rate controllers, stroke, mechanical and pharmacologic therapy, and it's enough to break the US healthcare bank. (But haven't we done that already?)

Nurse practitioner Beverly Mortimer works in a prevention-focused primary-care clinic in south central Kentucky. She teaches and preaches the gospel of good health every single day, but she bills under CPT codes for diabetes and hypertension. "I always add that comorbidity to ensure payment," she said when I phoned her today. But why should she have any uncertainty about the reimbursement for what is now proven by the LEGACY trial to be the most cost-effective afib intervention on the planet?

The mechanics for successful weight loss in LEGACY included a recommendation for 200 minutes of exercise per week, a high-protein, low-glycemic-index, calorie-controlled diet, and face-to-face "weight-loss-clinic" interventions. Good things happened when they counseled their patients, like reversal of glucose intolerance, a decrease in septal thickness, and a drop in CRP levels. When their body-mass index dropped below 27, their left atria, formerly stretched far beyond anything God intended, relaxed, as volumes decreased and, miraculously for many, paroxysmal atrial fibrillation went away. Poof! It disappeared!

A quick internet search yielded the cost of healthcare that should send our CMS accountants scrambling after today's presentation:

According to the latest ACC/AHA stats, approximately 480 000 hospital admissions list AF as the primary discharge diagnosis. Many of these patients will suffer a stroke and may require nursing-home care, prolonged hospital stay, and at-home therapy. Total US price tag: $26 billion/year.

Afib ablation x 1: $100K (one in three require two procedures!). Dr Mandrola saw the actual bill, okay?

Medical therapy postablation: $4300/year.

Total care (echo, office visits, finger sticks, etc) for outpatient afib patients: $10 000/year .

One hospital admission for rate control: $20 000 to $40 000.

Balance all of this against the cost of four office visits during the first month for obesity intervention added to monthly visits thereafter; heck, even throw in a gym membership, a Fitbit, and a pair of sneakers, and you have gold!

CMS, if you don't shift your reimbursement patterns to support counseling and implementation of diet, weight loss, and exercise after today's presentation; there is no helping you. Our bellies will continue to expand. More and more fat will choke, coat, and encase our epicardium . Our atria will rebel with chaotic electrical activity that resembles the night sky of a 4th of July celebration. Blood that should be happily free flowing will stagnate and clot in our dog-eared left atrial appendages. Chunks of white and red clot will be hurled into our cerebral circulation with the same force of hot lava showering from the mouth of Mt St Helen's. Then more of us will fall down than ever before, and more and and more of us will never get up again.

God help us if that is to be our legacy.


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