Supplemental oxygen therapy has been a mainstay of treatment for a variety of respiratory issues, including COPD, for decades.1 During that time, millions of people have experienced improved longevity and enhanced quality of life thanks to the use of supplemental oxygen, particularly in the United States. Unfortunately, many others have not been able to enjoy the maximum benefit this established therapy is known to provide. A variety of studies have found issues ranging from providing appropriate education in the use of oxygen equipment2 to lack of clinical guidance for prescription and assessment.3 The lack of proper training has been particularly insidious, causing one third of oxygen users to feel at least somewhat unprepared to actually operate their equipment and nearly half to feel frequently limited in their activities outside the home. Many of these people go on to then experience isolation and fear, and many new oxygen users worry the same will happen to them.4
Prior to the COVID-19 pandemic, a substantial majority of new oxygen therapy users (64%) reported being trained on the use of their equipment by the personnel delivering it from their durable medical equipment (DME) supplier.2 The COVID-19 pandemic created a new barrier to that training, with many delivery technicians prevented from entering the home and providing direct instruction. Multiple anecdotal reports provided to the COPD Foundation described equipment being dropped on a porch, signatures being obtained, and departures noted without a single minute of training time. This may seem inconceivable, but even before the pandemic, 10% of oxygen users reported that scenario had occurred.
Therefore, the question of who can provide the requisite training safely and effectively looms larger than ever. In this issue of Respiratory Care, Lacasse et al5 describe a theoretical model using respiratory therapists to deliver not only an intensive initial education program (as is standard practice in Canada) but a long-term follow-up education program including home visits. Their findings support the notion that providing such education can be a cost-effective way to significantly improve health care–related quality of life as well as potentially reduce overall health care expenditures. By ensuring new oxygen users actually know how to use the tools they have been given (and are able to retain that knowledge), we may finally be able to make progress in optimizing oxygen therapy for all who need it.
A common factor behind many of the barriers to oxygen therapy access is cost, as Lacasse et al5 mention as a rationale for their project. Oxygen therapy is known to be one of the most expensive treatment modalities for COPD, with the mean annual cost estimated at over $3,000.6 DME suppliers have been forced to shoulder more and more of the burden of this cost due to the impact of the Competitive Bidding Program from the Centers for Medicare and Medicaid Services (CMS) which, over the decade it has been active, has cut overall DME reimbursement rates nearly in half.7 This reduction has, in turn, led to the loss of access to certain oxygen therapy modalities; for example, Duan et al8 report that liquid oxygen claims have dropped 90% since 2011. These cuts have also led to widespread consolidation throughout the industry, with Duan et al8 also reporting the number of liquid oxygen suppliers dropping by 73%. Even the number of DME suppliers providing more conventional oxygen devices (concentrators and compressed gas) has declined by almost 40%. This consolidation has led to even lower access to delivery modalities that fit the user’s lifestyle rather than forcing them to adapt to the machine. At the same time, the Medicare population has grown by 2.6%, adding further credence to the thought that many who would benefit from supplemental oxygen cannot access it.
The model described by Lacasse et al5 has the potential to alter that cost curve. The study suggests that the addition of longitudinal education and assessment has the potential to improve adherence (and therefore longevity) at a relatively small cost. Whereas this cannot be a direct comparison due to the baseline differences in the way oxygen therapy is delivered in Canada and the United States (notably, United States patients do not receive intensive initial training on their equipment), this does also appear feasible here. The model suggests that long-term follow-up would cost slightly over one third of the mean annual amount spent on oxygen therapy in the United States.6 However, considering the lack of training that is commonplace for new United States oxygen users, there is likely additional benefit in quality-adjusted life years (QALYs) gained, making the program even more cost effective here.
By utilizing respiratory therapists, additional benefits may be realized as well. People living with COPD also frequently have significant knowledge gaps in other areas of their therapy plans, not just oxygen. Dhand et al9 reported that patients with COPD experience discordance between confidence in their knowledge of the disease and treatments and their actual familiarity with them. In addition, there are longstanding well-known issues with teaching and assessing inhalation device technique, and some question whether even experienced aerosol therapy users experience competency decays over time.10 Regular instructional and assessment visits from a respiratory therapist over the 5-year time window proposed in the Lacasse et al5 model could have a significant impact on patient self-management and inhaler technique, improve self-efficacy. There is a growing body of evidence to support the notion that improved self-efficacy can lead to greater adherence to therapy plans,11 which in turn has a positive impact on exacerbation frequency.12 Even a single home visit has the potential to modify adherence in certain cases.13 It is, therefore, reasonable to presume that regular contact with the unique knowledge and skills of a respiratory therapist providing patient-centered, personalized symptom management and instruction may confer additional QALY improvement and health care utilization reductions beyond what was demonstrated in the oxygen-only model. Certainly, all people living with COPD could benefit from such a program, but demonstrating cost-effectiveness in the subset of people with COPD using oxygen would be an excellent first step to making that the standard of care.
Reduction of unnecessary expenditures is certainly a laudable goal, but it seems clear that despite good intentions the CMS competitive bidding process is a deeply flawed way to achieve that goal in the ambulatory care setting. Models like the one presented by Lacasse et al,5 whereas perhaps requiring some additional financial outlay on the front end, have the potential to deliver the significant cost savings originally promised by competitive bidding while not sacrificing quality-of-life standards. By better utilizing respiratory therapists in the ambulatory care setting, payers like Medicare have the potential to save billions of dollars by improving the screening, diagnosis, and management of people living with COPD, obstructive sleep apnea, and other chronic lung conditions. It is well beyond time for our federal policy leaders to abandon initiatives that do not follow the science and instead embrace those backed by evidence and common sense. For example, allowing ambulatory respiratory care services to be directly reimbursed under Medicare Part B has a strong likelihood of saving the program money over the long term. These cost savings could lay the foundation for a truly innovative redesign of care delivery. Imagine a system where a supplemental oxygen system is viewed more as a lung prosthetic, working with a person’s physiology and physical needs to empower an active lifestyle, rather than serving as an anchor to the home. Our system will not become truly patient-centered until we better utilize these targeted approaches to health care costs instead of the same slash-and-burn tactics that have decimated the DME and home care industries.
Footnotes
- Correspondence: Michael W Hess MPH RRT RPFT, COPD Foundation, 3300 Ponce de Leon Boulevard, Miami, Florida 33134. E-mail: mhess{at}copdfoundation.org
See the Original Study on Page 1075
Mr Hess has disclosed no conflicts of interest.
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