Home Not So Sweet Home

Vol. 17 •Issue 2 • Page 29
Home Pathways

Home Not So Sweet Home

RTs help patients thrive, but lack of evidence-based research has led to reimbursement woes.

Hospitals employ the vast majority of respiratory therapists, but a growing number of RTs now work in home care. The opportunities for advancement, promotion, and significant salary increases occur more frequently in home care than in other settings.

The need for these RTs also should grow in the coming years due to the aging baby boomer population, the impact of environmental problems, and technological treatment advances that allow patients to be discharged home sooner and, in many cases, sicker.

These professionals, however, face one huge challenge: reimbursement. Reimbursement still does not exist for RTs in home care. In fact, payment for the clinical services provided by RTs is bundled in the reimbursement for equipment and the amount continues to decline.

A clinical foundation for effective therapy (positive patient outcomes) must be developed in order to create a payment system that supports the process of respiratory care and appropriate reimbursement of equipment, said Bob McCoy, RRT, FAARC, managing director of Valley Inspired Products, Apple Valley, Minn.

“We need to scrap the current system,” said McCoy, also chair-elect for the home care section of the American Association for Respiratory Care. “It started wrong and has gotten worse since its inception.”

Positive outcomes

The RT must get back into a clinical-service mode and focus on therapy because positive outcomes are based on the therapeutic nature of services provided by RTs and to a lesser degree the equipment, McCoy said.

His firm is one of a few organizations that supports research to validate the claims purported by manufacturers regarding the effectiveness of equipment. Even though RTs are knowledgeable regarding equipment, the equipment is a tool in the hands of skilled clinicians.

McCoy, like many of us in the home care industry, believes reimbursement should be predicated on good health outcomes relating to the services provided by RTs.

Unlike other allied health professionals (e.g., nurses, physical therapists, speech-language pathologists), RTs in home care have failed to document adequately evidence-based outcomes in peer-reviewed medical journals. This has resulted in the current reimbursement challenges.

Kent Christopher, MD, RRT, FAARC, a member of the Board of Medical Advisors of the AARC, and I spoke recently regarding the challenges home care RTs face. We discussed the need for proactive involvement by key industry RTs to help design the framework for outcomes that ultimately would support arguments for reimbursement.

This opinion is shared by many of our colleagues, but we have yet to make a significant impact.

New technology, new opportunities

The opportunity to create an outcomes-based home care delivery system exists now more than ever with the development of new technology.

Continuous positive airway pressure and some oxygen delivery systems are equipped with remote monitoring technology or telephony that allows the home care provider to assess patient compliance and monitor effectiveness of therapy.

New oxygen delivery devices such as portable oxygen concentrators let patients increase their activities outside of the home, travel by car and plane, participate in exercise or rehabilitation, and essentially eliminate the “tether” to the home that reduces mobility.

“There has been good progress made with the development of new equipment, yet education has not kept pace,” McCoy said. Too often knowledge of equipment is gained from the manufacturer’s sales representative rather than an independent source or RT.

More education needed

Dr. Christopher and I also spoke of the need for post-graduate symposiums at annual conferences. This would help educate physicians on the diverse types of equipment now available to patients and, more importantly, gain their support for clinical trials using home care RTs to establish evidence-based outcomes.

However, the greatest need for education is with family doctors since non-pulmonary physicians write the vast majority of prescriptions for patients who require oxygen therapy.

Thomas J. Williams, MBA, RRT, managing director of Strategic Dynamics Inc., Scottsdale, Ariz., believes RTs are absolutely essential in home care for education and clinical services.

“Roughly 80 percent of the prescriptions for home oxygen are written by non-pulmonary care physicians such as family practice, internal medicine, hospitalists, etc.,” he said.

These physicians often do not have the time, resources, or inclination to spend time explaining to patients why they have been placed on oxygen therapy or to educate them on the technology available, Williams said. “In home care instruction on equipment, assessment of benefit, and need for changes with certain respiratory equipment is managed by the RT.”

Strategic Dynamics conducts research and sales training, and develops evidence-based reviews and assessments of respiratory equipment. RTs are experts in employing sophisticated questioning techniques to understand the patient’s activities of daily living so they can recommend oxygen equipment that will be clinically effective.

“There are many factors involved in selecting the most appropriate equipment for the patient,” Williams said. “Furthermore, when patients have a question about their equipment, they call their home care provider and ask for the RT. They do not call their physician.”

Make your voices heard

Despite the losses in reimbursement, home care respiratory therapists remain staunch patient supporters.

“We have always embraced the role of patient advocate,” noted Nick MacMillan, RRT, FAARC, national clinical director for Rotech Healthcare, Orlando, Fla., and former home care section chair for the AARC. “Although in today’s challenging home care environment, our role of advocate must carry over in the political and reimbursement arenas.”

MacMillan believes all RTs must contact their elected representatives to make their voice heard on behalf of the patient. They also should encourage the patients they serve to contact members of Congress to describe the essential role of RTs in home care.

Lack of quantifiable data

Some states mandate the use of RTs to set up certain types of respiratory equipment, so policymakers need to be educated on the significance of reimbursement exclusive of equipment.

During hearings with the Centers for Medicare and Medicaid Services, Joe Lewarski, BS, RRT, FAARC, and I participated as expert witnesses and illustrated in detail the role of RTs and the importance of reimbursement in home care to effectively establish quality standards.

Home care represents the single most effective solution to reduce health care expenditures. Mobile oxygen-dependent patients live longer and are healthier, while sedentary patients are among those most frequently hospitalized and thus use up our health care dollars faster.

Yet because of the lack of quantifiable data, home care is consistently targeted for reductions in reimbursement at the federal level. This is despite mandates that require the use of RTs in home care at the state level.

Vernon R. Pertelle, MBA, RRT, is senior director/assistant vice president for Tri-City Healthcare District, Home Care, Occupational Health and Wellness, and Rehabilitation Services, Center for Wound Care and Hyperbaric Medicine, Oceanside, Calif. He can be reached at [email protected].

Milestone Legislation Aims to Reimburse Home Care RTs

A bill introduced by Rep. Mike Ross (D-Ark.), a member of the Health Subcommittee of the House Energy and Commerce Committee, seeks to improve patient access to important services provided by respiratory therapists outside of the acute care setting.

If successfully signed into law, this proposed legislation will provide the support for RTs to be reimbursed for services they perform in the home. Current reimbursement rules focus on the price of home care equipment and do not recognize the value of RTs who assess patients’ needs, select appropriate products, and monitor the effectiveness of treatment.

Clearly RTs who work in home care realize the importance of the services afforded to patients who receive oxygen therapy; however, we have had an uphill battle in quantifying the benefit of these important services for policymakers and, in particular, those responsible for establishing policy for chronic care at the Centers for Medicare and Medicaid Services.

Thanks to the efforts of individuals and organizations such as the American Association for Home Care and the American Association for Respiratory Care, the possibility for coverage exists. The Medicare Respiratory Therapy Initiative, H.R. 3968, would allow RTs to provide independently smoking cessation, asthma management, and instruction on self-administration of respiratory medication (including but not limited to inhalers and nebulizer treatments) to asthma and chronic obstructive pulmonary disease patients, as long as the services are prescribed by the patient’s physician and are under the physician’s general supervision.

Today, patients diagnosed with COPD, the fourth leading cause of death in the country, only receive the benefit of RTs’ expertise in acute care, long-term acute care, and — to a small degree — skilled nursing facilities, unless they are prescribed high-flow oxygen in the home.

Ross, co-owner of a home medical equipment business, has been a major supporter of home care and is a staunch advocate for reimbursing respiratory therapy services in alternate sites of care. The bill he introduced to the House of Representatives in October must be passed by Congress and ultimately signed by the president before the services can be reimbursed by CMS.

For more information about the legislation, visit the AAHomecare website at www.AAHomecare.org or the AARC website at www.AARC.org.

–Vernon R. Pertelle, MBA, RRT

Who Are Home RTs?

Of the licensed respiratory therapists in the country, approximately 20 percent work in settings outside of the hospital, including home care.

In home care, RTs perform clinical services such as facilitating high- and low-flow supplemental home oxygen; assessing and educating the patient under a physician’s order; instructing and establishing continuous positive airway pressure; instructing patients on the use of nebulizer compressors; and handling complex home mechanical ventilation.

A number of RTs in home care work in medical sales and diagnostics and perform research and education. RTs are branch and area operations managers, vice presidents of sales and operations, and owners and presidents/chief executive officers of home care organizations. They also serve on the board of directors and scientific advisory boards of major corporations and lobby on behalf of the industry at the state and federal level.

Despite the challenges with reimbursement in home care, RTs continue to have significant opportunities for comfortable salaries.

–Vernon R. Pertelle, MBA, RRT