Home oxygen providers, physicians, and managed care
organizations must work together to ensure that the benefits
of LTOT remain both accessible and affordable, and RCPs play a
key role in that success.
Since publication of the
landmark Nocturnal Oxygen Therapy Trial1 in 1980,
home oxygen use has grown steadily. That study irrefutably
demonstrated that “Long term oxygen therapy (LTOT) use
improves both the length and quality of life of hypoxemic
chronic obstructive pulmonary disease (COPD)
patients.”2 Growth has additionally been fueled by
the trend to send patients home “quicker and sicker,” negating
the once common practice of weaning patients from oxygen
before discharging them to home. Guidelines for home oxygen
prescriptions clarify the need for supplementary oxygen and
ensure that the patients who need it, get it, while virtually
eliminating abuses caused by providing unnecessary equipment
to patients who will not benefit from it.
Indications
Supplementary home oxygen
is indicated for any patient who presents with hypoxemia,
which may be differentiated from hypoxia. “Hypoxia is a
general term that means an inadequate availability of oxygen
for cell function, whereas hypoxemia refers to a diminution in
the actual content of oxygen in blood and implies tissue
hypoxia but does not indicate what tissue or to what
degree.”3 Hypoxemia can be either acute, as with
pneumonia or postoperative atelectasis, or chronic, as with
COPD or fibrotic lung disease.
The Centers for Medicare & Medicaid Services (CMS),
formerly known as the Health Care Financing Administration
(HCFA), provides guidelines for supplemental oxygen and sets
the standard for nearly all adult oxygen prescriptions whether
the patient has Medicare or a managed care (insurance)
provider. Hypoxemia must be documented by a physician’s office
or hospital, on room air, and must indicate a Pao2 of 55 torr
or less, or Sao2 of 88% or less at rest. These patients are
classified as Group I, making it permissible for the attending
physician to prescribe the LTOT for up to 99 months (also
known as “lifetime” in Medicare parlance). Documentation of
the patient’s oxygen saturation can never be provided by a
home oxygen company due to the obvious potential for conflict
of interest.
The CMS specifically requires the documentation to be
obtained on room air. Clinicians are sometimes surprised to
learn that documenting an oxygen saturation of 87% while the
patient is receiving 2 L of oxygen, for example, is
unacceptable.
The Certificate of Medical Necessity (CMN), which home
oxygen providers submit as documentation of patient need, also
has provisions for documenting oxygen requirements “with
sleep” or “with exercise.” It is important to note that home
oxygen providers cannot be reimbursed for providing both a
base (oxygen concentrator) and portable (E-cylinder outfit) to
patients who qualify only under one of the latter two
categories. They are reimbursed for providing only a portable
oxygen system to patients who require oxygen only with
exercise. And they are reimbursed for providing only a base
system for patients who require oxygen only when sleeping.
The definition of exercise can lead to confusion when
considering patients who may have relatively normal oxygen
saturations at rest, but who desaturate rapidly when
performing normal activities of daily living (ADL), such as
walking across the room. These patients clearly require a
continuous oxygen system, and their desaturation is not
confined to exercise. In these instances, most clinicians
consider saturations obtained while the patient performs
routine, nonexertional activity, to fall into the “at rest”
category. Conversely, saturations obtained during treadmill
studies, for example, clearly fall into the “exercise”
category. While these subtleties are sometimes lost on
clinicians documenting the patient’s oxygen needs, and
physicians who complete the CMNs, they are essential to home
oxygen providers who must choose an appropriate oxygen
delivery system and obtain reimbursement for the services most
appropriate to the patient’s needs.
There is an exception to the requirement for oxygen
saturations to be 88% or less, permitting saturations of 89%
or less for patients presenting with very specific clinical
conditions (cor pulmonale, congestive heart failure, or
erythrocythemia with a hematocrit >56). These patients are
categorized as Group II, and require recertification (via a
new ABG [arterial blood gas] or pulse oximetry test) between
the 61st and 90th day following the initial prescription
date.
Children and infants typically require home oxygen
resulting from clinical scenarios that are substantially
different from adults. This, coupled with the fact that their
oxygen requirements and goals of therapy may be more
patient-specific, has thus far enabled physicians to prescribe
home oxygen for pediatric patients with more latitude than for
adults. Frequent titration of oxygen liter flows in infants is
essential, requiring clinicians to use “...the lowest possible
oxygen flow needed to maintain normoxia in infants requiring
prolonged oxygen therapy via nasal cannula.”4
Modality
Home oxygen systems allow
delivery of both low flow oxygen via nasal cannula or
transtracheal oxygen catheter, and high flow oxygen via trache
collar, aerosol mask, or facemask. There are three modes of
delivery; each has relative merits and requires an experienced
clinician to match the advantages of the system to the needs
of the patient.
Oxygen concentrators are electrically powered and use a
compressor to force room air through a sieve bed, which
separates oxygen and nitrogen molecules from room air based on
size and polarity. These can achieve an oxygen concentration
of 90%-95%, and deliver flows of up to 5 or 6 L/min. When the
patient requires portable oxygen for use outside the home, a
supplemental system must be provided. Advantages of oxygen
concentrators include economy, convenience, and a high rate of
dependability. Disadvantages include noise generation, power
consumption, and the inability to function during a power
outage. A compressed gas backup system is normally provided
for patients who require continuous oxygen use. In the event
of a power outage, the patient’s portable oxygen system often
serves as an appropriate backup system.
Liquid oxygen systems utilize cryogenic technology to store
oxygen at minus 297° F. Because 1 L of liquid oxygen is equal
to 840 L of gaseous oxygen, a large quantity of oxygen can be
contained in a small receptacle. These systems provide a
stationary base unit, which is refilled at regular intervals,
and a lightweight portable unit that can be refilled from the
base. Home oxygen suppliers often help offset the considerable
labor costs of refilling the liquid oxygen base units by
providing (at no additional charge) an oxygen concentrator for
use when the patient is home. This practice invariably reduces
the frequency of liquid oxygen refills. Advantages include
silent operation (saving the occasional hiss of a pop-off
valve), and the convenience of a refillable, lightweight
portable tank.
The Money Crunch
CMS applies a
“modality neutral” method of oxygen reimbursement, which
applies the same fixed payment regardless of the mode of
delivery (compressed gas, concentrator, and liquid system);
however, the costs of supplying various systems can vary
considerably.
Because the fixed-rate reimbursement is all inclusive,
there are no additional payments for supplies or home visits
by an RCP. Transtracheal oxygen (TTo2) catheters are an
excellent example of an underutilized technology resulting
from this situation. The fact that oxygen suppliers must
provide the specialized tubing and catheter replacements every
90 days without additional compensation may discourage them
from proactively assessing patients and recommending the
technology to the physicians of appropriate patients.
In 1997, HCFA cut reimbursement of LTOT by 30% based on an
assessment of LTOT reimbursement in Department of Veterans
Affairs (VA) hospitals and additional cuts followed. Most
experts agreed the comparison was of questionable validity
because “VA hospitals’ costs are lower because of arbitrary
limits on the kinds of systems provided, regardless of patient
need. Most VA hospitals simply provide an oxygen concentrator
and a small number of wheeled high pressure oxygen tanks
(usually E-cylinders).”2 In addition, the cost
assessment did not consider costs for regulators, tubing, and
cannula. “The reimbursement reduction is causing some
suppliers to restrict the use of ambulatory oxygen systems in
the private sector, even though they are medically necessary
and prescribed by physicians.”2
Competitive bidding experiments, for example, increasingly
reward oxygen providers for cutting costs at all cost, while
offering only lip service to the concepts of customer service
and quality of life. “Many patients who once enjoyed monthly
visits by RCPs are now only visited quarterly (or less often),
and at times by nonclinicians. Further cuts in equipment
reimbursement via competitive bidding, application of inherent
reasonableness, and other reductions in equipment
reimbursement are currently being considered and
proposed.”5 If some of these proposals are
implemented, “the impact on patient care, patient safety and
patient outcomes would be devastating.”5
When oxygen reimbursement is cut dramatically, it becomes
increasingly problematic to provide quality service to
patients who live in remote areas, or to patients who would
benefit from oxygen delivery modalities they perceive as being
more expensive, such as liquid oxygen or TTo2 catheters.
Consequently, physicians may need to carefully specify the
most appropriate home oxygen delivery system if the patient is
to be optimally served. Meanwhile, oxygen providers may be
pressured into diminishing services and downsizing clinical
staff when reimbursement has been calculated on an unrealistic
model.
Recertification
Studies have documented
that at one time, up to 60% of patients receiving home oxygen
therapy could have potentially been discontinued from oxygen
if properly evaluated. Physicians who prescribed home oxygen
were sometimes lax in reevaluating patients’ conditions, and
although home oxygen providers sometimes asked physicians to
reevaluate patients’ conditions with the intent to discontinue
oxygen service, there was a financial disincentive to do
so.6 The Fifth Oxygen Consensus Conference
recommended that patients receiving LTOT be reevaluated within
90 days of discharge to home, and that recommendation is in
the process of being implemented by the CMS. The conference
further suggested, “If an ongoing need for LTOT is determined
at the 90-day retesting, then additional arterial blood gas or
saturation measurements are unnecessary.”2
In most cases, the documentation can and should be part of
routine follow-up visits that are essential to comprehensive
management of chronic disease; however, CMS has not made
entirely adequate provisions for recertifying patients by
providing reasonable compensation and convenient access to
retesting. When a physician’s office cannot provide overnight
oximetry, for example, the only alternative may be to admit
the patient into a hospital to conduct the testing.
The American Association for Respiratory Care has urged
consideration of the following
recommendations7:
1. Medicare should provide options for retesting in order
to ensure uninterrupted patient access to medically necessary
home oxygen.
2. Medicare should establish coverage of and reimbursement
for pulse oximetry in all care settings.
3. Medicare should provide fair compensation for pulse
oximetry.
4. Medicare should ensure appropriate oversight of home
oxygen patients in the recertification process.
“To enable patients to comply with recertification
requirements [CMS] must properly establish a retesting
mechanism that includes coverage of and reimbursement for
pulse oximetry in all settings, including the patient’s home.
This coverage would be especially helpful to home oxygen
patients in rural, urban, and other underserved areas.
Patients depend on these options.”7
Planes, Trains, and Winnebagos
Many
home oxygen providers agree that part of their service to
patients includes providing appropriate oxygen systems for use
during extended travel within the 48 states. Providing oxygen
aboard cruise ships, trains, and bus lines is usually in joint
agreement between the oxygen provider and the patient. The
oxygen provider almost never absorbs the costs of providing
oxygen for trips abroad. Kari Fritz, RRT, a consultant for
Banner Health Systems, says, “There’s a lot more CMS could do
to facilitate travel [for patients who require oxygen].”
Air travel can be problematic as CMS does not provide for
reimbursement for the cost of in-flight oxygen. Travel
regulations prohibit patients from using their own oxygen
systems on board, and there is substantial variability in the
availability of in-flight oxygen by the airlines. Most
airlines require patients to make in-flight oxygen
arrangements 2 to 7 days ahead of time, and a copy of the
prescription is normally required.
In some cases, in-flight oxygen is not available except for
emergencies, and, in others, there may be no ability to
specify the appropriate liter flow. Typically, airline charges
for providing in-flight oxygen are approximately $75 for each
leg of the trip. This can add $300 to the cost of a round-trip
flight that includes a single connecting flight, making air
travel all but impossible for individuals of limited
means.
The Fifth Oxygen Consensus Conference stated, “…patients
have a right to medically necessary oxygen during air travel.
The airline industry should develop and promote industry
guidelines regarding provision of and pricing of supplementary
oxygen during air travel.”2
Conclusion
The benefits of home oxygen
for patients who need it are well documented, and the United
States arguably surpasses any other nation in the ability to
deliver innovative, high-quality products, and affordable home
oxygen services to its citizens. The opportunity to be
discharged from the hospital more quickly with the benefit of
home oxygen enhances quality of life, while reducing overall
health care costs. As managed care guidelines for home oxygen
use evolve, RCPs have a greater responsibility than ever
before to recognize the challenges and opportunities presented
by the growing needs and limited resources.
John A. Wolfe, RRT, is a contributing writer for
RT Magazine.
References
1. Nocturnal Oxygen Therapy
Trial Group. Continuous or nocturnal oxygen therapy in
hypoxemic chronic obstructive lung disease: a clinical trial.
Ann Intern Med. 1980;93:391-398.
2. Petty TL, Casaburi R.
Recommendations of the Fifth Oxygen Consensus Conference.
Respir Care. 2000;45:957-961.
3. Egan DF. Fundamentals of
Respiratory Therapy. St Louis: CV Mosby Co;
1977:182-183.
4. Kuluz JW, McLaughlin GE, Gelman B, et al.
The fraction of inspired oxygen in infants receiving oxygen
via nasal cannula often exceeds safe levels. Respir Care.
2001;46:897-901.
5. Spratt G, Petty TL. Partnering for
optimal respiratory home care: physicians working with
respiratory therapists to optimally meet respiratory home care
needs. Respir Care. 2001;46:475-485.
6. Oba Y, Salzman GA,
Willsie SK. Reevaluation of continuous oxygen therapy after
initial prescription in patients with chronic obstructive
pulmonary disease. Respir Care. 2000;45:401-406.
7. AARC
comments submitted to HCFA regarding the transmittals on
February 15, 2001. Members contact Jill Eicher, AARC Director
of Government Affairs.