As I travel around the country and meet with home respiratory care professionals and business owners, I am regularly confronted with questions and concerns regarding the lack of and the need for objective standards for the delivery of home respiratory therapy products and services. In this new millennium, one would assume that medicine’s snowballing clinical and technological advances have spilled over into home care, providing for both a recognized and standardized practice model that ensures the quality and continuity of care for all patients. Unfortunately, there are many reasons why we are still struggling in this area. The most notable is the archaic coding and reimbursement system that governs our profession.

Many industry experts have noted that reimbursement drives home health care. This is more evident now than ever. The HME industry is a relatively young profession by health care standards, yet it is haunted by its own brief history.

Health insurance is, for the most part, a post-World War II product. The Medicare and Medicaid programs, which represent a large portion of the HME consumer base, are a product of President Johnson’s “Great Society” and Title XVIII of the Social Security Act of 1965. Early HME services focused on the delivery and short-term rental of basic medical aids, often referred to as sick room supplies, and included items such as hospital beds and wheelchairs. Since very little medical care was provided outside of the traditional acute care hospital setting, a discharge to home was often limited to very ill patients with short life expectancies. Family members often provided most of the routine patient care. Equipment services were designed to meet the limited medical needs of such patients, and it was often a sideline business for the company. It was common for families to rent hospital beds from the same companies that rented tables and tents for parties and post-diggers for farm work—with the service expectations essentially the same.

HME History Creates Image Problem
The third-party payment system that developed to accommodate the HME service was based on and around the practice of short-term rentals for “durable” medical equipment, items that could be easily cleaned, reused, and rerented—just like the party tables. The imprint this early business model has left in the minds of many of the payors seems to be that of a burly delivery man unloading a clunky and very durable hospital bed out of the back of a worn-out delivery truck. As a result, the payment system we operate under for HME and home respiratory care is based solely on the perceived “rental” or “purchase” price of the particular item, with essentially no consideration for the associated costs of service. It is clearly designed and viewed by many as a commodity business model, which is evidenced by the introduction of competitive bidding.

Hindsight is 20/20 and when confronted today, most HME providers acknowledge the reimbursement system was flawed from the onset. Our years of naïveté and our willingness to overlook the system’s flaws because of a favorable payment program have helped bring us to this place. Some argue that we are paying the price for the sins of our forefathers. Regardless of the reasons and forgiving the mistakes of our predecessors, we are now faced with a reimbursement system that is woefully inadequate to meet the needs of patients and providers of HME and that encourages practice at the lowest acceptable level.

The advances in medicine have found their way into home health care. No longer are we servicing end-stage patients with limited life expectancies and very basic equipment needs. Today, HME providers often deliver sub-acute level care, assuming the responsibility for care of sicker patients with greater medical needs. We service the medical needs of complex neonates through end-stage geriatric individuals. Our patients are afflicted with chronic lung diseases, cancer, respiratory failure, congenital heart problems, congestive heart failure, asthma, cystic fibrosis, premature birth- related disorders, sleep disorders, AIDS, muscular dystrophy, amyotrophic lateral sclerosis, and the list goes on. The equipment has advanced to include sophisticated oxygen delivery systems, ventilators, cardiorespiratory monitors, pulse oximetry, mucus clearance devices, sleep therapy devices, etc, all of which require professional training and oversight.

Low Payments Create Catch-22
HME is clearly a professional medical service and the respiratory therapist one of the central players. The equipment is only one component of the overall care and service being provided, and in many cases falls secondary to the professional component. This now leads us to the Catch-22 dilemma the HME industry is faced with and the major obstacle confronted by the champions for home respiratory care standards of practice: How do you establish a high standard of practice and expect providers to comply when the payment system barely covers the cost of basic equipment services?

Home respiratory therapy was not a well-thought-out process. The role of the home respiratory therapist was often carved out of market and sales programs. In more favorable reimbursement times, HME providers sought ways to differentiate their equipment services from those of the competitor. Since the equipment varied little by provider, the free “value-added” service practice developed—a system that still challenges us today. In the early HME days, offering regular home respiratory therapist visits as part of an oxygen program was a method of encouraging discharge planners (often the hospital respiratory therapy department) to use a particular company. This same process quickly spilled over into aerosol compressor setups, apnea monitoring, and subsequently CPAP, bilevel therapy, etc. Although many companies used (and still use) this strategy to encourage referrals, the policies and processes employed by the home respiratory therapist varied greatly by company and there was little objective material and few third-party agencies to benchmark against. In fact, local market competition and the need to keep up with a competitor tend to drive the local standard of practice more than published or regulated standards. This system has left us with great variance in the way home respiratory policies and procedures are employed.

Despite what may have been less than pure intentions, home respiratory therapy is here and has grown to be a major part of the HME business and the respiratory profession. It is estimated that more than 10,000 respiratory therapists work in home health care. This is quite significant since, for the most part, home respiratory therapy services are not directly paid for.

An Argument for Standards
Most experienced home respiratory therapists and pulmonary physicians I have encountered believe that we need to standardize the respiratory care being performed in the home. Many argue that the third-party accrediting agencies have not filled this void, nor have most state respiratory therapist license laws. The primary reason: The lack of direct payment for respiratory therapist services in the home prevents most groups from demonstrating a willingness to commit to the obvious. How can we set standards for care when there is no payment for the care? The real question is—How can we not?

The barriers for entry into the home respiratory industry are set too low. Almost every HME provider I meet tells me of a company they know of that, in their opinion, provides home oxygen and/or other respiratory products in a manner they consider unacceptable or below the standard. Although I may be inclined to agree, how can you judge them if the standard is unwritten?

It is time to fight the battle to unbundle HME products from the professional services that support them. The payment system employed by the Centers for Medicare & Medicaid Services and adopted by most private insurance companies is outdated and inadequate. It requires a complete overhaul. Concurrently, we, the providers, need to begin closely examining and critiquing the home respiratory therapy profession and our peer companies. We need to embrace our colleagues at the professional respiratory therapist and physician organizations and jointly work to develop an objective and evidence-supported consensus on the minimum acceptable standard of practice for the provision of home oxygen and other respiratory care-related products and services. If we don’t raise the bar, how can we create a strong argument for change?

The only constant in this industry is change—we now need to be the thought leaders, guiding the changes that will become the foundation for the future.

Joseph Lewarski, BS, RRT, is director of the National Respiratory Network of the MED Group, Lubbock, Tex, and the 2001-2002 recipient of the Invacare Award for Excellence in Home Respiratory Care presented by the American Respiratory Care Foundation. He has worked in health care for 18 years and in HME for 10 years. His office is in Richmond Heights, Ohio.