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

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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