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.

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.  

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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