Lobby Efforts Ongoing To Have Respiratory Therapy Recognized By CMS

What happens outside the hospital setting

At the present time, respiratory therapy services are not recognized by the Centers for Medicare & Medicaid Services (CMS). Therefore, our services outside the hospital settings cannot be reimbursed for. This works to the disadvantage of both us RTs and the patients we serve.

In July of 1965, Medicare was created under Title XVII of the Social Security Act. It was signed into law by then President Lyndon B. Johnson. The act provided health insurance to people over the age of 65.

There are various professions that are listed under the bill. These include physicians, nurses, physical therapists, speech therapy, and occupational services. This made it so that any services provided by  these professionals was reimbursable by CMS.

This is why you see nurses in nursing homes but no respiratory therapists in nursing homes. This is why you see nurses working for home health care services, but rarely see respiratory therapists working for home health care services. This is why physical therapists can open up physical therapy clinics outside hospital settings, and you see no such respiratory therapy clinics.

So, basically, if it were not for these professions being recognized by CMS, these services would not be provided. Lacking these services, patients wouldn't get the ideal care after being discharged that they so deserve. This would have a negative impact on patient outcomes, and would negatively impact patient morbidity and mortality.

There was a push to have respiratory therapy added to the bill. However, despite respiratory therapy being an established profession by 1965, the profession was not listed on the bill. For this reason, respiratory therapists are only able to work in the hospital setting.

Yes, it was recognized that respiratory services might be needed outside the hospital setting. But, it was determined that our services could be just as easily be provided by nurses.

However, since that time various studies show that our profession is the best at teaching inhaler and nebulizer technique to the COPD and asthma populations. And that patients surely would benefit from our services outside the hospital settings. So, various organizations, such as the American Association for Respiratory Care (AARC) and the Allergy & Asthma Network, have been pushing for bills to recognize respiratory services.

Each year, the AARC and the Asthma & Allergy Network sponsor lobby weeks on Capitol Hill. Over the years they have sponsored various bills that would recognize our profession, thereby allowing our services to be funded outside the hospital setting.

A few years ago there were lobbying efforts to include respiratory therapy on the appropriations bill that funds the Department of Health and Human Services. This did not get through, but perhaps it will in the future.

In 2013, there was a bill called the Medicare Respiratory Therapist Access Act. If passed, this would have allowed for reimbursement for self management education for COPD patients by qualified respiratory therapists.

A bill introduced to the 116th Congress is H.R. 2508. This bill is called the "Breathe Act." If passed, would provide a pilot program to include respiratory therapists as telehealth practitioners under the Medicare Program. This bill doesn't go far enough, but at least it would be a start.

Sources.

1. "Whats our plan to get Respiratory Therapy service reimbursed by Medicare and Insurance for SNFs," COPD foundation. 
2. "Allergy & Asthma Network Urges Support For the Following Bills Before the 116th Congress," Allergy & Asthma Network. 
3. "Should Medicare Allow Respiratory Therapists To Independently Practice?" Chest Journal. 

Does your patient need and qualify for oxygen therapy

The following was originally published on April 15, 2015 at healthcentral.com/copd.

Do you need oxygen therapy? 

Sometimes people with COPD need to inhale more oxygen than what is provided in the air. The way this is accomplished is by using oxygen therapy. So what is oxygen therapy, and do you need it?

Oxygen in room air contains 21 percent oxygen. Usually this is plenty of oxygen. However, certain disease conditions, such as what may occur as COPD progresses, or during COPD flare-ups, may create areas inside your lungs where oxygen is inhaled, but cannot get to your bloodstream. When enough of these areas exist, your blood oxygen levels may decline.

To learn more about oxygen and oxygen levels, please read my post “Understanding Oxygen and Oxygen Levels with COPD.”

What is oxygen therapy? It involves inhaling supplemental oxygen, or oxygen percentages that are greater than 21 percent. It allows you to inhale 22-100 percent oxygen, depending on the device used.

Nasal Cannula. This involves inserting prongs into your nose. A low flow allows you to inhale anywhere from 22-44 percent oxygen. This is all that is needed for most people with COPD. It is very comfortable and tolerable.

Masks. A variety of masks can used to provide up to 100 percent oxygen. These are not used very often, but are available if needed.

To learn more about oxygen devices read my post “Oxygen Therapy Made Easy.”

There are three ways of getting oxygen therapy into your home.

1. Compressed Oxygen Gas Cylinders. These are tanks with regulators and flowmeters. Some are larger and stay at your home, and some are smaller for travel. 
2. Liquid Oxygen. They hold more oxygen and are smaller and more lightweight, making them ideal for people who are constantly on the move.
3. Oxygen Concentrators. They are electronic devices about the size of end tables that make oxygen by concentrating oxygen from room air. These are nice because, so long as you have electricity, you always have a source of supplemental oxygen. 

These are described in more detail in the post “The Three Types of Oxygen Therapy for COPD.”

Most people who require oxygen therapy will use oxygen concentrators at home, and have a variety of tanks as a backup in case of a power outage, and also for travel.

Do you need oxygen therapy? If your oxygen levels are chronically low, this puts strain on your body that can shorten your lifespan. That said, supplemental oxygen is the only drug proven to prolong life.

Common signs and symptoms of low blood oxygen levels (hypoxemia) are.

• Bluish tinge to your fingertips, toes and lips
• Rapid heartbeat
• Sweating
• Confusion
• Feeling winded, especially with exertion

If you, or a loved one, observes these signs, you should seek medical attention immediately. Your doctor may at first treat your COPD flare-up. Once you are deemed to be in a “chronic stable state,” your doctor may qualify you for oxygen therapy.

Do you qualify for home oxygen therapy? The qualifications for home oxygen are set by the Centers for Medicare and Medicaid Services (CMS), and they prefer numbers over subjective signs and symptoms. So qualifying is determined by the following test results:

• Arterial Blood Gas: Your PO2 is at or below 55
• Pulse Oximetry: Your SpO2 is at or below 88 percent

The basic premise goes like this: you qualify for oxygen therapy if your:

• PO2 is 55 or less or your SpO2 is 88 percent or less at rest while breathing room air.
• PO2 is 55 or less or your SpO2 is 88 percent or less while you are sleeping; or, if your PO2 drops 10 percent or more, or your SpO2 drops 5 percent or more, while you are sleeping, and you are also displaying symptoms of hypoxemia. 
• PO2 is 55 or less or your SpO2 is 88 percent or less while you are exercising.

How much oxygen do you need? The goal of oxygen therhapy is to provide you with the least amount of supplemental oxygen to maintain an SpO2 at 90 percent or greater. Usually, a low flow of 2-3 LPM using a nasal cannula works great. And, considering the benefits, most people tolerate it very well.

Further Reading:

• Understanding Oxygen and Oxygen Levels with COPD
• The Natural Progression of COPD
• The Three Types of Oxygen Therapy for COPD
• Oxygen Therapy Made Easy
• How to qualify for home oxygen therapy
• What are blood gases
• Pulse Oximetry Monitoring -- Do You Need It?: 

New mandate may benefit COPD patients

This post was originally published at healthcentral.com/copd on 5/5/14

Obamacare may benefit COPD patients

The Patient Protection and Affordable Care Act, nicknamed Obamacare by some, might perhaps be the most controversial law of our generation. Despite this, it might prove to be a boon for patients with chronic obstructive pulmonary disease (COPD).

According to the Centers for Medicare and Medicaid Services (CMS):

“Section 3025 of the Affordable Care Act added section 1886 to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to hospitals with excess readmissions, effective for discharges beginning on October 1, 2012."

Readmission is defined as any patient who is readmitted to the hospital within 30 days of discharge from the same or another hospital. While the initial conditions applicable to this measure were heart attack, stroke, heart failure and pneumonia, COPD has since been added.

While hospitals may already be punished for excessive readmissions for these other diseases, hospitals may start being punished for excessive COPD readmissions beginning in October 2014.

So an effort is now ongoing by hospitals and hospital groups to create programs meant to benefit COPD patients.

Perhaps the driving force behind this movement are the following statistics, provided by the American Lung Association, the COPD Foundation and the Agency for Healthcare Research and Quality:

• COPD is now the third leading cause of death in America
• About 1 in 5 hospitalized individuals over 40 has a diagnosis of COPD
• 24 million adults have it
• About 715,000 patients were discharged from hospitals with a COPD diagnosis in 2010
• The disease cost the nation an estimated $49.9 billion in 2010
• Over 800,000 hospitalizations per year from COPD
• About 20% of hospitalized patients are readmitted within 30 days
• Up to 76% of readmissions occurring within 30 days are potentially avoidable
• Avoidable hospitalizations and re-hospitalizations are potentially painful, harmful, and always prolong recovery
• The average cost of an initial hospital admission with COPD is $7,100
• An average cost for a 30-day readmission with COPD is $8,400, which is 18% higher than for the initial admission

It’s understandable that COPD patients will have flare ups and will need to be admitted to a hospital from time to time. However, readmissions can often be prevented. So the crux of this movement is to prevent COPD readmissions.

So, should you ever find yourself admitted to a hospital with a diagnosis of COPD, what changes should you expect to see? Based on successful programs already created, here is what you might find.

1. More questions: Health care providers are going to ask you a plethora of questions to learn more about you and why you were admitted or readmitted. Questions may include: Do you understand your disease? Do you understand your medicine and why you need to take it exactly as prescribed? Do you know how to use your inhalers and nebulizer properly? Do you understand why you need to take your medicine? Do you understand how to prevent lung infections? Do you understand why it’s important that you quit smoking? Do you know how to recognize your COPD signs and symptoms? Did you wait too long to come in?

2. Better education: You will literally be the center of attention for health care providers, who will visit you often, not just to treat you, but educate you about your disease. You will learn basic lung anatomy, and how COPD affects your airway. You will learn about pulmonary function testing and how COPD is diagnosed. You will learn the stages of COPD and what one you are in. You learn that, while there is no cure, COPD can be controlled. You will learn about COPD medicine, how they work, and why it’s important to take them exactly as prescribed. You will learn the difference between maintenance and rescue medicine. By the time you are discharged you will know this disease inside out and upside down. By the time you go home you will feel confident and competent about how to effectively manage your disease.

3. Caregiver involvement: In many instances you will need help managing your disease. This person could be a spouse, parent, child, other relative or even a friend. If you have a caregiver, this person should be involved in the entire process. Every time there is a scheduled teaching opportunity, your caregiver will be strongly encouraged to be present.

4. COPD Action Plan: This is a plan that teaches you to recognize your COPD signs and symptoms, and what action to take. Ideally, you will learn to recognize when your breathing is just starting to flare up so that the action you take stops it. The idea here is to help you treat yourself at home so you do not need to seek help. However, should you need it, the plan will also help you decide when to call your doctor, and when to call 911.

5. Bronchial Hygiene: Since COPD is a condition that may result in increased and thick secretions blocking your air passages, you will need to learn methods of clearing these from your air passages.

6. Breathing techniques: There are certain breathing techniques that may help you to keep your lungs open. One technique commonly taught is pursed lip breathing, where, when you are having trouble breathing, you purse your lips and slowly exhale. You may also be taught some methods that should help you create a better cough.

7. Pulmonary rehabilitation: This is a program made just for COPD patients to help you keep in shape. It is a proven fact that if you keep your heart and lungs strong, you are more likely to stay healthy. Upon discharge, arrangements should be set up for you to participate in such a program, with transportation arranged.

8. Follow-up interview: This might include a visit to your home or a phone call by a caregiver. The purpose is to make sure you are feeling okay, but it is also to answer any questions that might have developed since your discharge. For instance, there have been instances where patients kept returning to the hospital with a COPD flare-up, and upon visiting the patient's home it was realized the nebulizer or oxygen equipment wasn’t working right. So, this is our opportunity to keep an eye on you, making sure you’re doing alright post-discharge.

9. Follow-up doctor visit: Not only will staff schedule you a follow-up appointment with your doctor in 2-10 days, they will make sure you have transportation. This is the type of thoroughness that is essential to helping you control your COPD.

10. Discharge instructions: Last, but not least, you will be discharged. In the past this may have been the only education you received during your visit, but no more. Now, by the time you are ready to go home, you will have already been presented with any wisdom you need to live with COPD, and had time to hash it over in your head and review it with your caregivers. Ideally, anything you hear at the time of discharge will simply be a summary of what you already know.

Bottom line: It’s surprising it took a government initiative to focus on preventing COPD readmissions, as studies clearly show they are both unnecessary and costly. Likewise, it’s impossible to know what methods individual hospitals will create; although, one might imagine that any efforts in this regard will help COPD patients live better lives.