When oxygen concentrators first became widely available two decades ago, the in-home oxygen-manufacturing devices were touted as a way for HME providers to save money by stretching the spacing between scheduled deliveries of oxygen in tanks.

The idea was that patients receiving oxygen primarily from a concentrator would use fewer cylinders of oxygen and, therefore, would need to be resupplied with tanks less often.

But, for many HME companies today, it is not working out that way. “Patients have increasingly wanted to be mobile, something concentrators do not allow them to be,” says Roberta Domos, RRT, owner and president of Domos HME Consulting Group in Redmond, Wash. “So providers have increasingly ended up equipping patients with portable oxygen systems. And equipping increasingly mobile patients with portable oxygen usually means many deliveries to the home.”

Still, HME outfits have not lost faith in concentrators. And for good reason, experts believe. “Concentrators remain the most cost-effective way to provide oxygen,” Domos says. “Portable oxygen—although it is growing in demand—continues to be expensive to provide.”

Domos estimates it costs the typical HME provider as much as $50 in gasoline, vehicle wear and tear, insurance, and labor-related expenses for every home-oxygen delivery. The actual figure may be even higher when the costs of filling the tanks and satisfying the regulatory delivery paperwork are factored in.

“Because of that, I think the future is bright for concentrators,” she adds. “I do not see them going the way of the buggy whip.”

Today, in fact, most home oxygen programs are anchored by concentrators, says Bob McCoy, RRT, managing director of Valley Inspired Products LLC in Burnsville, Minn.

“The promise of concentrators was simply to manufacture oxygen in the home, and they have lived up to that,” he says. “They are able to generate adequate levels of oxygen and have evolved to the point where they are consistent, reliable, and reasonably priced.”

Joseph Lewarski, RRT, president of Hytech Homecare and Hytech Medical Supply, Mentor, Ohio, and the former director of the MED Group National Respiratory Network, agrees. “The improvements in quality and performance—ie, noise, heat, power consumption, and reliability—over the last 10 years or so have made the concentrator the best, most affordable, and most efficient low-flow stationary oxygen delivery system. Sure, concentrators have sometimes disappointed us, but the disappointments are more or less associated with the technical limitations of the devices. The production of oxygen via pressure swing absorption [PSA] requires certain minimum specifications, including an air compressor, multiple valves, significant power, and ceramic zealite. As a result, it has made it very difficult to develop a system that is lightweight, uses little power, has adequate flow, and can be used as an ambulatory system.”

Striving for True Portability
Concentrator manufacturers have long sought to develop an oxygen-making device weighing less than 10 pounds. Such a concentrator would be light enough to satisfy mobility-craving patients, McCoy says.

“Progress is being made on that front,” he says. “One company has been showing a 9.5-pound model that it plans to soon bring to market, and a second company is expected to start shipping a similar product in about 18 months.”

The chief limitation on this first iteration of portable concentrators is their operating time. The internal battery on one lasts only about 50 minutes before it needs recharging, an amount of time too short to be practical for most mobile patients, McCoy says.

In addition, while pent-up demand for lightweight concentrators is huge, McCoy believes manufacturers might encounter initial difficulty capitalizing on it because the first under-10-pound concentrators will probably carry a suggested retail price of about $2,000. In comparison, the average price of a standard concentrator is about $700.

“Sticker shock may very well result,” he says. “Of course, seasoned dealers will remember the price of the first concentrators to reach the market as being about $3,000 apiece.”

Another important innovation of late is a stationary concentrator capable of refilling portable cylinders right at home.

“This type of concentrator should greatly reduce the costs associated with inventorying cylinders and delivering them since the patient will be responsible for filling them,” McCoy says.

The downside is, once again, price. Manufacturers are asking about $2,500 for these devices, McCoy says.

“Dealers react adversely when they see the price,” he says. “But if they would first do the math, they would see that this is a small price to pay for the savings that can result from virtually eliminating the need to deliver cylinders,” he says.

A word of caution here. These cylinder-refilling concentrators can manage only approximately 93% oxygen content, McCoy warns.

“Since provider-filled cylinders contain 100% oxygen, there will be some question as to whether a home-filled, 93% oxygen cylinder—especially one fitted with an oxygen-conserving device—will allow the ambulatory patient to maintain appropriate oxygen saturation levels,” he says. “Studies on this have yet to be conducted.”

Room for Improvement
While McCoy credits concentrator manufacturers with having done a good job of solving basic issues of machine reliability, he nevertheless faults them for failing to be responsive to identified market needs.

“It seems like the bigger the manufacturer, the less willing the company is to invest in innovation unless it is forced—and the only time that happens is when they perceive a threat from a smaller competitor that has made the investments in innovation and come up with something good,” he says.

Part of the problem is that the concentrator industry has shed most of its players in the last few years, McCoy contends. Where once there were 30 companies involved in making this type of equipment, now there are just five—and one of them alone controls fully half the market for concentrators.

While McCoy blames intense competition on price as the factor that drove many manufacturers out of the concentrator market, low prices are essential for HME providers because the third-party payors they rely on for reimbursement also watch the price.

For example, Domos says that if prices on the new $2,000 home-fill systems do not drop, few HME providers may believe they make economic sense. “Those concentrators will have to come down to under $1,000 before dealers and providers will find them attractive enough to acquire,” she says. “I don’t know what the prospects are that this can happen, given the amount of research and development costs the manufacturers have to recoup.”

Good Investment
Still, despite the high cost of some equipment, experts are largely in agreement that as long as providers take measures to ensure the cost-effectiveness of the total home-oxygen program, even the basic, standard concentrator of today represents a good investment. Lewarski, for example, says using oxygen-conserving devices in conjunction with whatever tanks are delivered to the home can reduce the number of delivery trips.

He also recommends taking steps to appropriately assess patients for their actual oxygen need before starting delivery and then again at regular intervals afterward.

Domos, meanwhile, suggests verifying prior to making a delivery trip to a patient’s home that no more than 3 months have lapsed since the concentrator was last inspected and given a clean bill of health. “This helps minimize the potential for having to make separate trips for delivery of tanks and for maintenance of the concentrator,” she says.

McCoy advises supplementing concentrator fleets with newer technology. “The fleet of concentrators the typical provider currently has in place is probably effective,” he says. “But they need to be taking steps toward doing things smarter. For example, they should consider bringing in a number of combination systems, where you use a concentrator and a liquid system in tandem and have the concentrator serve as the base unit, and the liquid system for mobility. Using such technology would allow a provider to change the delivery cycle for portables from once a week to no sooner than once a month. There is a manufacturer working on a system that takes gas from a concentrator and liquefies it for filling a liquid portable. This would eliminate delivery of portable cylinders.

“But, invariably, some providers are resistant to this. They ask why they would want to put two pieces of equipment in a home when they can get by with only one. Well, you would do it because the math works—it lowers your expenses, you service the patient better, and you maintain profitability.”

Clearly, McCoy is sold on concentrators.

“They are the solution for the future,” he says. “Consider refrigeration, how it has evolved. In the early days of refrigeration, a block of ice had to be delivered to the consumer’s home in order for the icebox to work. Later, technology advanced and iceboxes began producing their own refrigeration—no one had to come out to the consumer’s home anymore with a delivery of ice. The same sort of thing is occurring with the use of oxygen in the home. Indeed, the concentrators that are in the market today will probably be obsolete 5 years from now. At that time, the mainstays of the market will be concentrators that fill cylinders and liquid portables, or are in the 10-pound range with 4 to 5 hours of battery operating time.”

Lewarski, too, is confident that concentrators have a bright future.

I think that concentrators will be around for a while,” he says. “However, there is some oxygen innovation on the horizon. There are numerous companies in the United States and abroad working on non-PSA and nonliquid oxygen delivery systems. This includes the long-researched ceramic membrane technology, along with some new ideas, including a fuel cell-like electrochemical device that has few moving parts and very low power needs.

“Time and research dollars will help move to market some of these new and exciting ideas. I think everyone’s goal is to ensure excellent patient care and quality of life while operating profitably.”

Rich Smith is a contributing writer for Dealer/Provider.