Oxygen Therapy: The Need to Promote Service

• By Bob McCoy
• Jan 07, 2008

Long ago, there was an oxygen patient who was stable in the hospital and only needed supplemental oxygen in her home so she could be discharged safely and treated for a chronic pulmonary condition. A rental company had just learned of new oxygen equipment that could be used in the home and decided to add the equipment to their rental fleet. (At the time, patients were discharged with oxygen as a last resort.) A call was placed, the equipment was delivered and the bill was submitted to an insurance carrier and paid. Equipment drop off, payment and delivery — end of story.

Fast forward to 2007. There are 1.5 million oxygen clients that need supplemental oxygen to keep them out of the hospital.  An estimated 80 percent of these clients are ambulatory, which is why they are staying out of the hospital. There are multiple options for stationary oxygen, portable oxygen and accessories. There are 8,000 providers of home oxygen equipment, and in the past 30 years, these providers have been adding services to the rental of equipment to compete for market share.  Now there is a perception that home oxygen therapy requires significant service to support the equipment such as AAHomecare’s recent market research project. Who asked for the service?  What research has supported the need for the service?  Is there clinical evidence for the effectiveness of both the equipment and service? 

There is a big difference between home oxygen equipment and home oxygen therapy.  Equipment in the home gives an opportunity for oxygen to be delivered to the patient safely and effectively. Oxygen therapy requires intervention by a skilled clinician who measures the effectiveness of the delivery of oxygen and makes appropriate adjustments to ensure the patient is properly oxygenated at all activity levels. Patients and their diseases are dynamic and can change from one day to the next.  Oxygen equipment can do only one thing, deliver oxygen. If the delivery does not provide therapy, what’s the point?

Starting in 1986, Medicare switched payment methodology from a fee for service for home oxygen equipment to a capped rental. This change in payment methodology resulted in a change of home oxygen providers considering the costs associated with long term oxygen therapy (LTOT) and how to control expenses. Prior to this change, the patient received a system best suited for their needs, and equipment evolved to improve reliability and capabilities. With capped rental came a focus on the expense related to the oxygen system and the costs of service to deliver the equipment. Providers looked for ways to reduce operating expenses. Equipment or programs that required frequent service were scrutinized to see if they were absolutely necessary.

Portable oxygen is absolutely necessary to keep patients ambulatory and out of the hospital, yet refilling and delivering portable oxygen is the most expensive component to an oxygen provider’s service.



Enter Non Delivery Systems

Non Delivery Options:

•    Oxygen concentrators that fill cylinders

•    Oxygen concentrators that provide gas to a Cryo Cooler that fills a Liquid Oxygen Portable

•    Portable oxygen concentrators (POCs)

•    Patients that pick up their portable oxygen system from the provider. This is not really a system, yet some patients prefer to pick up their oxygen supplies on their timetable rather than the providers’ timetable.

Oxygen concentrators that fill portables have been around for several years as payment cuts forced providers to ask manufacturers for options. A concentrator transfilling system allows the oxygen to be made in the home and then pressurized to fill oxygen cylinders.  The patient only needs a few cylinders in their home and will fill the empty units as necessary, similar to a LOX system. These cylinders can be of any size as the patient does not need to worry about a small system not lasting for very long; they would just refill the cylinder as needed. If more cylinders are needed for trips outside the house or vacations, they can request or purchase additional cylinders.  Issues to be aware of with trans-filling systems:

•    Purity of the gas is 93 percent +2/ -3 percent:  This less than 99 percent purity can be compensated with a slight bump in the liter flow or pulse setting if the patient is not at the top of the delivery range.

•    Pressure in the cylinder:  Most cylinders are filled to 2000 psig, yet if the pressure is less than full, operating time will be impacted.

•    Oxygen conserving devices: OCDs have been an issue with all oxygen delivery systems as each OCD provides a different pulse volume at a specific setting. Some of the devices drop the pulse volume as the patient’s respiratory rate increases. If the OCD is integral to the cylinder (the oxygen conserving device can’t be changed) and the patient cannot adequately oxygenate, especially with exercise, the entire transfilling system will not be adequate for the patient and another system should be evaluated.

•    Increase in heat, noise and electricity: The extra pumps on these systems will enhance the problem associate with concentrators in the home. Although additional heat, noise and a higher electric bill will not impact the provider, patients’ individual situations should be evaluated to determine if these factors will present a significant burden to the patient. Some systems have separate pumps and may not have as significant impact on the patient.

•    Fill times of the cylinders:  Some systems are faster than others in filling portable cylinders which is a marketing feature that can be attractive to the patient.

Liquid oxygen (LOX) has been popular for years since it allows for a lightweight long-lasting portable system in which the patient can fill a single unit. The down side of LOX is the provider needs to fill the base unit frequently which is expensive. The delivery of LOX to a patient’s home is complicated as large trucks need to make frequent trips to the patient’s home. Each step of the LOX delivery requires packaging, transfer and monitoring and each step has a cost associated with it. Additionally, LOX is always evaporating which provides the operating pressure necessary to drive the oxygen flow yet creates the “use it or lose it” mentality with patients and providers.

Oxygen concentrators that provide gas to a cryo cooler that fills a liquid oxygen portable in the home have just become commercially available. Oxygen that is generated from a concentrator is sent to a cryo cooler system and liquefied.  This gas in not 99 percent pure gas, as some trace gases still get into the system that dilutes the oxygen. These systems provide 94 percent oxygen in a liquid state. The advantage is the weight to range benefit as the LOX has an 860:1 expansion ration. The patients can get the benefit of a lightweight oxygen system, and the provider does not need to have the expense of delivering bulk liquid oxygen. Liquid oxygen has the clinical benefit of a light weight portable that encourages ambulation, plus high flow capabilities that may be necessary for oxygen patients with high demands.  The issues to be aware of with home generating LOX systems are similar to home cylinder transfilling systems with the addition of these new cryo systems are very new and issues may come up that are related to any introduction of a new product.

Portable oxygen concentrators (POC) have been a request from early oxygen consensus conferences where it was identified that ambulatory oxygen patients needed a better solution and a concentrator offered many benefits. Even though the first POC was introduced in the mid 1990’s, it was not until a few years ago that several manufacturers introduced POC products. The key to a POC is the efficient concentration and delivery of oxygen. Many portables today use the same technology as the larger concentrators. The amount of oxygen concentrated in a minute is determined by the amount of sieve material available. A small amount of sieve will weigh less and produce less oxygen. A larger amount of sieve will produce more oxygen in a minute. The amount of oxygen produced in a minute determines the dose volume available at a range of settings.  Less oxygen means lower dose of oxygen per breath. The other factor is the POC makes a specific amount of oxygen in a minute. If the patients’ breathe rate increases, the POC cannot make more oxygen so the purity of the gas may decrease. It is difficult to determine how a POC will work with individual patients unless the patient is tested on the device at all activity levels.

Portable oxygen concentrators have been a valuable addition to the options available for ambulatory patients. The POCs have allowed for more travel both by car and airline, they have allowed for extended times away from home with the option of plugging into any available electricity source and they provided a sense of freedom for patients that felt limited in their ability to travel.

On the flip side, POCs have entered the market with very little research on their capabilities, applications and limitations. These devices work very differently than traditional oxygen delivery and most physicians are not aware of the issues. The systems produce less than pure oxygen, they use conserving devices and they provide less oxygen as the patient increases respiratory rate. With the lack of research and the lack of understanding of how the devices work, many patients are becoming the test pilots for providers and clinicians to learn how the equipment operates. This is not quite the best way to learn of medical product capabilities.

Issues to watch for with POCs:

•    Maximum oxygen production per minute

•    Oxygen dose per setting

•    How the device responds to increased respiratory rate

•    What affects the alarms and patient alerts

Therapy Means More than Delivery vs. Non Devlivery

The difference between a non delivery system and a delivery system might just be “in the delivery.” The therapy component to oxygen clients is more critical than whether a product can be classified as delivery or non delivery.

As home care evolved, patients became more mobile and required portable oxygen.  Home care providers added clinical services to the home care program which benefited patient care and added a marketing feature. Despite its obvious value, this increase in service was never documented as beneficial, valuable or needed. As cost to payers increased, the Centers for Medicare and Medicaid Services (CMS) reviewed each segment of home oxygen therapy and started to reduce payments. Equipment was the basis for payment, so equipment costs were evaluated. 

Delivery of portable oxygen systems was a service to the patient and an opportunity for a representative of the provider to meet with the patient. This gave an opportunity to check the operation of the equipment and the patient. If a clinician was providing the service, observation skills could identify a patient change. If a driver was providing the service, there still was an ability to identify if the patient felt different. This interface with the patient is a basic component of home oxygen therapy. If we move to non delivery and a representative of the home care provider does not meet with the patient, how will we know if the patient or the equipment has changed? Is there a plan to do systematic checks of the patient and equipment?  If there is, who will pay for that service and what standards will be applied?

If we move to a drop-off service for home oxygen equipment (non-delivery) and there is little to no follow-up, what makes this different than UPS delivering the oxygen? 

Equipment alone does not treat patients. Service has always been expected, yet not identified, documented and researched. We are moving towards the greatest number of LTOT patients in history with  baby boomers entering the age of exasperation of their COPD and the need for supplemental oxygen. If clinical services can be identified and paid separately from the equipment component of LTOT, then the non-delivery systems can be tools in the hands of a trained professional that will assess the patient, choose the appropriate type of equipment and monitor the patient for positive outcomes. This is providing therapy, not equipment. We should have started with this philosophy a long time ago.

Now we know better. It is time to focus on medicine, appropriate patient outcomes and a therapy approach to long term oxygen.

This article originally appeared in the December 2007 issue of HME Business.