When the objective is prevention or treatment of bronchospasm, respiratory infections, and other breathing-related ailments, the intervention of choice these days is aerosol therapy. It offers the fastest, most effective means of delivering medications right where they are needed—deep inside the lungs.

HME outlets providing the equipment necessary to administer such therapy often express a preference for disposable T-shaped nebulizers, those handheld receptacles into which a measured dose of medicine is poured and then converted by air pressure from a compressor into tiny, inhaled particles.

Originally designed for hospital applications wherein a staff respiratory therapist would supervise the patient’s intake of medicine, disposable T nebulizers in the home setting make for an inexpensive, convenient, short-term solution—especially if a ventilator is involved—since the T shape permits easy connection to a vent circuit. However, when dealing with a patient at home on a sustained basis, an even better solution is a reusable jet-style nebulizer. “Reusables are simpler to operate, more durable, long-lasting, and easy to clean, and consist of only a few components,” says Chris Kane, director of marketing for Pacific Pulmonary Services (PPS) in Novato, Calif. “Most important, they enable more medication to reach the patient’s airway, which is vital for any user of aerosolized medications but especially so for the elderly person with chronic COPD and comorbidities—like CHF—who has to take treatment three or four times a day.”

Many Variables
To be clinically effective, aerosolized medicine particles must be sized within one to five microns. This is known as the respirable range. Particles smaller than 1 micron tend to remain suspended in the inhaled air, only to be blown right back out of the lungs as soon as the patient exhales. Particles larger than 5 microns will end up deposited in the upper and central airways, completely missing the target area and introducing the possibility of systemic side effects.

In all fairness, the actual delivered dose of an aerosolized medication depends on numerous variables, not just the type of nebulizer being employed. Still, the effect of those variables is minimized with a jet nebulizer. Jets operate on a principle of physics known as Bernoulli’s Law: basically, by directing pressurized airflow through a restricted orifice within the nebulizer, airflow velocity accelerates, thereby causing negative pressure; this negative pressure draws the liquid medication up through a capillary tube and, when that medication hits the fast-moving stream of air, aerosol particles are formed. The jet flow, combined with the patient’s own inspiratory flow, increases total output of the aerosol particles—resulting in roughly 70% or more of them exiting the mouthpiece in the desirable one- to five-micron range.

At the same time, the jet’s design prevents exhalation from mixing with the aerosol, so there is a drastic reduction in medication wastage. In contrast, about half the medication contained in a disposable T nebulizer can be expected to be wasted thanks to built-in inefficiencies that allow the aerosol to continue flowing full-force during the intervals between inhalations. “With disposables, you have an open circuit—more than one exit for the medication,” says Kane. “But with reusables, you have a closed circuit and only one exit—the mouthpiece.”

Because just 30% of the aerosol particles inhaled from a disposable T nebulizer can be counted on to fall within the respirable range, treatment time runs about 15 minutes (compared to 5 with a reusable jet). Other shortcomings of disposable T nebulizers: the devices contain small parts (making them hard for the elderly to work with), their performance deteriorates in a matter of days, they are not dishwasher safe, and you can’t sanitize them in a pot of boiling water or in an autoclave.

Not Killed On Price
Kane’s organization is a 12-state home respiratory provider with a clientele made up mostly of elderly patients. The company has used both types of nebulizers—disposables and reusables—but a few years back began shifting more and more toward jets, until now those are about all it stocks. That, Kane explains, has been helpful in PPS’s efforts to differentiate itself on the quality of care it offers, since the company carries only those reusables qualifying as top-of-the-line. “Admittedly, in this industry, it is very difficult to lead on the basis of equipment alone,” Kane confides. “The thing that really differentiates a company is how well you work with providers and patients—but that’s why you want to use that top-flight equipment in the first place—to be able to offer top-flight service.”

Using the best meant having to forfeit some of the margin on reimbursement, but PPS executives correctly projected that they would not be harmed in so doing. They were aware that reusables qualify for HCPCS Code A7005, with an allowable reimbursement of $26.21 to $30.83 every 6 months (equaling up to $61 and change annually). At first blush, that looks like a loser compared to disposables, which qualify for HCPCS Code A7003, with an allowable reimbursement of $2.33 to $2.74 twice monthly (working out to as much as nearly $66 annually). However, the roughly $5 maximum a year advantage disposables have over reusables is offset by handling costs: with reusables, you deliver replacements only two times a year and generate billings only two times a year; with disposables, for just one patient, you have 24 shipments per year and 24 individual billings.

“The way we look at it, where you get killed is by using low-grade equipment to maximize reimbursement—you are in effect stepping over a dollar to pick up a dime,” says Kane. “Conversely, the additional margin you have to invest to provide really good equipment is money well spent—not only because it is more cost-efficient in the long run, but also because you gain a better patient experience, which in turn leads to a better outcome.”

FEHBP A Reality?
Come January, the Medicare Modernization Act kicks in with a requirement to trim what is spent on provider goods and services. “Congress has asked CMS to adjust reimbursement so that it aligns better with the median reimbursement paid out by the Federal Employees Health Benefits Program (FEHBP),” says Kane. “The problem is that there are a significant number of FEHBP health plans out there from which the median will have to be determined. So it is not yet clear what the adjustment will be in Medicare reimbursement—could be anywhere from 5% to 20%, because there is a lot of complexity.”

No matter how it all plays out, lowering the rate of reimbursement won’t affect PPS strategy. According to Kane, the company will continue to provide those high-end reusable nebulizers. It can’t afford not to, he hints.

Securing Compliance
A bigger concern than reimbursement for Kane’s company is the matter of patient compliance. “Compliance for the elderly COPD patient is tough enough as it is, and that is why we like reusable nebulizers,” he says. “Our patients appreciate the fact the reusables are easier to hold. Because of that, they are more likely to be in compliance. And if you have to take medication four times a day for the rest of your life, ease of use is critical.”

Kane finds that reusables—being simpler to disassemble and reassemble—also encourage seniors to be in better compliance with the cleaning regimen between uses. That is crucial, too, because a neglected nebulizer quickly transforms into a veritable petri dish brimming with gruesome bacterial bugs.

Easy-use equipment is not all that is necessary for compliance. There is also education. Without it, patients tend to develop dangerous misconceptions about nebulizers, such as the device can last forever and that it must be working fine as long as mist still exits the mouthpiece.

In the years ahead, the number of aerosol medications on the market will go up. Consequently, aerosol therapy will become increasingly widespread in the home environment. However, Kane feels that for the average HME, breaking into the nebulized medication space won’t be easy. “Those downward reimbursement pressures are significant,” he says. “That is going to more and more put a premium on efficiency and knowledge to properly service the patients and support the physicians. It takes years to acquire both.”

But as tough as getting a foot in the door will be, keeping it there will prove even harder still, he contends. “You can’t,” says Kane, “approach nebulized medication in a casual way. And if you are not focused on it, it will be very difficult to be good at it.”

Rich Smith is a contributing writer for Dealer/Provider.