Congress proposes major changes in oxygen reimbursement.

The only constant in health care is that it is always changing and evolving. Changes are constantly occurring not only in regards to clinical procedures but to the process by which health care is reimbursed as well. The home care respiratory care professional must be vigilant to stay abreast of changes in the standard of practice for clinical and financial aspects which effect how home respiratory care is to be performed.

In December 2005 the United States Congress debated and voted on a bill known as the Deficit Reduction Act of 2005 (Senate Bill no. 1932). The bill, if it becomes law, is expected to save the United States government, according to the Congressional Budget Office, approximately forty billion dollars over the next four years. Medicare and Medicaid cuts, freezes and changes in reimbursement are expected to provide a little over six billion dollars in Medicare savings and approximately five billion in Medicaid savings. The bill has slated changes for acute care hospitals, specialty hospitals, physicians as well as durable medical services.

The bill passed the House of Representatives and narrowly passed in the Senate by a vote of fifty one to fifty with Vice President Chaney casting the deciding vote. There are differences between the bill passed in the Senate and the House of Representatives which will require the House of Representatives to choose one of the following options:

* Pass the Senate version of the Deficit Reduction Act of 2005

* Take the Senate version of the bill back to committee for discussion and revision

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The House of Representatives is expected to take action on the bill in either late January or early February 2006 when congress reconvenes.

If the current form of legislation is adopted, the changes proposed for home oxygen therapy reimbursement may effect how home oxygen therapy services will be delivered in the future.

Historically, oxygen therapy was reimbursed as a monthly rental and was paid for indefinitely as long as there was medical necessary for the therapy to be provided. Other respiratory care services such as aerosol therapy or continuous positive airway pressure therapy (CPAP) received reimbursement for a specific number of months with the patient having a choice at ten months whether they wanted the device to be purchased for them, where the home care provider would receive an additional three months reimbursement prior to the title for the equipment being transferred to the patient or choosing to continue to the equipment remain the property of the home care provider where the provider would receive an additional five months rental payment and maintenance payment equal to one months rental every six months. The home respiratory care provider was required for the patient who chose the rental option to maintain the equipment for the patient as per the manufacturers' guidelines and replace as needed for as long as a physician determined that the services where medically necessary. Oxygen was a therapy that was always an indefinite rental due to the frequent service requirements of the equipment. If the patient chose the purchase option the patient then owned the equipment was responsible for any maintenance required.

If the current draft of the Deficit Reduction Act of 2005 becomes law oxygen therapy will become a purchase item similar to aerosol therapy and CPAP but with the following change. Oxygen would be reimbursed for thirty six months and maintenance would only be paid for if it was proven to be necessary for the appropriate operation of the equipment. The current draft of the bill also reduces the rental payment for aerosol therapy and CPAP from fifteen months to thirteen months and no biannual maintenance reimbursement. The current average length of usage for oxygen therapy in the home for Medicare recipients is between twenty four and thirty months. While it is noted that the average patient does not utilize oxygen therapy for more than thirty months, there are still a large percentage of patients who do use oxygen for several years passed the thirty six month cap on reimbursement.

Keep in mind that the majority of home oxygen therapy usage is utilized by patients with Chronic Obstructive Pulmonary Disease (COPD), the fourth leading cause of death in the United States. COPD is a grouping of several progressive lung diseases which can cause a patient's oxygen requirements to change over time. With disease progression not only the amount of oxygen requirements change but the type of system providing their oxygen may changes as well. A patient may begin home oxygen therapy with an oxygen concentrator with compressed gas cylinders as their ambulatory system but after a year or two may require a liquid oxygen system due to increased liter flow or due to changes in the patient's ambulatory needs. Once an oxygen system reaches the thirty six month cap, the patient would be responsible for determining when maintenance is needed for their equipment. The government feels that this is giving the patient more control over their equipment but for the majority of patients if would be impossible for the patient to determine when maintenance is required or if the system is functioning appropriately. Currently oxygen systems are checked and maintained by home care providers at intervals equal to or greater than intervals determined by the oxygen therapy equipment manufacturer.

Another down side for the patient with equipment being capped or purchased at thirty six months is who will provide emergency services in cases of equipment failure, community electrical failures and natural disasters? When equipment is rented from the home care provider, the home respiratory care professional is there to take care and meet the technical and clinical need of the patient twenty four hours per day, seven days a week. Patient owned equipment would require the patient to make their own arrangements for services if there was an equipment failure, power failure or natural disaster.

Technology is always advancing as well. In the past few years delivery less oxygen systems including portable battery operated concentrators and systems where the patient can fill their own ambulatory compressed gas cylinders from an oxygen concentrator have emerged. These newer technologies have given freedom for the patient to leave their homes for longer periods of time and in some cases the ability to travel. New technology will not be available for a patient if he or she is the owner of a prior oxygen system thus limiting their ability to live their life to the fullest utilizing the latest technology available.

While it is important for the United States government to respond to need to reduce the deficit, it should not occur at the expense of the home oxygen therapy patient. The AARC and AARP have opposed these changes as detrimental. Regardless of where a respiratory care professional practices respiratory care, he or she must have a basic understanding of the all domains where respiratory is performed and the necessary tools and reimbursement available in order to meet the needs of the respiratory patient.

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by James Stegmaier, RRT-NPS, RPFT, CCM