Closing the quality gap in a competitive bidding environment with clinical respiratory standards.

The disturbing gap in quality that exists in healthcare can be remedied by implementing consistent clinical quality standards that ensure quality while decreasing healthcare costs. The U.S. health care system's spending growth outpaces all other industrialized countries. The United States spends about $1.7 trillion or almost 15 percent of its Gross Domestic Product (GDP) on health care. In 2002, Americans spent $5,267 per person on health care in addition, from 2000 to 2005 the rise in health care costs alone is estimated to absorb an astounding 25 percent of the nation's projected economic growth. If it continues unchecked, fewer and fewer employers will be able to afford health care for their employees and public health care spending will skyrocket. Moreover, the coordinated delivery of health care has become so complex that physicians, nurses, and other providers with responsibilities for patient care in the acute care settings often find they can no longer devote the time necessary to assimilate the ever-expanding numbers of clinical studies and emerging treatment advances. Additionally the increased burden to expedite patients along the continuum of care from the high cost acute settings--to the low cost home care setting adds to the challenges. In addition there will ultimately be a growing population of Americans who do not qualify for public benefits and cannot afford to insure themselves. The crisis is not just one of cost, however it is a broader crisis of quality and access to quality care.

In part as an effort to control these costs, CMS (Centers for Medicare and Medicaid Services) has moved rapidly in the direction of managed care. The hope is that these delivery changes can not only control costs but also improve the quality of care. CMS at the federal and state level are spending a great deal of time developing and implementing mechanisms to realize these hopes. Many policy makers believe that competitive bidding in home care will help to reduce these costs however without clinical standards costs will increase. Clinical standards in home care are absolutely essential in a competitive bidding environment to prevent compromise that could lead to increased healthcare costs and poor clinical outcomes.

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Scientific studies have proven that following [consistent clinical standards] reduces morbidity and mortality; improves quality of life and clinical and economic outcomes (reduced costs). Many reasons exist for the quality gap between the best, evidence-based models of patient treatment and the actual care received by patients. Chiefs among them are increased operational expenses, skepticism regarding the observed increase in effectiveness through participation in accreditation and insufficient staffing or equipment resources. There is also the possibility that clinical standards shown to be highly effective in the acute care setting are not practical for HME providers in home care. Thus the development and implementation of such standards is absolutely essential in competitive bidding.

In the hospital and other acute and sub-acute care settings explicit clinical standards have been developed to give assurances of quality. In home care with HME providers the lack of established clinical standards in some cases causes a quality chasm between discharges from the institutional setting to home. The intent of competitive bidding is to reduce costs, however the negative impact could be low-or-no quality without clinical standards thus increase costs. Standards make an enormous contribution to most aspects of our lives but goes unnoticed. It is the absence of standards that often identifies and magnifies their importance. The lack of clinical standards for home care providers in competitive bidding will result in potentially negative clinical outcomes [poor patient care, poor quality and limited access to equipment and services] with a resultant negative impact on economic outcomes.

A major criticism of HME providers in home care is that the services are not patient-centric. The consumer--the patient--feel they don't have information on quality to make choices, physicians lack information on clinical best practices in home care, and don't believe they exist; and believe their prescriptions are not followed consistently. Quality of care must be a focal point of all efforts to eliminate these criticisms and the time for clinical standards in home care to assure quality in the opinion of many is long overdue. Clinical standards help to improve the quality of patient care and encourages clinicians to utilize best practices, including disease prevention and management. They can eliminate the negative perception that home care providers' services are not patient centric and finally, focus on reducing system waste, promote collaboration among providers and patients, and reduce medical errors.

The standards will assure patients are informed about options and equipment and services are driven by physician's orders and managed by credentialed and licensed health care professionals. The standards will ensure that equipment and services are provided by competently trained technicians when allowed by federal and state laws but the plan of care is established by licensed, credentialed health care professionals under the direction of a physician's order. Technology is advancing at a rapid pace and patients are discharged home from the acute care settings sooner and sicker. Many of the patients who are discharged have greater technical and clinical home care needs and as much as we spend on health care in the acute settings, we achieve only mediocre results as gauged by our population's health and clinical outcomes. Many other countries spend less and achieve better returns on their health care investments. Much can be done to improve the efficiency and effectiveness of the nation's health care system without changing its basic structure or threaten quality by investing more resources in home care. Clinical standards will encourage communication with doctors to report changes and develop processes to administer services that help reduce costs while meeting patient needs in the least cost environment for care--their homes.

Clinical quality standards are critical for addressing our nation's greatest health care concerns; medical errors, inconsistent practices, poor services and skyrocketing costs. It is time for us as a home care industry & profession to embrace clinical standards for HME providers in home care and lay the foundation for the future of the home care industry as the least cost environment that yields a positive clinical and economic return on investment.

by Vernon Pertelle RRT MBA