From: Home Care

FORD CITY, Pa.—Three birds in a cage positioned over a nebulizer and an oxygen concentrator—that’s what was causing the patient’s distress.

“He was inhaling bird droppings,” said Kimberly S. Wiles, BS, RRT, vice president of respiratory services for Ford City, Pa.-based Klingensmith Healthcare.

It’s likely that patient’s condition would have continued to worsen had it not been for the respiratory therapist from Klingensmith who visited his home to assess the situation—and quickly determined it was a bird problem.

“No one would have known that over the phone,” Wiles said.

But “over the phone” is how much clinical assessment might have to be done in the new world of competitive bidding. That worries Wiles, whose company garnered Round 1 rebid contracts in several product categories, including oxygen, and who fears that the slashed Medicare reimbursement will result in sicker patients and more hospital readmissions.

“At $100, not a lot of companies are going to be able to have respiratory therapists working on titration,” Wiles said. (The Pittsburgh CBA charted the lowest Round 1 oxygen concentrator reimbursement at $102.84.) She added that will be so even though it is well documented that 40 percent of all oxygen patients are not properly titrated.          

It’s a problem for companies like Wiles’ that have a tradition of closely monitoring patients to ensure they are getting proper care. Klingensmith, in fact, has a singular goal for respiratory patients: to keep them from being readmitted to the hospital.

Last December, the provider initiated a program designed to capture outcomes showing that with high-end service, the rate of hospital readmissions within 30 days of discharge can be affected. That service includes frequent visits from clinicians to help with disease management, such as ascertaining the correct titration level. It will not be a service that is available to Medicare patients, according to Wiles, because the funding will not be there.

“The Medicare patient is the one that is put by the wayside,” she said, adding, “The government is paying for a delivery service. That is all.

“We are looking at how we are going to handle this. We will always have respiratory therapy capability there. Will it be as often, will it be as frequent? Probably not. Will you have it initially? Always.”

It is the ongoing contact, the visits that keep patient care on track, that will suffer, she believes. “I am not saying you need a therapist every day, but initially, you need to visit to see what you are working with,” Wiles said. “It’s that face-to-face contact, looking at their home to see what you can do there. We’ve got to find ways to look into that patient’s home.”

Most patients would have a difficult time monitoring themselves, but that appears to be where Medicare is headed, according to Wiles. “We’re putting a lot of trust in the patient being a respiratory therapist,” she said. “I know patients are not being oxygenated, which leads to the whole cycle of patients being readmitted [to the hospital]. So we are taking a setback.”

The importance of monitoring the patient’s situation was underscored recently when Klingensmith got a call from a physician that an oxygen patient had a new, drop-shipped oxygen concentrator and needed the old one to be picked up. As a precaution, the company sent out an RT, who discovered that, although the patient needed a minimum five titrate level, the concentrator only went to level three.

“You can get anything cheaper on the Internet if you look hard enough. But you have to look at the service that goes along [with the equipment],” Wiles said. “You’ve got to provide the service that patient needs. How can you do that with a flyer, a phone call and a website?

“We don’t want to be that Internet provider that just throws equipment at patients,” she added.

Wiles is also concerned that patient confusion will help push Medicare beneficiaries back into the hospital. For example, one of Klingensmith’s current patients will have four different providers under competitive bidding, she said.

“It’s really difficult trying to keep the continuity of care and trying to make the patient understand who they need to call for care,” Wiles said. Patients could become so confused that they simply call 911 and end up back in the hospital.

“And that is just what we do not want to happen,” Wiles said.

So how will Klingensmith service its Medicare beneficiaries under the constraints of competitive bidding when it goes into effect Jan. 1? Wiles is not sure what that new service will look like, though she said the company is exploring the possibility of starting a home health agency. That would allow Klingensmith to “bring in respiratory therapists as a consult and try to get them in that way,” she said.

In the end, she said, “We still have a mission and we still have a goal and we’ve got to do whatever we can to … keep that patient out of the hospital. We’ll just have to readjust and realign and see how it goes.”