The executive director of the Washington, DC-based NAMDRC offers an “inside the beltway” view of key issues in the respiratory care arena.

 We all have our own “tunnel vision,” a distinct way of viewing an issue, patient, or solution to a problem. NAMDRC (the acronym is no longer an abbreviation) is a national organization of physicians that addresses regulatory, legislative, and payment issues regarding health care delivery to patients with respiratory disorders. We admit to our own tunnel vision, frequently focusing on the nuances of coverage and payment by Medicare. An “inside the beltway” perspective to health policy may not always be the healthiest approach, but given the realities of our nation’s health policies—or lack thereof—such an approach has value in the context of pursuing goals that remove regulatory and legislative barriers to appropriate treatment.

For two decades, NAMDRC has assisted pulmonologists and other physicians in respiratory/critical care. Now might be a worthwhile time to evaluate where we are, and to begin a creative dialogue to determine the best directions to go.

If you ask the average person on the street about diabetes, you might get a response that includes the word “insulin.” If you mention asthma, the response might include “breathing problems” or “attacks.” But mention chronic obstructive pulmonary disorder (COPD), and invariably the response will be a glassy-eyed stare. Tragically, most people don’t know about COPD, certainly don’t know it is the number-four killer in the United States, and don’t know that its incidence is on the upswing—thus differentiating itself from the nine other leading causes of death in the United States.

NAMDRC believes this is a problem. The solution to this perceived problem is complex and costly, and reasonable people can and do debate the relative value of public knowledge of COPD. The COPD Coalition, pharmaceutical companies, and the National Home Oxygen Patients Association are among the organizations working to educate the public. But perhaps what is really needed is to educate Congress. In the past several years Congress has shown a growing, albeit very modest, interest in chronic illnesses. It has addressed biennial PAP smears, biennial screening for glaucoma, colonoscopy screening, and mammography screening, as well as medical nutrition benefits for people with diabetes, disease management for the severely chronically ill, routine thyroid screening, preventive interventions in primary care, and lifestyle modifications.

There really is no reason why COPD is not on that list. It might very well be time for the pulmonary community to step up to the plate and push for what is truly best for patients with COPD.

Home Oxygen
The current modality neutral payment system for home oxygen creates incentives for providers to offer patients the most economically practical system(s) rather than the most medically appropriate ones. I hope no one will argue with the medical principle that one goal of long-term oxygen therapy is to permit mobility and ambulation. The difficulty patients experience in securing state-of-the-art lightweight ambulatory systems is contrary to optimal care for the patient regardless of the understandable economic incentives currently in place. While the Centers for Medicare & Medicaid Services (CMS) has the authority to address this issue without Congressional intervention, it has shown no willingness even to acknowledge the problem, let alone explore solutions.

Pulmonary Rehabilitation
The most glaring example of regulatory barriers to access to quality care for patients with respiratory disease might very well be pulmonary rehabilitation. In 1981, shortly after Congress authorized comprehensive outpatient rehabilitation facilities (CORFs) as providers of services, Medicare also notified NAMDRC that the new CORF language simply complemented the existing coverage of pulmonary rehabilitation. For years that communication stood as the guiding authority for coverage of pulmonary rehabilitation services.

In the late 1990s, Medicare signaled to its contractors that pulmonary rehabilitation really is not a benefit authorized by the existing statute, even though many of the component pieces of pulmonary rehabilitation are indeed covered services. Confusion ran rampant, and even today pulmonary rehabilitation is not available to beneficiaries across the country. In a small bit of irony, CMS apparently acknowledged the benefit of pulmonary rehabilitation when it approved it as the standard of care in its protocol examining lung volume reduction surgery.

In another not-so-subtle policy swing, CMS created the G codes that effectively clarified its own stance, signaling the circumstances under which RTs, nurses, and others could bill for certain hospital outpatient services, generally known to us as pulmonary rehabilitation exercise training. In 2003 there are still Medicare contractors who believe the G codes are some sort of optional health policy and they do not have to process bills for those services.

NAMDRC, along with the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Association for Respiratory Care, the American College of Chest Physicians, and the American Thoracic Society, has submitted a formal request to CMS for a national coverage decision related to pulmonary rehabilitation.

Barriers at Home
Perhaps the most obvious barrier to access to quality care is the dismal recognition of professional services offered by RTs in the home. For all the wrong reasons, the industry has itself to blame for that. As the home oxygen benefit evolved, oxygen suppliers, eager to provide a value-added service, began providing home care even though there was no formal mechanism to reimburse suppliers for those services. Over time, most suppliers expanded the scope of services offered, reaching out to patients with nebulizers and ventilators.

While I hope no one will argue over the benefit of those services, trying now to get Congress to pay for services that were long received free is, to say the least, no small barrier. It is a challenge facing not only Medicare and Congress but the entire respiratory care community.

We readily acknowledge our tunnel-vision view. We leave other equally valuable struggles to our sister organizations. While we lend support, we let them lead the campaigns related to tobacco, funding for NIH, and other obvious battles to be fought. It is through NAMDRC, with its mission of improving access to quality care for patients with respiratory disease by removing regulatory and legislative barriers to appropriate treatment, that we try our best to address these and other issues.

Phillip Porte is executive director of NAMDRC.