Cut Costs, Spend on Therapists

Those of you who grew up in the 1950s may recall William Bendix who played Chester A. Riley in the television program “The Life of Riley.” Chester always seemed to get the short end of the stick. At the end of each show, poor Chester would turn to the camera and exclaim, “What a revoltin’ development this is!” During the past 13 years, home medical equipment suppliers have been experiencing one “revoltin’ development” after another with reimbursement rates for oxygen falling by 50 percent since 1997. And unless lobbying efforts can change the course of the CMS competitive bidding program, another 30 percent or more decrease is coming to “winning” bidders in nine areas in January, with 91 areas to follow in 2013.

Well, where does that leave all us Chesters in home care? In dire need of cost-cutting, efficiency-building measures, in part to save those at the core of our service — respiratory therapists.

How Therapists Figure in the Cost Equation

In the 1980s, HME suppliers began to employ respiratory therapists as a marketing tool to differentiate themselves from other suppliers. Over time, these clinical services have become expected by physicians and discharge planners and even mandated by practice acts and regulations in some states. However, clinical respiratory services in the home are not typically reimbursed by third-party payers. The common perception has been that the clinical respiratory services were related to monitoring the equipment and the patient’s response to the use of the equipment.

Unfortunately, HME suppliers and respiratory therapists are caught in the confl ict between cost of care and quality of care. As respiratory therapists who work in the home, we know how valuable our services are to patients who rely on them to stay well enough to avoid hospitalization or admission to a nursing home. We all realize the cost savings inherent in home care for patients and taxpayers alike — not to mention the marked improvement in patient care and outcomes. Yet, we are burdened with a dysfunctional government payment system in which the right hand does not fully understand what the left hand is doing. Medicare Part A, the hospital side, is doing everything it can to decrease costs by pushing the patient out of the hospital as soon as possible. Medicare Part B, the home care side, focuses its efforts on decreasing costs by various means, including deep oxygen reimbursement cuts.

The reality is that respiratory therapists are a cost center in HME businesses. Someone needs to answer the phone to accept a new order; someone needs to deliver the equipment; and someone needs to bill and collect for the equipment. As we have witnessed at countless HME companies — mom-and-pop shops and nationals alike — when costs must be cut, respiratory therapists are expendable. Will respiratory therapists in home care go the way of the dodo?

They can’t — not if we are to fulfill the industry’s mission to provide the safest and highest-quality care to patients. Respiratory therapists must be available to assess and educate patients. For example, each patient must be assessed and titrated by a respiratory therapist at rest and exertion for the specific oxygen conserving device he or she will use. No respiratory therapist means no titration; no titration means no conserving device; no conserving device means heavier portable oxygen equipment and less exercise; and less exercise means decreased mobilization of secretions, which means more pneumonia and more hospital stays.

Assuming no change to the current payment structure, the continued availability of respiratory therapists to serve patients at home depends on improving the utilization and efficiency of our limited resources. “We have always done it that way” can no longer be the excuse for resisting change. We must accept change.

Why Technology Can Bring Efficiency Gains

Ever-improving technology offers a number of ways to decrease costs. Today’s apnea monitors and positive airway pressure devices have been enhanced to store equipment-use and patient data for access and analysis remotely via the Internet, saving visits to the home. The resulting reports can then be sent to physicians electronically as well.

Deliveries are the single largest operating expense for most HME suppliers. But far too many drivers rely on dog-eared, low-tech paper maps to get around. The cost of an electronic navigation device is likely about the same as all those map books and will improve efficiency. Better yet, automated routing software or services typically provide reductions of 10 percent to 15 percent in miles driven, 5 percent to 10 percent in the number of vehicles needed, and 15 percent to 35 percent in staff time and overtime, all with a return on investment as quick as a few months.

Staggered shifts for delivery staff decrease the need for overtime and provide for better after-hours coverage. Companies with a large enough delivery staff may benefit from a change to 12-hour shifts instead of the traditional 8-hour shifts. The same number of delivery drivers will be required, but fewer vehicles will be needed, overtime will decrease and coverage will improve.

The cost of having a courier service pick up equipment when patients no longer need it is less than the cost of sending an employed and highly trained member of the delivery staff. Employed delivery staff can then focus on equipment setup and patient education.

The dynamics of oxygen cylinder delivery have changed altogether with the advent of high-tech oxygen equipment. Portable oxygen concentrators and systems that allow patients to fill cylinders in the home are reliable and safe. In addition to the cost benefit for the HME supplier, patient benefits include lower power consumption, no need to be home for deliveries, increased mobility, and a safer home environment free of the 50-foot oxygen tether. HME suppliers using nondelivery technology report they can serve up to 50 percent more oxygen patients with no increase in staff or vehicles.

What Therapists Can Do to Save

Are respiratory therapists utilized where they can do the most good for the patient and the HME supplier? All companies can benefit from a policy review to determine if changes are indicated. If a therapist must check a specific piece of equipment, perhaps visit frequency can be decreased due to improved equipment technology or reliability.

Instead of heading out to patients’ homes every time, a respiratory therapist can perform telephone visits to triage patients and determine the need for a face-toface professional visit. A patient with a chronic respiratory disease and co-morbidities may receive a greater benefit from a therapist visit than one with a shortterm or self- limiting disease. Telephone triage and assessment may also decrease the need for unplanned or off-hour visits.

To seek further efficiencies, centralized scheduling of therapist visits has been shown to increase the number of visits per therapist by up to 17 percent, thereby decreasing the need for additional staff. And visits performed at the HME company location may also increase the number of patients a therapist can help per day. Exchanging therapists’ “windshield” time for face-to-face time provides more time for education in a controlled environment free of household distractions. With more availability, it’s possible for therapists to boost sales efforts and contribute to the revenue stream by demonstrating the HME supplier’s clinical proficiency, educating referral sources, and assisting with the ever-increasing burden of obtaining clinical documentation.

Shown to improve both patient care and therapist productivity, therapist-driven protocols have been used for years to manage invasive ventilation. There is no reason not to use such protocols in home care. A therapist-driven protocol is a physician-authorized, patientspecific set of orders that allows the respiratory therapist to initiate, alter or discontinue therapy without the need to contact the physician for each change. For example, the therapist can select the equipment, titrate the therapy, assess the patient’s response and plan future visits. Therapist-driven protocols improve outcomes, maintain referral loyalty and, because reports take the place of requests for orders changes, keep physicians happy.

In the 1994 article “Current and Future Role of Respiratory Care Practitioners in Home Care,” Executive Director of the American Association for Respiratory Care Sam Giordano, RRT, wrote, “Ultimately, third-party payers will recognize the value of reimbursement for the professional services component of respiratory care because it makes good economic sense to do so.”

That has not happened yet, but an April 2010 white paper published by the U.S. Food and Drug Administration supports Sam’s vision. In its paper titled “Medical Device Home Use Initiative,” the FDA lists the benefits of home-use medical devices as quality-of-life improvements and cost savings, and the challenges as caregiver knowledge, device usability and environmental unpredictability. Examples of reported adverse events that occurred in the home include inadequate information or training for users and lack of consideration of users’ physical capabilities. Patient and environmental assessment as well as caregiver and patient education are the therapists’ responsibilities in home care. The FDA gets it; third-party payers still do not.

Rehospitalizations among Medicare beneficiaries are prevalent and costly. From 2003 to 2004, 22.6 percent of Medicare COPD patients were rehospitalized within 30 days of discharge. A disease management trial using respiratory therapists to educate and monitor a group of VA Medical Center COPD patients reduced hospitalizations for cardiac and pulmonary conditions by 49 percent. More evidence-based reports of the improved outcomes and lower overall costs of home care are needed. Only then will the cost of care provided to the home respiratory patient be considered a direct reflection of the quality of care resulting from the professional services of the respiratory therapist.

This article originally appeared in the Respiratory & Sleep Management September 2010 issue of HME Business.

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