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. 

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 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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