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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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.

Filling the Disease Management Gaps in COPD

Vernon Pertelle

Reflect for a moment about the changes in healthcare over the past five years.  Now think about the transition from filling the inpatient beds and increasing overall volumes for surgical cases to reducing the length of stays and performing more procedures in same day centers or through robotics and minimally invasive methods. 

Then consider the methods and madness surrounding reimbursement for services and products under the Medicare Part B benefit; and the increased level of scrutiny and vigilance with utilization of resources relative to medical necessity.  No matter how you are affected, it is plain to see that things have definitely changed. Some may argue for the better because we are now charged with demonstrating value by improving health outcomes while reducing costs; while others may say things have changed too drastically and the patient will suffer as a result of the shift to value based healthcare.  

We have embarked on a new horizon in which health policy in our country is now focused on the patient. This is a very good thing because the system just might move away from a capitalistic and business centric model in which coverage has been the determining factor about using an effective resource; to one that will help improve healthcare in our country because using a resource that is effective - - is the right thing to do.  

The reality is that Centers for Medicare and Medicaid Services (CMS) has effectively gotten our attention to truly focus on establishing value for our patients; and will reward us for demonstrating better outcomes while reducing costs. 

We now must quantify data that clearly shows the use of resources results in better outcomes while reducing costs.¹ So, in the words of Michael Porter, management guru from Harvard Business School (HBS): "Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge."² So, the question then is how do we deal with the new normal in which we must demonstrate our value? 

Well, it begins with evaluating all of the resources in our armamentarium and critically assessing each intervention in terms of the value it adds to improving outcomes while reducing costs.  Take for instance patients that are diagnosed with Chronic Obstructive Pulmonary Disease (COPD); and the typical historic interventions and resources used to improve outcomes while reducing costs.  

Based on the evidence, we have done a poor job of effectively improving the outcomes of patients to the extent CMS has now included the diagnosis of COPD in the Hospital Readmission Reduction Program (HRRP) for FY 2015. We now must address the need to improve outcomes by considering tangible and effective alternatives that will help improve the overall care and outcomes.  The resource is a respiratory therapist (RT); specially trained, with laser sharp focus on the management of patients with COPD. The key is of course in developing programs and services that are centered on the patient with interventions that improve their engagement with self-management as well as adherence to their treatment plan.  

There are countless examples in regional and even some national managed care organizations on the effectiveness of this resource, yet - - by-and-large - - RT's have not been considered as essential in filling the disease management gaps. That said more must be done to demonstrate value and in essence establish RTs through validated clinical studies to once and for all get a better handle on the management of patients with COPD to improve health outcomes while reducing costs.

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 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 Patient's Experience with Care: Getting out of the box

Vernon Pertelle

We have heard countless clichés regarding the focus on the patient [which of course is intended to improve employee engagement with campaigns] to raise HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey scores.  The reality is that the vast majority of organizations rely on folks on the front lines to positively impact change, however the people who are in direct contact with the patients are typically overworked and stretched so thin that they tend to be task oriented versus patient centric.  The challenges with improving the patient’s perception of care stem from not having enough time to spend with each patient to make them feel like a person instead of an object.  The truth is that 'patient as customer' can sometimes be a burden on the healthcare worker when it comes to delivering exceptional person centered care.  

So, the question is how do we positively impact the patient's experience and most importantly how do we embed the processes and tactics into the culture of an organization? The answers vary based on the size and complexity of systems, workflows and whether or not best people is central to the organization.  However one prevailing fact is that people are people and if we start with the patient as person then that is a good beginning.  

The Arbinger Institute produced and wrote a book called "Leadership and Self Deception - Getting Out of the Box", in which the authors emphasized the need for everyone to be mindful of the roles they play in improving a situation or making it worse. The book provides life examples in a story on how various circumstances causes us to treat others as objects that help us accomplish our goals.

The authors have coined the term as "being in the box".  This of course is in contrast to viewing others as people, with hopes, dreams, desires and needs in which case the person is then considered to be "out of the box".  

It all sounds interesting right? It actually is and the book is very insightful and should be mandatory reading for an organization that is trying to shift the culture to one of accountability and patient centricity.  Put plainly, when a person is "in the box", they are essentially betraying themselves by not fulfilling their obligation to view each individual as a person.  Just imagine for a moment how you may have interacted with someone yesterday or today in which you were so focused on completing a task that your only concern was how the person [or object in this case] would contribute to you getting the job done.  This type of behavior limits our ability to excel, be fully engaged and mindful of the individual as a person. 

We often try to treat each individual as a person; but when we are deceived by the need to get the job done, and focused on our selfish needs; it forms the basis of self-deception.  This leads to blaming others, viewing ourselves as righteous, thus justifying our behavior.  In essence self-betrayal in practice causes self-deception.  When people question our behavior, we view them as enemies, however when they reinforce and agree with our behavior we view them as allies. 

When we apply these same concepts to patient care it is easy to understand why it is difficult to sustain the gains made from campaigns to improve the patient's perception of care. If we focus on the results alone then we are "in the box". When we are too busy with the task and our own results, versus the patient and what's best for the patient as a whole then we treat them as objects. 

The problem with being in the box is that it causes lack of commitment to each other and the team; conflict, stress, lack of trust, accountability and poor communication. The way we get out and stay out of the box is by having the servant mentality, being mindful of the needs of others and focused on the results of the organization and success of the team instead of ourselves.  So, now think for a moment, and ask yourselves the question:  How often am I "in the box" toward others?  As a leader, how often am I in the box towards my colleagues and subordinates? As a caregiver, how often am I in the box towards my patient? You'll be surprised by the answers.

In order to be effective with consistently improving the patient’s experience with care, the focus must be on the patient as person and must be a part of the culture.  Take a chance and read the book, then share it with others in your organization.  Then, suggest the book be a requirement of all new hires as well as existing staff, then have each person create three powerpoint slides in which first they describe their reaction when first asked to read the book; second, their perception after reading the book and third what they intend to do with the new knowledge.  Your patient’s will be the direct beneficiaries and your scores regarding their perceptions of care will improve.

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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.