Pulmonary Horizons 1st Annual COPD Conference - San Diego, CA

www.pulmonaryhorizons.com

Bob McCoy, RRT

Brenda Salas, FNP

Trina Limberg, RRT

Tom KallStrom, RRT - ACA Presentation

Vernon Pertelle

Vernon Pertelle

Tom Kallstrom, RRT

Tom Kallstrom, RRT

Engaged Participants

Tom Kallstrom, RRT

Jim and Mary Nelson

Brian Carlin, MD

Brian Tiep, MD

Brian Carlin, MD

Jim and Mary Nelson, Jean Rommes

Telehealth for Chronic Obstructive Pulmonary Disease (COPD): Opportunities for Respiratory Therapists (RTs)

Vernon R Pertelle

The New Healthcare Normal under the Patient Protection and Affordable Care Act (PPACA) contains several provisions that create new and emerging opportunities for RTs to leverage technologies to improve health outcomes and reduce costs associated with the care of patients COPD. 

The Centers for Medicare and Medicaid Services’ (CMS’), Centers for Medicare and Medicaid Innovation (CMI) is charged with identifying innovative health care delivery models that utilize electronic monitoring or Telehealth to coordinate patient care throughout the healthcare continuum.  Telehealth creates the capacity for allied health personnel and physician extenders to provide health services for patients with chronic conditions such as COPD. 

Accountable Care Organizations (ACOs) are required to promote evidence-based medicine and increase patient engagement, coordinate care of patients and report on quality and cost measures (meaningful use), to demonstrate their value in improving outcomes of patients with COPD.  Telehealth and other unobtrusive enabling technologies along with the expertise of RTs are essential for ACOs to succeed.  The face to face requirement, in which physicians certify the medical necessity for skilled home health care services under Medicare Part A or Durable Medical Equipment (DME) under Part B; can be accomplished through Telehealth in coordination with the RT in the home for Medicare beneficiaries with COPD.  

The PPACA also allows for a "Health Home" for patients covered under Medicaid (Section 2703; State Option to Provide Health Homes for Chronic Conditions) as an alternative for patients with COPD in which wireless health technology [or Telehealth] is used to coordinate care, improve the management of complex respiratory conditions and ensure full patient engagement with their treatment plan. The provision supports the use of a team of professionals including RTs to develop the framework for a comprehensive Health Home through the use of Telehealth.

The scope and impact of many of the provisions within the PPACA will be revealed as the rules and regulations are implemented. The opportunities for new and innovative programs involving the use of RTs are great; however requires us as a profession to collaborate, put aside differences and create services and programs to care for patients with COPD.  However, we must eliminate silos and I dare say – competition – in order to establish lasting solutions for RTs to thrive in the New Healthcare Normal. 

Integrating RTs in Accountable Care Organizations (ACOs)

Vernon Pertelle

Despite the myriad of settings RTs have worked; we have not always been keen on embracing change, particularly when it has been driven by new payment systems or reengineering to reduce operational expense.  Respiratory Therapists (RTs) are specialized professionals that help to improve the health and well-being of patients with respiratory illness. RTs have provided clinical services in acute care hospitals, long-term acute care and skilled nursing facilities, home care (skilled under Part A and durable medical equipment (DME) providers under Part B); as well as pulmonary rehabilitation, in medical groups alongside primary care physicians and have demonstrated value in meeting the complex needs of patients.  In the era of The New Healthcare Normal, RTs are poised to be at the forefront of change and distinguish the profession as paramount in creating solutions under the Affordable Care Act (ACA) by serving in various roles in Accountable Care Organizations (ACOs).  

An ACO is a network of physicians, hospitals and other providers, that share responsibility [or financial risk] in coordinating the care of patients with the goals of improving outcomes while reducing costs.  Providers are jointly accountable to ensure cost effective care for their patients and are financially incentivized to cooperate and facilitate practical solutions that support quality and improved care for patients. Hospitals and physicians must meet specific quality benchmarks and the central theme is in managing patients with chronic disease through prevention and intervention that keeps the patient in low cost environments of care.  

The Centers for Medicare & Medicaid Services (CMS) evaluates ACO quality performance using a pre-defined set of quality measures.  The measures are related to patient and caregiver experience with the care, coordination of care and patient safety, and key to RT's role - appropriate use of preventive health services and improved care for at-risk populations [such as patients diagnosed with Chronic Obstructive Pulmonary Disease - COPD].  

CMS will reward ACOs when they demonstrate through meaningful use data that it has saved money, provided high-quality care resulting in improved health outcomes; and prevented utilization of high-cost health care that occurs in the emergency room or from unscheduled hospital admissions.  RTs are key to the success of ACOs particularly as it relates to the care, treatment and management of patients with COPD.  RTs are integral to ACOs accomplishing their goals of high-quality, low cost health care.

So, now is the time to seize the day and create the framework of successful programs that contribute to the goals and objectives of Value Based Health Care (VBHC) delivered in ACOs; and become the authors of change versus waiting on the sidelines for it to occur.

We Must Determine the Clinical Efficacy of Medical Devices

Vernon Pertelle

The demand for Home Medical Equipment (HME) will increase according to an independent study conducted by a Texas based company (See Medtrade Monday Article).  The firm recently conducted market research on the HME industry and forecasts an 8.2% increase, resulting in an industry that will tout well over $12.6 billion by 2018.  Industry leaders lauded the report as evidence on the value of the medical device focused meetings to support education and training on new and emerging medical devices. Additionally, noted the importance regarding the role of medical devices in meeting the needs of patients in low cost environments - the home.

While this is in part true based on the acute care shift; what is lacking currently with regards to medical device education is the evidence on the clinical utility to determine the effect on health outcomes and cost reduction.  This is the crux of the issue with the HME industry and the reason for the challenges that exists today under the competitive bidding program. Value Based Health Care (VBHC) is where the industry must focus its efforts to establish the role of HME providers as essential in the continuum of care.  The equipment is integral to patient care but the focus must be the patient; not the equipment (See Article on Value Based Health Care).

The fact is that not all medical devices are created equal when it comes to performance and frankly not all medical devices meet the therapeutic needs of patients with complex respiratory disease such as Chronic Obstructive Pulmonary Disease (COPD).  While one device may oxygenate a patient to ensure saturations are above 90%; an equivalent device may not - - for the same patient.  The problem is that the process that the Food and Drug Administration (FDA) utilizes to grant Pre Market Approval (PMA) for a manufacturer to sell a device to the general public is fundamentally flawed. Most devices in the category of 510(k) product approvals do not require clinical data for regulatory review in order to be approved by the FDA.

Many of the devices used for patients in the post acute environments are considered Class III (high-risk devices that may cause significant risk of illness or injury); although they do not require the level of rigor in the form of clinical trials to establish the efficacy of the device.  Oftentimes medical devices are approved based on substantial equivalence of a predicate device that has historical evidence of safety and efficacy; but the question is, what was the predicate device approved under? Another device? Rhetorical questions of course, and highlights the vicious cycle of no evidence on the clinical utility (efficacy) of a particular device for patients. The dilemma with the lack of evidence has created the perception of medical devices used in home care as commodities.

In my humble opinion the industry must focus the education and training regarding medical devices on the unique application of a particular device when used on patients; based on objective evidence on the efficacy to ensure positive health outcomes.  This is what the healthcare continuum demands and is a basic requirement under VBHC.  Until the conferences centered on medical devices begins to focus on the patient, improving health outcomes while reducing costs versus generating revenue; the industry will continue to face challenges with price compression and perceptions that it does not contribute directly to solving the problems associated with caring for patients with complex medical needs.  

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Hope for the Future: RT Role in Value Based Health Care (VBHC)

Health care has changed at a rapid pace over the past five years.  While we're fully aware of the changes occurring under the Affordable Care Act (Act), Respiratory Therapists (RTs) are very familiar with change.  We've seen departments in the hospitals go from centralized to decentralized just  to go back to a centralized model; coverage under the 'Medicare Part A' benefit in skilled nursing facilities (SNFs) for RT services discontinued under the Balanced Budget Act (BBA) during the Clinton administration, and now the role of the RT being eliminated altogether at certain organizations. (see The KentuckyOne Case)  We've embarked on an era that I call "The New Healthcare Normal", in which Value Based Health Care is central and the products and services (inputs) are measured based on the relative value of the outputs (improved health outcomes while reducing costs).  

The vast majority of organizations have always prioritized cost reduction and resource stewardship, however payors including and most importantly Centers for Medicare and Medicaid Services (CMS) will only reimburse/reward providers and organizations if they demonstrate improved quality, better outcomes while reducing costs.  The good news about VBHC is that it's designed to improve access to important health care services by removing barriers and encouraging consumers of care to become more engaged to live healthier lifestyles. VBHC is predicated on developing networks that prioritize high-quality and high-value health care to mitigate the need for high-cost medical services.  

This creates an opportunity for RTs to thrive by providing exceptional respiratory patient centered care for patients diagnosed with Chronic Obstructive Pulmonary Disease (COPD).  While there are many more conditions that are relevant under the VBHC methodology; the burning platform is in controlling and reducing costs associated with COPD.  CMS' Readmission Reduction Program will include COPD in FY 2015 and providers, organizations will be assessed penalties based on CMS' Excess Readmission Ratios.  (See CMS Readmission Reduction Program Overview).  CEOs and CFOs of organizations are aware of the penalties and charged with developing solutions to prevent them. The impact on the bottom line could be significant based on the overall revenue of the organization.  Thus the timing is ideal for RTs to demonstrate value through programs and services that can help with the challenges of managing patients with COPD.

The first step is in developing a comprehensive strategic plan that is value based; second is to identify key stakeholders to demonstrate the program's value and third is to build a network that is scalable to assure the program's effectiveness and success.  Now is certainly not the time to wait on the sidelines for the changes to occur; we now have an opportunity to be proactive and develop solutions that establish RTs as a valuable and essential component of the continuum of care.

1 Michael E. Porter and Elizabeth Olmsted Teisberg, Redefining Health Care: Creating Value-Based Competition on Results (Boston: Harvard Business School Press, 2006), 86-87.

2 Michael E. Porter, “What Is Value in Health Care?” New England Journal of Medicine (2010) 363:2477-2481.

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Time to Focus on the Patient and less on the Equipment

Vernon Pertelle

I've been following tweets about the "doc-fix" bill and comments about the replacement of Centers for Medicare and Medicaid Services’ (CMS’) Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) competitive acquisition program [aka competitive bidding]; with the Market Pricing Program (MPP) and have been perplexed by the ongoing focus on equipment.  

Value Based Healthcare is the way in which healthcare is delivered now in our country; the inputs (resources or products used) don’t matter but the outputs (better outcomes at reduced costs) are most important. The DME industry must focus its efforts on providing Value Based Healthcare. 

The president signed into law on Tuesday a bill that gave doctors temporary relief from Medicare's sustainable growth-rate formula that would have resulted in a 24% reduction in their fees.  While the law delays cuts for physicians and extends the deadline for ICD-10 implementation, it did not include within the final markup provisions to repeal or replace the controversial competitive bidding program. 

The stakeholders in the DME industry have consistently criticized CMS' design of the program, and as such pursued an alternative through lobbying efforts with members of congress.  Proponents of the MPP believe a binding bid (unlike the current bidding methods according to industry stakeholders) will assure consistency with prices identified in bid awards and prevent CMS from increasing rates post awards due to their reasonableness methodology.  (CMS raises prices because they feel they are reasonable).

CMS’ perception of the relative importance of binding bids is not the same as the DME industry’s.  CMS believes the program will continue to be widely successful in savings.  Their estimates are $25.7 billion between 2013 and 2022 (see CMS FAQ) for equipment and beneficiaries will save $17.1 billion over the same period.  Repealing or replacing the program is likened to the Affordable Care Act (ACA).  It simply will not happen.  In fact, the ACA calls for expansion of the program nationwide by 2016, beyond the current areas. 

The DME industry must shift its focus and demonstrate value by providing services that help to improve health outcomes while reducing costs.  There needs to be a concerted (not fragmented) effort on program development that involves clinical services, which are essential for the population of patients served by DME providers; those diagnosed with Chronic Obstructive Pulmonary Disease (COPD).  

I recall co-authoring a white paper on behalf of the American Association for Homecare (AAHomecare) with Joe Lewarski, BS, RRT, FAARC, entitled “Value of Homecare: COPD and Long-Term Oxygen Therapy” in which we highlight the importance of oxygen therapy on health outcomes; cost utility and effectiveness.  While oxygen therapy adds value and is important in the treatment and management of patients with COPD; the clinical services are of paramount importance to support patient engagement and education, monitoring to prevent emergency room encounters, hospital admissions and ensure an overall better quality of life. All of which are value-based services.

The reality is that CMS’ focus is on establishing value for our patients; and will reward us for demonstrating better outcomes while reducing costs.  The question then is how do we deal with the new normal in which we must demonstrate value?

There are countless examples in which respiratory therapists (RT's) have demonstrated value at certain organizations by improving the treatment and management of patients with COPD; which has resulted in better health outcomes while reducing costs.  The problem is that the vast majority of DME providers have eliminated or reduced the role of the RT to the extent it would be difficult to create and scale programs in a manner in which they are effective.  Now is the time to retrench and consider where healthcare is today and where we are heading for the future.  We have a burning platform of change that now requires us to focus on the patient and develop meaningful clinical services that add value.  

First Medicare, Then the HMO Act, Now the ACA

Vernon Pertelle

The deadline for enrollment under the new healthcare law has come and gone; well for most it has but for a few [that experienced technical issues], they will have a couple of weeks to sign up for health insurance under the Affordable Care Act (ACA).  The target for total enrolled was initially 7 million; then the Congressional Budget Office (CBO) scaled back the number to 6 million. The final numbers based on preliminary results will be close to the original estimates of the CBO.

So, what does it all mean? There has been a lot of chatter surrounding the need to repeal or replace the law because it will kill jobs, create higher premiums for most and simply not work.  Well, it might not be perfect to begin with - - but we have to begin somewhere if we're going to improve access to care for the uninsured and reduce expenditures as a percentage of the Gross Domestic Product (GDP). The Affordable Care Act (ACA) essentially empowers patients with rights and ensures access to quality and affordable healthcare.  While it’s not clear if the law will be successful, we'll soon find out.   

Travel back in time for a moment: In 1965 under the Social Security Act, Medicare was enacted to ensure seniors received health insurance that was paid for by the federal government.  The measure received significant resistance from the American Medical Association (AMA) for fear of socialized medicine.  However if you try to change reimbursement nowadays there is significant uproar.  Just think: if the pressures against the provision of care for seniors would have resulted in the elimination of the services; the elderly would be hard pressed with paying for health care.  Medicaid soon followed to provide coverage for the poor and has proven to be a safety net for young adults and children. 

Now let’s reflect for a moment on the HMO Act, which changed the organizational structure of providers and hospitals and the way care was delivered.  It formed the basis for managed care, disease management, case management and other important mechanisms of care for a population of patients to improve health outcomes.  

While none of the early efforts were perfect in the beginning; through a series of amendments and changes that followed, the laws have transformed the way we care for patients and has improved over time. The challenges with caring for the uninsured, unemployed or under-insured; or adversely selected patients due to pre-existing conditions has resulted in increased costs with poor outcomes. The goals of the ACA are to give more Americans access to affordable, quality health insurance, and to reduce the growth in health care spending in the U.S.; which ultimately will help to reduce costs and improve health outcomes.  

There are many opponents of the ACA that creates many myths that cloud the facts but we have to start, if we are to improve as a nation in providing basic health insurance for everyone.  Unless there is a viable alternative, we have to support the goals and be mindful of the need for valid change when required.