• Oxygen and Reimbursement: "A Most Important Issue"
  • By Thomas L. Petty, MD
  • Oxygen is the only proven treatment for advanced stages of COPD that has been shown by first rate studies to increase both the length and quality of life and to reduce hospitalizations. Today a million Americans, most of whom have COPD, receive long term oxygen therapy (LTOT) in the home.
  • The specter of "competitive bidding" looms large and has already passed the House of Representatives. I hope it can be thwarted in the Senate. IF competitive bidding remains MODALITY NEUTRAL, this will be a disaster, because the new advances in ambulatory technology, which are naturally more expensive, will be threatened.
  • The reason is simple. Providing a stationary concentrator and an E-cylinder on wheels is cheaper. But this system inhibits ambulation and activities of daily living. The Nocturnal Oxygen Therapy Trial (NOTT) showed an improvement in survival and a reduction in hospitalizations for groups with an ambulatory system. These groups could do more exercise than groups limited by a stationary system.
  • Ambulatory oxygen has become the standard of care, as indicated in "Recommendations of the Fifth Oxygen Consensus Conference" (Respiratory Care, 2000, 45:957-961). This is undoubtedly the most important issue facing any COPD group, and NECA should be the standard bearer for this issue. [NECA is the National Emphysema COPD Association] It is an important part of the efforts of NECA, NLHEP, the National Lung Health Education Program, and others, to promote public awareness that COPD is a long standing and progressive chronic disease. We need to work together not only on early identification and intervention, but on the entire continuum, from asymptotic to late stage disease.
  • And what can you do about that? Read the following article for help.

  • COMPETITIVE BIDDING WRITE YOUR CONGRESSMAN AND SENATORS TODAY!
  • We have received permission to reprint this excellent letter written by Jon Tiger, NHOPA President. NHOPA is the National Home Oxygen Patients Association. Readers who wish to write or email their members of Congress regarding concerns related to competitive bidding for oxygen are encouraged to do so. NHOPA has told us that you should feel free to borrow from this letter written to House and Senate conferees on the topic:
  • "The Congress is currently considering legislation that would, if the version approved by the House of Representatives prevailed, mandate competitive bidding for home oxygen currently provided as a Medicare benefit to approximately 800,000 Americans. We are fearful that such a move would have a seriously deleterious effect upon the availability of oxygen systems to Medicare beneficiaries for several reasons:
  • As we are sure you know, the Medicare payment methodology for oxygen is based upon a "modality neutral" model, thereby creating strong financial incentives to provide the cheapest oxygen equipment. Under a pure competitive bidding structure, ambulatory systems would become even less readily available, as indicated by the preliminary results of the current demonstration projects being conducted by Medicare in San Antonio, Texas and Polk County, Florida.
  • Medical evidence is accumulating that use of lightweight ambulatory oxygen is more effective in restoring vital functions than oxygen delivered by stationary systems. Both length and quality of life is increased and hospital use reduced by the use of ambulatory systems. [Editor's note: While not yet established, this is the subject of a proposed research.
  • With a system that encourages ambulation, patients are more active, one of the clear paths to a longer, more productive life. Obviously, the availability of such portable systems is vital for these patients, and we are fearful that a national program that is modeled after the current Medicare demonstrations would unquestionably be detrimental to the health of hundreds of thousands of Medicare beneficiaries.
  • An integral part of the Medicare benefit is the availability of professional medical support, usually provided by respiratory therapists. It is our understanding that this professional support has also virtually disappeared during the two Medicare demonstrations currently underway.
  • We strongly urge you to oppose any effort to mandate competitive bidding for home oxygen systems unless there are explicit requirements that would ensure the availability of the specific oxygen system requested by the prescribing physician and the resources of health professionals such as respiratory therapists and others who are trained in the area of chronic obstructive pulmonary disease, the primary diagnosis of supplementary oxygen patients."

  • We know that many of you remain interested in what the government has decided to do about payment for Lung Volume Reduction surgery. The California Thoracic Society (CTS) provided us with the following article taken from the New York Times.
  • Medicare to Pay for Major Lung Operation
    N Y Times August 21, 2003
    By DENISE GRADY
  • Medicare will begin paying for a major lung operation for certain people 65 and over who have severe emphysema with specific traits that make them likely to benefit from the surgery, the government announced yesterday.
  • The operation, lung volume reduction surgery, involves cutting away diseased parts of the lungs to help the remaining healthy tissue work better. As much as 30 percent of the lungs may be removed. The operation costs about $60,000. Private insurers and state Medicaid programs generally follow Medicare's example.
  • Medicare said yesterday that it would cover the operation for two groups of patients: those who have severe emphysema in the upper lobes of their lungs, and those who have both severe disease elsewhere in the lungs and a poor ability to exercise. In addition, such patients would need certain other test results to make sure they were not at high risk of dying from the surgery itself.
  • Medicare will also require that patients be given an extensive exercise and education program to improve lung function both before and after the surgery.
  • The operation will be covered only at certain hospitals accredited by the Centers for Medicare and Medicaid Services; the hospitals have not yet been named.
  • Two million Americans have emphysema, but only a small fraction - perhaps as few as 10,000, researchers say - would qualify for the surgery. The disease, which destroys the air sacs in the lungs, makes it increasingly harder to breathe. It is nearly always caused by smoking. Emphysema is incurable and often fatal, and it causes or contributes to 100,000 deaths a year in the United States. Caring for people with the disease costs more than $2.5 billion a year.
  • The decision to begin covering the lung reduction surgery is based on the findings of a government-sponsored study published in May in The New England Journal of Medicine. That study, called NETT, for National Emphysema Treatment Trial, found that in about 25 percent of participants, the operation improved both quality of life and length of survival. In others, it did not prolong life but did improve exercise capacity or overall quality of life. In an additional 30 percent, the operation was either too risky or simply did not help. Lung reduction surgery, developed in the last decade, quickly became popular even though, until recently, no large, rigorous studies had been done to find out whether it was safe or effective. Medicare initially paid for the surgery and then stopped, citing the lack of data. It then agreed to cover the procedure only in patients who enrolled in NETT, which started in 1996.

  • The insistence on rehab, before and after the surgery, is a positive step toward a more favorable reimbursement policy for those of you who wish pulmonary rehab without the surgery. Those of us who believe so strongly in rehab applaud this!
  • Till next month, stay well.

  • Donations to PERF
  • Bill and Shirley Grindrod of Anaheim, CA have made another donation to the Chair. Bill and Nancy Gibson made a donation to PERF. Thanks, folks.
  • Jinny von Goerlitz died last week after a long illness. Her husband, Ted, kept us apprised of her valiant struggle. Ted credits Jinny's pulmonary rehabilitation program for her more than ten years of high quality life. Memorial donations to the Chair and PERF were made by Dr. Rich Casaburi, Mary Burns and Elaine Von Goerlitz in memory of Jinny von Goerlitz.

  • Do you have a question about respiratory disease that has been bothering you? If so, feel free to write and ask us, either through our web site or by mail. We answer all of your letters.