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.  

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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