Disease Management

Hard Decisions

Disease management in home respiratory and sleep care

• By Joseph Duffy
• Oct 01, 2011

To HME providers and the industry as a whole, disease management has become a casualty of cuts, caps and competitive bidding. As an HME industry concept and practice, disease management involves prevention tactics that help avert further escalation of patients’ problems, encourage healing and foster compliance with current treatment. In theory, keeping a patient from falling further into the healthcare system by preventing hospitalization, emergency room visits or the need for further expensive treatments should help keep healthcare costs lower and inspire the healing process.

The waning of disease management as part of the HME provider’s protocol has helped turn the tables not only on providers’ revenue but on their psychological well being, too. What used to be an uplifting, often highly anticipated part of the job, including frequent patient follow-ups and at-home visits, has become a point of frustration.

“The providers I have the pleasure of working with struggle with this paradox daily,” says Joseph Lewarski, BS, RRT, FAARC, vice president of clinical affairs for Invacare Corp. “Many continue to drive out cost elsewhere, trying hard to keep clinical services a key component of their business model. Some are trying to get better and objective outcomes measures to help determine what interventions are creating value and what services can be reduced or eliminated without compromising care.

“Some, despite their best efforts, simply cannot afford to provide non-covered clinical services and are forced to eliminate them and do the best job they can within the reimbursement constraints,” he continued. “No matter how committed, the best providers cannot sustain operating at a loss and must make tough choices.”

For providers, this must feel like a shock to the system, as so much about disease management has seemed to change in so little time.

“Oh my goodness,” says Kelly Riley, director of the National Respiratory Network, MED Group. “In the ‘good old days,’ patients were visited every 30 days by a therapist, had pulse oximetery checked, lung sounds evaluated, pulse checked, and cough and any edema evaluated. If there were significant changes from the previous visit, the physician was notified. Often this resulted in a trip to the doctor and a dose of antibiotics, steroids to calm an exerbation, or change in diuretics.

“This certainly does not happen anymore, and while we do not have data to prove our suspicions, it would make sense there has been an increase in trips to the ER and cases where the patient went to the hospital or doctor much further into the adverse condition,” Riley says. “CMS made it very clear back in 2006 that this was not the role of the HME, and that they only paid for equipment. We believe, of course, this is very short sighted, but again without data we don’t have enough to stand on.”

Where’s the Data?

In fact, many see that data as critical, and Riley isn’t the only industry expert who says collecting data is an important step from anecdotal information about the deleterious effects of HMEs’ struggling disease management component.

“Other than the public information published about companies reducing or eliminating clinical staff and services, it is very difficult to objectively note what has been scaled back or eliminated, along with any impact because there was little data about clinical activities available from prior periods,” Lewarski explains. “In addition, with the wide variances in the clinical services provided, scaling back for one company may be the norm for another.”

And although it would seem that by scaling back clinical respiratory and sleep care services there might be a rise in overall healthcare costs, the lack of data again proves problematic in helping the HME industry to state a case.

“I am not aware of any large, controlled studies performed in the U.S. that specifically compare various types of HME and clinical interventions (or lack of) against hospital admissions and other healthcare costs,” Lewarski says. “The lack of any standardized baseline for care makes a control group difficult to match market to market.

“An obvious hypothesis from those involved in homecare, which I support, suggests that reducing HME care and service activities will drive up costs elsewhere in the system and conversely, quality and intensive homecare clinical interventions will reduce readmissions and cost associated with certain high-risk populations, such as patients with COPD, CHF and asthma,” he continues. “There is some limited but growing work in this area, including work performed by HME providers. This is supported by controlled studies from other countries demonstrating clinical interventions and follow-up with certain populations (O2 patients, ventilator patients) reduces readmissions and other hospital-related costs.”

There are a number of studies that document either the value or superiority of respiratory therapists (RTs) in educating patients in disease management and self-administration of therapy, says Louis M. Kaufman, RRT-NPS, AE-C, FAARC, vice president of patient/client services forRoberts Home Medical Inc. Several of these studies, he says, have documented significant decreases in 30-day hospital readmission rates with respiratory therapist education and follow-up after hospital discharge.

Even so, Kaufman says, “There is not a wealth of data available and designing and implementing valid studies is difficult. For example, we know from work published in 1980 that long-term oxygen therapy decreases mortality. How can that study be re-produced without withholding oxygen therapy from a control group?”

Kaufman is surveying providers’ use of RTs during the past three years. While the survey was scheduled to close in September, Kaufman says preliminary data from 126 respondents shows 56 percent of suppliers in Round One have decreased RT staff (compared to 19 percent in non-competitive bid areas); 56 percent of Round One suppliers have decreased the frequency of RT visits to patients (compared to 35 percent in non-competitive bid areas); and 33 percent of suppliers in Round One have stopped RT visits for one or more treatment modalities (compared to 20 percent in non-competitive bid areas).

Although more extensive data may be needed to show CMS what many HME providers already feel is integral to their profession and their patients’ quality of life, providers are trying to cope with the cuts and caps that are affecting their business. To survive, HME providers are redefining how they perform disease management.

“Many of the companies I work with that are still providing some level of clinical services have looked to cut costs elsewhere in their organizations and reallocate those monies to support their clinical activities,” Lewarski says. “Stripping away many of the non-valueadded activities ingrained in the homecare culture can free up valuable resources and monies. Examples include using oxygen systems that are self-monitoring and reduce the need for frequent service checks, using sleep devices with wireless or other download systems to obtain compliance data, having patients come to their stores for education and dispensing of product, using automated phone technologies to perform patient monitoring activities, and of course, eliminating the delivery of portable oxygen and replacing it with non-delivery systems.

Lewarski also suggests driving out non-value added activities and trying to measure work objectively. Ask yourself, what level of care and service is truly required and what really makes a difference for patients? The answers, he says, are not always obvious but the topic is one that is very emotional and associated with strong opinions. This is the time to be truly objective and scientific in your approach to the clinical and other operational activities you perform.

Riley says, “Organizations have learned it is better to trade ‘windshield time’ for ‘patient time.’ This can be done when taking the time to explain to referral sources all the ways the patient benefits from a HME location setup versus an in-home setup. There has been some tremendous success also seen in-group setups. I know of a few organizations that give patients a choice of a group setting (limited to four people) versus individual. Fifty percent choose the group setting. This can also help enhance the numbers for compliance by making the patient a part of something larger.”

What About the Patients?

The most important factor in all this is the patient, but when it comes to disease management, patients have been, perhaps, the most silent.

“Patients have the most important voice but unfortunately, because they are a fragmented, often-isolated group, I fear their concerns are not heard,” Lewarski says. “It’s also important to recognize that with a high turn in patients, new patients coming onto service are typically naïve and have no reference point for clinical services.”

Although CMS believes providers’ job descriptions shouldn’t include disease management services, as Riley pointed out earlier in the article, there was a time when providers were very much a part of patients’ at-home care. With that dissipating, the all-important question becomes: Are patients as safe as they were before cuts and caps forced providers to start scaling back?

“As I start to answer this, it is important to remember that CMS makes it very clear that clinical services are not a component of the HME benefit, so those HMEs providing clinical services do it based on their beliefs and protocols,” Lewarski says. “That said, since there are little objective data to understand what the baseline is, it is very difficult to measure the impact of any changes, making this a somewhat complex question. This is compounded by a lack of clinical standards of care for most homecare services. A reduction in clinical services at one provider may be the standard of practice at another. Homecare providers are in the business of caring and servicing patients and safety and those I work with are making every effort to ensure safe and appropriate care and service. As health systems start close monitoring of, and more importantly, getting penalized for early re-admissions, I think more information about patient activities and outcomes will surface.”

Riley says safety depends on where and how providers have made their cuts to service. For example, if you are providing respiratory services without a credentialed therapist or nurse on staff to provide mentoring, education and overall oversight of applications, then no, patients are not safe, she says.

To summarize the peculiar position patients are in, Riley says, “Most new patients don’t know what they don’t know. It is only through the collection of data that we can make an impact and facilitate change.”

This article originally appeared in the Respiratory & Sleep Management October 2011 issue of HME Business.