FOR SELF-FUNDED EMPLOYERS | A HEALTH BALLISTICS™ PRACTICAL TOOL

You paid for the cardiac procedure. Did your employee receive the rehabilitation?

After a heart attack, coronary stent, or bypass surgery, guideline-supported cardiac rehabilitation is an important part of recovery. Yet rehabilitation often does not appear in the claims that follow. Explore the gap and what closing it might mean for health and medical-cost exposure.

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THE MISSING FOLLOW-UP

A discounted claim is still a claim.

The next question is whether an established intervention that helps reduce subsequent events was delivered.

01 / IDENTIFY
Qualifying event or procedure
Identify unique people with potentially eligible cardiac events, then confirm clinical eligibility.
02 / FOLLOW THROUGH
Referral and actual attendance
A referral is a starting point. Look for evidence that rehabilitation began and track attended sessions.
03 / MEASURE
Recovery and outcomes
Review participation, functional recovery, and subsequent care with the clinical team.

A missing CR claim is a reason to investigate, not proof that care was never delivered. Referral, eligibility, medical clearance, benefit design, claims completeness, and actual participation are distinct questions.

PUBLISHED PARTICIPATION GAP

Coverage does not establish participation.

Pollack and colleagues studied 143,870 commercially insured U.S. adults aged 18–64 with qualifying events in 2017–2022 and follow-up through 2023.

24.2%enrolled among qualifying people

13.9average sessions among enrollees

9.6%of enrollees completed at least 36 sessions

This commercially insured cohort is a reference population, not a forecast for your plan. Read Pollack et al., 2025.

CLINICAL EVIDENCE

Established care. Outcomes that matter.

The September 2026 Cochrane plain-language summary describes 107 trials involving 26,886 people with coronary heart disease. It reports fewer myocardial infarctions and likely fewer all-cause hospital admissions with exercise-based rehabilitation versus no structured exercise. Mortality findings depend on outcome and follow-up; repeat PCI and CABG showed little or no difference at 6–12 months.

Participants included people after myocardial infarction or revascularization and people with angina or coronary artery disease. These findings do not establish employer-specific savings or a guaranteed reduction in procedures or deaths.

The publisher’s plain-language summary and technical abstract contain inconsistent hospitalization estimates. No clinical effect estimate is preselected here. Review the evidence or see the verification note.

CARDIAC REHABILITATION MISSED OPPORTUNITY CALCULATOR

Explore the care gap. Then the potential savings.

Start with unique eligible people, not total workforce size. Every result is an illustrative educational scenario, not a clinical or actuarial prediction.

The claims-audit question comes from Health Ballistics™: A New Healthcare Architecture for Precision Health, Chapter 24, “The Blind Spots in Claims Data.” Explore the book.

Choose a starting point Explore an example Use aggregate claims counts

Use aggregate counts only. No names, dates of birth, individual diagnoses, or claims uploads. Entries stay in this browser tab and are not stored or transmitted.

1. Define the group and audit window Unique eligible people with qualifying events or procedures

Count each person once, even after multiple procedures. Confirm eligibility and medical clearance.

12-month index period

For example, enter the calendar year or plan-year dates being reviewed. Aggregate period only.

Post-event participation review window

Apply the same window after each person’s index event. Allow full follow-up and claims runout. A shorter audit can miss later starts; this selection describes the counts you enter and does not estimate later care.

2. Describe participation

Observed enrollment rate (%)

Published commercially insured cohort benchmark, editable. Your workforce and audit window may differ.

Potential enrollment target (%)

A user-selected scenario assumption, not a demonstrated achievable effect.

3. Estimate incremental program fees Sessions per additional participant

36 is a course benchmark for this illustration, not a requirement for every person.

Fee per session ($)

$40 is a user-provided illustration, not a nationwide price or complete program cost.

One-time additional cost per participant ($)

The $0 placeholder omits assessments, physician oversight, facilities, administration, and other costs. Enter the appropriate additional amount.

ILLUSTRATIVE CARE GAP

What appears in the follow-up?

Example estimates based on the selected enrollment rate.

Qualifying eligible people: 20
Estimated CR participants: 4.8
People without a documented CR claim: 15.2
Potential additional participants at target: 5.2

An apparent documentation/participation gap, not confirmed untreated people. Example counts are benchmark-derived estimates.

Indicative incremental program fees$7,430

Calculated without rounding intermediate participant estimates.

A target below current participation produces zero additional participants. Fractional modeled people describe a scenario, not identified employees.

OPTIONAL FINANCIAL SCENARIO

What could fewer hospital admissions mean financially?

Explore illustrative potential savings

Supply your own baseline hospitalization probability, select a relative reduction assumption, and enter a plan-paid admission amount. No hospitalization reduction assumption is preselected.

Explicit financial assumptions

Baseline probability of any all-cause hospitalization (%)

Without CR, for a comparable eligible group over the selected outcome interval. Do not substitute an index-procedure cost or repeat-stent rate.

Hospitalization outcome interval

Match baseline risk and the selected reduction assumption to this same interval. It is distinct from the claims audit window.

User-selected relative hospitalization reduction (%)

An illustrative assumption, not a verified default clinical effect. Explore lower values, including zero; even a large assumed benefit may not offset fees.

Average plan-paid all-cause admission amount ($)

Prefer your plan’s paid claims for the comparable group and interval, not billed charges, Medicare averages, or PCI/CABG procedure prices.

Illustrative potential avoided admission claims$0

Illustrative potential net savings after program fees$0

Potential net savings can be negative, indicating modeled added cost. These are conditional estimates, not measured savings. The probability model counts people with an admission and assumes one paid admission per affected person; it does not model recurrent admissions.

Relative risk reduction assumption
Absolute risk reduction
Baseline → scenario hospitalization probability
Expected admissions without → with scenario
Expected difference in admissions
Break-even absolute risk reduction per participant

Sensitivity: same inputs with lower relative reduction assumptions
Relative reduction	Absolute reduction	Potential avoided claims	Potential net savings

WHAT TO ASK YOUR TPA OR BENEFITS CONSULTANT

Ask for the follow-through, not just the procedure price.

Count unique people with qualifying events in a defined 12-month index period. Deduplicate multiple procedures and confirm clinical and benefit eligibility.
Check referrals where those data exist. A referral, medical clearance, and actual attendance answer different questions.
Match at least one billed CR session within a transparent post-event window. Review 12–16 weeks and a longer sensitivity window using complete follow-up.
Review attended sessions, enrollment, completion definitions, payer-specific coding, coverage, exclusions, and data completeness. Confirm codes with the benefits administrator.
Allow for claims lag, loss of enrollment, alternative delivery, and services not captured in the extract. Investigate apparent gaps with clinicians before concluding that care was missed.

FROM HEALTH BALLISTICS™

Look for what the claims do not tell you.

Health Ballistics™: A New Healthcare Architecture for Precision Health connects measurement with decisions that can change future health and medical-cost exposure.

Chapter 24, “The Blind Spots in Claims Data,” pp. 170–176: the cardiac rehabilitation claims crosswalk, especially pp. 173–176.
Chapter 26, “The Health Wealth Economy,” pp. 181–184: rehabilitation evidence and access, especially pp. 182–184.
Chapter 23, “From Clinic to Employer ROI,” pp. 165–169: the separate prediabetes cost exercise.

The book supplies the author’s conceptual framework. Clinical outcome evidence comes from the cited research.

Explore the book

What would this question reveal in your workforce?

Talk with Peter about aggregate findings, care gaps, and practical next steps. Please do not send identifiable employee health information.

Talk to a Human about your workforce

Sources, definitions, and methodology

Evidence and calculator version: October 20, 2026 · Draft 1.0 · Illustrative educational scenario, not a clinical or actuarial prediction.

Source register and limits of interpretation
Source / version	Population and interval	Use in this tool
Pollack LM et al. Cardiac Rehabilitation Trends Among Commercially Insured Adults in the United States, 2017–2023. Circ Cardiovasc Qual Outcomes. 2025;18:e012067. DOI: 10.1161/CIRCOUTCOMES.125.012067.	MarketScan adults aged 18–64; qualifying events 2017–2022, follow-up through 2023. 143,870 unique people. Session and completion metrics use enrollees as denominator.	24.2% enrollment reference; 13.9 sessions; 9.6% of enrollees completed ≥36. Not a plan-specific participation estimate. PubMed record and methods.
Dibben G et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2026;9:CD001800. DOI: 10.1002/14651858.CD001800.pub5. Published September 18, 2026.	Adults with coronary heart disease; outcome analyses depend on follow-up. Short-term interval: 6–12 months.	Descriptive clinical context only. Full published review and summary-of-findings reconciliation remain outstanding. No default effect estimate or absolute-benefit conversion is used.
Cochrane accessible news summary, September 18, 2026	Publisher’s overview of the review.	Context only. News, plain-language, and abstract figures are not combined in financial estimates.
Health Ballistics™, Chapters 23, 24, and 26	Author’s claims-audit and employer-cost framework; printed page references above.	Conceptual framework, not independent clinical outcome evidence.

How the scenario is calculated

Documented participants = min(eligible people, entered participants) in claims mode, or eligible people × observed rate in example mode. Apparent gap = eligible people − documented participants. Additional modeled participants = max(0, min(eligible people, eligible people × target rate) − documented participants). Incremental fees = additional participants × (sessions × session fee + other per-person cost). No intermediate estimates are rounded.

For the optional financial scenario: expected admissions without = additional participants × baseline probability; expected admissions with = expected admissions without × (1 − user-selected relative reduction). Potential avoided claims = admission difference × average plan-paid admission amount. Potential net savings = potential avoided claims − incremental fees. Absolute risk reduction = baseline probability × relative reduction, reported in percentage points. Break-even absolute reduction = per-person program fees ÷ plan-paid admission amount.

The model uses the probability of any admission, assumes one admission per affected person, and does not estimate repeat admission counts. It assumes the selected effect applies to the additional participants over the chosen outcome interval. A shorter or incomplete CR course need not produce the same benefit as research programs. Sensitivity rows vary assumptions; they are not confidence intervals. No NNT estimate is combined with this relative-risk model.

Definitions

Qualified / eligible: A unique person with a qualifying event whose clinical eligibility, coverage, and clearance have been confirmed.
Referral: A recommendation or order for CR, distinct from attending it.
Enrollment: At least one attended session; in claims mode, participation is evidenced by at least one documented session.
Completion: At least 36 sessions in the Pollack research definition, not a universal individual requirement.
Claims-observed: Captured in the available claims extract within its stated window, subject to coding, coverage, lag, and capture limitations.
Modeled: An estimate created from selected assumptions, not an identified person, confirmed care gap, or measured financial outcome.

Related guideline, trial, and utilization references

AHA: referral and participation; AHA/ACC referral measure; Trial evidence; Medicare expenditure analysis. These references are also preserved on the employer page. Medicare expenditures and utilization may not generalize to commercially insured populations; no Medicare dollar amount is used as an input default.