Today’s healthcare system perpetuates a view of DME (durable medical equipment) providers as deliverers of equipment, not providers of care. But thanks to the expertise on staff, including the work of RTs, DME providers can ensure that the right oxygen equipment is matched to a patient and literally deliver a breath of fresh air.

By Renee Diiulio

When a patient suffering hypoxia takes a breath, even if the breathing comes easy, they are still not obtaining enough oxygen. So it’s ironic that the companies that help patients to breathe must fight a similar state. Due to a role designed by today’s healthcare system, they are often seen as conduits for equipment rather than oxygen.

“DME [durable medical equipment] providers are not perceived to be ‘providers’ of care. They are perceived to be ‘deliverers’ of equipment,” said Mitchell Yoel, executive vice president of business development for Drive Medical, Port Washington, NY.

Yet, those who are most successful at “equipment delivery”—from both a patient and a company perspective—often include respiratory therapists on the care team who ensure proper oxygenation. Working with the physician, patient, and DME provider, an RT can help to ensure that the right equipment is matched to a patient.

RTs guide patients through the varying types of oxygen delivery methods, the associated advantages and disadvantages of each, and the devices themselves. After equipment is selected with a focus on patient needs and lifestyle, the therapist can establish the appropriate settings for patients and educate them on its use. If part of a consistent care team, the RT can also follow up with additional information and care as needed.

“RTs are a very significant component to the success of patient outcomes. We’re seeing that patients who work with their therapist to develop an outcome-based program show high levels of compliance and better outcomes,” said Larry Mastrovich, president and chief executive officer of Breathe Technologies Inc, in Irvine, Calif. Breathe Technologies offers ventilation products, some of which can be used in conjunction with oxygen therapy.

Better outcomes are better all around: patients are healthier and happier; caregivers are rewarded with those healthy patients, who require routine care but fewer emergency visits; hospitals see readmission rates and the subsequent costs associated with care for those patients decrease; and payors pay less throughout the entire length of care.

“Essentially, the cost of 1 day in the hospital is equal to about 1 year of the cost of home oxygen therapy, so it’s in everyone’s interest to make sure patients have the right oxygen modality that enables them to be compliant and maintain a level of activity,” said Byron Myers, founder and vice president of marketing for Inogen Inc, Goleta, Calif.

Chronic Condition, Emergency Care

Healthcare providers, however, are not faced simply with the cost of an emergency visit and hospital admission for these patients. The majority of patients on oxygen suffer from COPD (chronic obstructive pulmonary disease). Bob Messenger, BS, RRT, FAARC, manager of Respiratory Clinical Education for Invacare Corporation, Elyria, Ohio, estimates roughly 90% of oxygen therapy patients have a COPD diagnosis.

If mismanaged, the condition can result in recurring visits, multiplying expense, and worsening outcomes. Hospital readmission rates for the condition have not fallen over time. “COPD all-cause readmission rates remain stubbornly above 20%,” Yoel said. COPD has, therefore, found itself on the list of Centers for Medicare and Medicaid Services (CMS) core measures for hospital performance.

If an institution exceeds the set thresholds for 30-day readmissions related to COPD, it can face significant fees. “So hospitals have a vested interest in making sure a patient stays home for 30 days when discharged, and with COPD patients, it benefits them to align with an oxygen provider that will finish the education that began in the hospital,” said Messenger.

Unfortunately, however, that alignment does not cross over into care as a part of a standard protocol but varies with each institution and provider. The decision to prescribe oxygen therapy is easy. In fact, it may be too easy as Messenger noted that hospital patients are often surprised by the news closer to discharge, if not the day they leave. “The physician knows in the back of his mind that the patient will need oxygen, but it is still a last-minute decision with very little discussion,” Messenger said.

Medicare requirements for reimbursement of oxygen therapy are relatively simple and clear-cut. The most basic criteria for COPD patients (outside of their diagnosis) are an arterial Po2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, taken at rest with breathing room air. It’s after the prescription is written when the guidelines become vague.

RTs, the Right Stuff

Patients who meet the criteria for oxygen therapy may qualify for coverage of a portable oxygen system by itself or its use in conjunction with a stationary oxygen system. “Medicare data indicates about 68% of the patients analyzed are using some sort of portable system in conjunction with a stationary system. Only a very small population are prescribed just portable oxygen,” Messenger said.

On the other hand, patients who qualify for oxygen based solely on blood gas studies obtained during sleep are not eligible for portable systems. “According to Medicare data, about 30% of oxygen patients are nocturnal only, so the rest would qualify for portable oxygen, but it’s determined by the physician’s office what will be prescribed,” Myers said.

Physicians have a wide range of options, though they may be narrowed depending on institutional policy. With readmission rates in mind, partnerships with DME providers can help to lead to more effective care and more efficient economics—if the right provider, or providers, are picked.

There is a growing consensus that the right provider includes RTs on the staff, despite the lack of reimbursement for their role. Medicare is very clear that respiratory therapy services are not included under provisions for coverage of oxygen services. The irony is not lost on an industry that is realizing that the outcomes are worth its own outlay in this regard—particularly as care models are so varied.

Myers has seen the gamut, from physician offices with RTs that lay out all of the options, pointing out optimal choices and helping to guide the patient in a decision, to those where the patient is referred to the home healthcare provider to determine the best product for their needs. Both models can work with an RT at the helm, whether employed by the healthcare provider or by the DME provider.

Portability Pushes Development

The key is to understand what patients want to do and how they want to live in conjunction with their specific oxygen needs, noted Myers. Quality of life and mobility are often important factors in the decision, though cosmetics play a role too. Although a small matter from the provider’s perspective, they can have a big impact on compliance. “We aim to provide products that patients aren’t embarrassed to use,” Myers said.

New products are beginning to “mask” themselves as elements that more naturally fit into an environment or a lifestyle—lightweight devices disguised as small bags, interfaces that blend with existing garments, oxygen produced “from the air” for unlimited supply and additional freedom. Today’s innovations tend to focus on improving oxygen delivery in smaller, more efficient ways with greater economic benefit.

Liquid oxygen is a dying technology as a result, noted Messenger, stating, “It won’t ever completely go away because it is best suited for some patients, but they represent a small portion of the overall population.” The rest prefer not to be further tethered to a tank delivery.

Cylinders may be very lightweight and quiet, but the oxygen contained within is finite and certain activities may require multiple tanks or an early departure. Patients must devote time to awaiting routine cylinder deliveries and must ration their activities around the number of cylinders left.

The introduction of converter technologies in the late seventies, which “concentrate” oxygen pulled from the room’s atmosphere to provide patients with an unlimited oxygen supply, allowed another option that freed patients from these negatives. Providers are just as happy to cut the cord to cylinder-based systems, finding that in the reimbursement crunch, the elimination of cylinder deliveries is an effective way to reduce cost. With the latest improvements in the technology producing decreased weight and increased power, portability is now more easily possible.

Delivering Oxygen, Not Just Breath

Whether portable or stationary, liquid or concentrated, when used properly, oxygen therapy is, quite literally, a breath of fresh air. But it isn’t always used properly, so the RT and the patient must work together to keep the oxygen flowing. “The amount of oxygenation does matter and is part of determining the best fit for the patient,” said Myers.

This means the settings on the instrument should match the patient’s changing needs and offer adjustment capabilities that allow alteration of the oxygen flow to meet the range of those needs, from resting to maximum activity, without wasting resources. The goal is to maintain the blood oxygen saturation levels at the percentage prescribed by the physician. “Our internal RTs verify that patients have achieved these goals and educate them on how to improve,” Myers said.

Part of this process is achieving the right settings on the oxygen delivery device. No standards have been developed, so every instrument has its own associated flows. “At a setting of two, you may put out 22 cc of oxygen and I might put out 15 cc, so they are not equal,” Messenger said.

As a result, some patients are not being properly oxygenated. RTs and patients must therefore work together to determine which settings on a particular instrument are appropriate for which activities. This should involve measurements at rest and various activity levels both on and off oxygen, using the specific device. Some devices will offer more settings or more flow per setting and may therefore be a better fit for certain patients.

Investing in the Future

New developments in the field are taking concerns about adequate oxygenation into consideration. “Most recently, auto-adjusting conserver technology has taken the industry by storm and has caught the attention of some major hospital systems and payors. This technology recognizes that the vast majority of portable oxygen patients need different doses of oxygen depending on their activity level,” Yoel said.

Rather than rely on the patient to remember to adjust the setting as they go about their day, auto-adjustors perform the task electronically based on the patient’s needs. Newer technology exists that can better match dose to patient need via measurement of patient motion or respiratory rate and I:E ratios, making appropriate adjustments to oxygen dose automatically. “There is a conserving technology for every part of the disease continuum in progressive lung diseases,” Yoel said.

Using the wrong technology can result in desaturation, shortness of breath, a learned sedentary lifestyle, and negative health consequences. Yet, reimbursement for this care is nonexistent. “The HME (home medical equipment) industry has been initially excluded from the [accountable care organization] model as well as hospital readmission mitigation programs precisely because we have not connected the dots between our expertise in selecting the right HME products for the right types of patients and how that relates to positive patient outcomes,” said Yoel.

Companies are fulfilling the role anyway, finding that the expense saves money over time through improved outcomes. Inogen’s RTs work with patients from the beginning to ensure they are receiving the right amount of oxygen. “It’s a critical role that begins right out of the gate, training the patient to make sure equipment is used and cared for properly,” Myers said. Because then, everyone breathes easier.


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