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. 

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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The New Healthcare Normal

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.

The future of big data

Vernon Pertelle

Healthcare organizations and providers are charged with having the ability to quantify the data obtained from patients in the electronic health record (EHR) to show that the resources utilized in the care and treatment of patients results in better health outcomes while reducing costs.  

The expectations under the new healthcare laws and regulatory requirements; call for each entity whether hospitals and health systems or physicians to demonstrate meaningful use three (3) in which the data shows that the entity effectively cared for their patients.  So what does this mean for data analytics and dedicated resources with clinical and financial expertise to compile the information in a manner that is useful for the organization, relevant to Centers for Medicare and Medicaid Services (CMS) and allows for performance improvement?  

The future, current trends and direction of the New Healthcare Normal of pay for performance creates opportunities for information technology (IT) professionals that have expertise in clinical informatics and financial systems, budgeting and resource allocation. 

In order to effectively quantify your organization's performance in demonstrating meaningful use, establishing successful practices that lead to better health outcomes and cost reductions; as well as creating consistency with regards to connecting financial expenditures with clinical activities, each organization must create a new role that is focused solely on meaningful use demonstration.  

The individual is potentially a clinician with a passion for IT and formal education & training; and most important, understands the link between financial and clinical data.  This new role is one that may have existed in some organizations well in advance of the changes under the New Healthcare Normal; however will be essential for hospitals, health systems and physician practices to ensure the entity receives the rewards for performing better.  In addition, the role becomes a major component of the budgeting team to ensure resources are planned for and implemented at the right places, doing the right jobs, and for the right purposes.  The person is potentially a mid-level manager or director that reports in a matrix to the CFO, CNO; with regular interface with the CEO to ensure adequate authority and influence over the various teams and individuals accountable for performance.  

We have a plethora of data due to the systems and significant amount of information compiled via the EHR, financial systems, human resources and purchasing that can be leveraged to transform organizations into well run, efficient and quality driven entities. However there must be a dedicated resource that is accountable for quantifying the data in a manner that shows cost effective healthcare to demonstrate meaningful use.  The individual will help to shift the data paradigm to identify successful practices that can be shared throughout the organization and ultimately the healthcare industry.

The KentuckyOne Case - Respiratory Therapist (RT) Value

Vernon Pertelle

When reviewing the article regarding the changes that were announced: KentuckyOne cuts respiratory therapists from emergency rooms; a few thoughts came to mind. First and foremost is the fact that the health system is a Market Based Organization (MBO) of Catholic Health Initiatives (CHI) of which, I was employed as the Vice President of Clinical Operations at another one of CHI's MBOs.  So I understand fully the period of discernment that occurs when making difficult decisions.  Second is the fact that respiratory therapists (RTs) are essential to meet the complex medical needs of patients with emergent and acute conditions of the lungs. Third, is that the perceived value relative to the actual benefits of the expertise RTs offer, was not clearly understood or articulated during the deliberations that concluded with the removal of respiratory therapists in the emergency rooms. 

The administrators of KentuckyOne made a decision that I'm sure they believed was in the best interest of Stewardship and possibly Growth; however may not have considered the potential negative impact on Quality and People. Each of the aforementioned [People, Quality, Stewardship and Growth] are core strategies of CHI and their MBOs.  Based on my understanding of those strategic pillars, having experienced them first hand (and selected as Top Talent in 2011 by demonstrating them); it is difficult to understand how respiratory therapists would be eliminated from the emergency rooms.  

The Centers for Medicare and Medicaid Services (CMS) has included Chronic Obstructive Pulmonary Disease (COPD) as one of the conditions that the Hospital Readmission Reduction Program (HRRP) will penalize hospitals for readmission. Respiratory therapists represent the single best resource to mitigate penalties for readmissions of patients with COPD.  The impact on Quality and frankly the patient's perceptions of care and their experience will be negative and ultimately will affect Growth, Stewardship and People. Nurses in the emergency room will be required to take on the role of respiratory therapist. The learning curve that the nursing staff will experience is difficult to quantify because it is possible (although not likely) that the nurses had begun a training program in anticipation of the change.  While nurses, based on their scope of practice are licensed to perform the procedures; their competence and skills may be lacking and as a result compromise health outcomes and lead to increased costs.  In FY 2014 the maximum penalties increased to 2% and in FY 2015 the maximum penalty will increase to 3% for the additional conditions including COPD.

Respiratory therapists add value to the goals of improving quality while reducing costs; which are central principles of the Affordable Care Act.  Eliminating the role of respiratory therapists in the emergency rooms may result in short-term savings for the health system, however the long-term repercussions on People, Quality, and Growth could be greater. Patients have choices about where they receive their care and they are more informed now, more than ever before, thus the changes will potentially impact the volumes of the health care system in outpatient settings, which is an area for Strategic Growth of CHI and their MBOs.  Maybe there needs to be reconsideration of the changes and rather than eliminate the role of respiratory therapists; expand the role in non-traditional areas such as Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs) and take advantage of the expertise respiratory therapists provide and create solutions to improve quality while reducing costs.

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Time for Change for the Better of the Patient

Vernon Pertelle

The New Healthcare Normal, requires organizations and health care workers to retrench and repackage in order to ensure survival in the era of the Affordable Care Act (ACA).  Market consolidation and new entrants are causing disruption in some areas, which is cause for concern for those that have not been proactive and have effectively prepared for change.

The healthcare industry in our country is relatively young, thus has experienced transitional evolution to where it should be focused - - - on the patient.  Too often we have been task oriented based on activities that generate revenue. Quality obviously has been a focus by most, but has not resulted in better health outcomes and reduced costs.  So, we are now charged with truly placing the patient at the center of everything we do on a daily basis.  It is interesting to note, that while we understand the needs of patients, it is much more enlightening when you or loved-ones are actually a patient; particularly if you are a healthcare worker.

The changes that are occurring may not be perfect for everyone but we have to start somewhere.  It is the fact that the costs overall are out of control and millions of Americans have lacked access to important care and services that could prevent serious illness and most important poor quality of life.  We frankly need to try to adjust in a way in which the patient and each citizen benefits from quality and affordable healthcare whenever they need it.  I was moved recently by a speech by president John F. Kennedy while visiting the presidential library in Boston, to learn that the prevailing issues of the day during the 60's included access to quality and affordable healthcare. So, if we consider the major events that have occurred in our nation, healthcare is right at the forefront of the need for change and improvement.

So let's for a moment reflect on the traditional healthcare models and how effective or frankly ineffective they have been to improve health and financial outcomes.  Overall we have struggled to improve in the very basic areas due to a clinical-financial disconnect.  While there has been significant evidence of certain interventions and clinical services to improve outcomes, little has been done to implement some of the services because of the lack of coverage or reimbursement.  Now we have an opportunity under Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs) to finally utilize services and solutions irrespective of whether or not they have been covered traditionally.  The key of course is to have the courage and innovative fortitude to integrate alternatives that will make an immediate impact on the improvements in health and financial outcomes.

The reality of change is here to stay and despite how you may feel about the politics or the policies, we absolutely must do something and rethink how we deliver healthcare in our country, so that the patient benefits from our efforts - - - for a change.