News of changes to reimbursement policies of the Centers for Medicare and Medicaid Services (CMS) is rarely met with anticipation and cheer, but Judy Tietsort, RN, RRT, FAARC, chief executive officer of Respiratory Management Consultants in Denver, has found something to be optimistic about: opportunity. “There are opportunities with what’s going on with Medicare now for us in respiratory therapy to look at and take advantage of. [RTs] can do a little research and maybe get some programs going that they couldn’t implement before, such as pulmonary rehab and protocols,” says Tietsort.

The challenges are not easy—time can sometimes be the most difficult resource to secure. “Medical staff has been cut, administrative staff has been cut, and educators have been cut in many facilities. But [at the same time], in many instances, managers have been given more departments, thus more responsibilities. They don’t have a lot of time to put together and justify a program,” Tietsort says.

Grabbing hold of the opportunities requires some research and focus, but if the resources can be found, the reward can be great for both RTs and the health care institution—from new responsibilities for the therapist to new financial resources for the hospital. The benefits can have a positive impact on not only the bottom line, but also patient outcomes and quality of care, bringing even greater reward.

Rose-Colored Reimbursement
Judy Tietsort

Judy Tietsort, RN, RRT, FAARC

Unfortunately, these benefits and opportunities have been obscured by a lack of understanding of CMS policies, which are constantly evolving. Tietsort has met many RTs who are surprised to learn that submitted charges do not necessarily result in revenue. Currently, there is no guarantee that any submitted charge will result in an actual financial reimbursement. In fact, that has not really been the case since the implementation of diagnostic related groups (DRGs) in 1983, according to Tietsort. Back then, charges were submitted to Medicare and reimbursed at 80%.

“Today, there’s no reimbursement for charges submitted. In most hospitals, the only reason charges are submitted is because each procedure has a time unit attached that regulates staffing,” Tietsort says. Unfortunately, many RTs do not understand this, thinking instead that every charge submitted is reimbursed.

Complicating matters is the fact that the codes are constantly changing. Over time and often influenced by economics, they have become more complex, often eliminating or reducing reimbursement wherever possible. Today, reimbursement could be based on volume of admissions, number of patients enrolled, patient length of stay, and/or diagnosis. Each insurance company has its own method. Additionally, more codes have incorporated quality measures and pay-for-performance initiatives. For instance, in 2008, Medicare no longer reimbursed hospitals for certain hospital-acquired conditions, a list that has continued to grow since then. In an effort to identify poor clinical care and postdischarge coordination, potentially preventable readmissions or PPRs seem likely to make it into the next bills, according to Tietsort. The top 10 related DRGs include simple pneumonia and pleurisy; COPD (chronic obstructive pulmonary disease) is the second most frequently admitted diagnosis in the acute care setting.

As many health insurance providers follow CMS’ lead, the impact on revenue resulting from the passage of such policies could be significant. This means RTs have a unique opportunity to implement programs that can help a hospital to achieve quality goals while potentially having a positive impact on reimbursement. Two prime opportunities for RT departments lie with the development of pulmonary rehabilitation (and asthma education) and protocol programs, both of which have been shown to reduce hospital readmissions.

The Silver Lining of Pulmonary Rehabilitation

According to research dating back to 1970, pulmonary rehabilitation helps to decrease hospital readmissions, reduces unscheduled visits to the emergency department, lessens the intensity of service if admitted, and increases a patient’s quality of life, notes Tietsort in a presentation on the subjectDuring that time, the reimbursement was poor, resulting in few hospitals with pulmonary rehabilitation programs. “We do now get reimbursed for pulmonary rehab. It’s not necessarily the money we would hope that would be there, but there is money there. In addition, if we can prevent losses that will occur when Medicare begins not paying for ‘preventable’ readmissions, then the opportunity is there for [RTs] to either restart programs or get a new program going,” Tietsort says.

Pulmonary rehabilitation programs have been in use since 1968, but many programs were closed due to economics. “Hospitals had great pulmonary rehab programs, but they lost them because there weren’t enough dollars to support the people who ran the programs and the rent for the space, for example,” Tietsort says.

Now, with the situation reversed again, pulmonary rehab programs may once more be able to flourish. “If we were to look at the data in our hospitals to see how many patients were readmitted with a diagnosis of COPD or emphysema—or a secondary diagnosis of [either of] those conditions—and then estimate, for example, that 10% of those readmissions will not be paid for, in most hospitals, that would be enough to justify a pulmonary rehab program,” Tietsort says.

It’s likely that many facilities will find more justification: 10% is a very low number. “Medicare states that at least 75% of readmissions are preventable,” Tietsort says. Medicare will determine whether a readmission was preventable by using a computerized grouper.

The key, therefore, to making a pulmonary rehabilitation program successful is to drive it with data (“You need to database everything,” Tietsort advises), deliver quality, and make sure the staff is properly trained.

Glass Half Full of Protocols

Similarly, staff has to be well trained to take on protocols, but beginning a protocol program can bring benefits similar to those for pulmonary rehabilitation. Respiratory therapy orders have traditionally been physician driven and physician ordered, but through the use of a protocol program in which therapy is ordered by the therapist, using preapproved guidelines, misallocation numbers have been shown to decrease significantly.

These programs allow the therapist to initiate, discontinue, refine, transition, or restart therapy. Ideally, the respiratory professional can determine the need, mode, and frequency of therapy, as well as when the therapy outcome has been met. Patient care plans are based on clinical practice guidelines (CPGs) and reviewed and accepted by the medical staff; methods should be driven by specific patient data, rather than simple time frames.

Protocols themselves can be simple or complex. Tietsort uses examples that include bronchial hygiene, bronchodilator therapy, lung hyperinflation, oxygenation, and mechanical ventilation. Responsibilities can include performing FEV1 (for appropriateness, smokers, and high-risk postoperative patients), peak flow (on asthmatics), and O2 saturation/titration to D/C; delivering patient education; and offering referrals for pulmonary rehab or smoking cessation.

Ultimately, a protocol program should impact care, improving factors such as misallocation. “In many hospitals, between 25% and 40% of the therapy that is delivered could be done better,” Tietsort says. Therapy may be ordered too frequently or too infrequently; it may not be ordered when it should be, or it may be unnecessary altogether; or it may be ordered with an incorrect mode. RTs with the proper training can help to correct these errors, saving money and increasing the quality of care.

“But you have to start with good people, even if it’s only a handful. You will not get a second chance,” Tietsort says. If a department lacks the staff to initiate a program, there are options, including courses and competency training. “You can also start with initial assessors and expand as the team gets more comfortable with the program,” Tietsort says.

Pollyanna Politics

For busy managers, there are existing programs that can be adapted to a department’s specific needs. For the particularly time-pressed but highly motivated, consultants can do much of the work for them. The process of starting a program involves research, justification for administrative buy-in, and clinician education and competency testing.

The most significant barrier to protocol implementation is the medical staff, emphasizes Tietsort, who notes one of their concerns is whether the RTs have the skills to implement the protocols. But these same medical staff can be won over with data, performance, and follow-up data. Tietsort recommends approaching the program as a presented quality assurance (QA) study.

“You need to present to the medical staff. Start by defining the percent of misallocated care and presenting it as a QA study: You have identified a problem; you are going to address the problem through your protocol program; you will then restudy the problem and re-present in 3 to 6 months,” Tietsort says.

She recommends reaching out to colleagues in utilization review or QA who sit on medical staff committees to help get on their agendas. “Once they look at the misallocated care percentage, they’ll help you get started,” Tietsort adds.

At the same time, when starting a new program, either pulmonary rehabilitation or protocol, the RT manager will want to reach out to the staff on the floor directly, including physicians and nurses. “The program needs to be presented to them in a way that allows them to see it as an advantage to them—and the patient, of course,” Tietsort says.

In today’s extreme-pressure health care environment, medical professionals often do not have the bandwidth to take on a lot of change. Physicians may fear losing control of treatment, and most staff are unlikely to be aware of the potential benefits. Education and communication can help to clear these myths.

“I always like to go to the head nurse committee meetings and present the program to them, the data and motivation,” Tietsort says. Most times, she gets requests to be part of the pilot.

Three to 6 months provide an adequate amount of time to collect supportive data and illustrate the competency and usefulness of the staff and program. But, again, Tietsort emphasizes, it is important to get it right the first time. Approached the right way, RTs have the ability to create opportunity out of a difficult situation and grab that brass ring off the reimbursement merry-go-round.

Renee Diiulio is a contributing writer for RT. For further information, contact [email protected].