HME Today: Why should respiratory providers who are doing well with traditional portable systems consider switching to and/or adding portable oxygen concentrators (POCs) to their product mix?

Robert K. Jacobson, vice president and general manager, Medical Products Division, AirSep Corp, Buffalo, NY, responds: POCs facilitate travel for oxygen patients, while eliminating the logistical complications for home care providers. More than 60 airlines accept certain POC devices for patient-supplied oxygen, allowing patients/passengers to freely travel the world without the worries of running out of oxygen or needing to make arrangements to be met at the airport by an oxygen company. POCs are considered much safer and have a nonhazardous rating, as compared with traditional liquid and cylinder "contents-based" portable oxygen systems that hold a quantity of pressurized oxygen.

Robert K. Jacobson

Providers like the idea of marketing the advantages of the POC. Patients can stay out further and longer from home, as they become extremely confident in knowing they can generate oxygen with the ease of a choice of any available power sources. Family events, vacations, spontaneous overnights, and freedom for just doing the things they desire, without the worry of running out of oxygen, are enjoyed and cherished by POC users.

Other types of nondelivery portable oxygen systems are currently being marketed: cylinder and even liquid refilling systems operated by patients in their homes. These systems take oxygen from an oxygen concentrator and either compress the gas to fill cylinders, or refrigerate the gas to fill a liquid oxygen canister. They are contents-based and, therefore, cannot address the travel needs of patients or meet the desire to ambulate for a longer period than the allotted time dictated by the oxygen "contents" they carry. Once patients are exposed to the oxygen-making capability of a POC, they readily appreciate the advantages that only this device can provide.

HME Today: How have POCs evolved over the last 5 to 10 years, and what do you think the future will bring?

Jacobson: Since the launch of the first POC with the LifeStyle™ by AirSep Corp in 2002, POCs have greatly facilitated travel and ambulation for oxygen-dependent patients. Almost immediately, all those involved with the LTOT market realized the positive contributions and implications these devices would impart. The immediate acceptance and impact of this just-under-10-pound POC proved that it was the right concept at the right time, and would vastly change ambulation as we know it.

Patients quickly identified with this new concept of managing power instead of contents. POCs operate on multiple power sources, including A/C, D/C (auto), and batteries (internal and external)—even solar power. Patients easily move from one power source to the next, finding them readily available, both indoors and out. Power is what enables patients to make their own oxygen from these miniature oxygen plants. Patients, too, become empowered in this process, leading to a sense of self-reliance.

This process is totally different than needing to carry around a finite amount of oxygen "contents." With contents-based systems, the second patients make use of their oxygen, the clock starts ticking, along with their worries about running out. Any delay cuts their venture short and brings up concerns about running out and having to get back. These fears and limitations are eliminated by the remarkable technological breakthrough of the POC.

For the POC market to fully evolve, the most important and desirable patient considerations required fulfillment. A lighter weight and more compact design needed to be developed to transition POCs from specialty travel/ambulation products to mainstream "wearable" portable oxygen systems, enabling them to be direct replacements for traditional gas and liquid oxygen content systems.

FreeStyle's introduction 2 years ago again proved POCs could compete in size and weight with any portable system, while providing the freedom to travel that is possible only with the oxygen-making capability of these devices. At 4.4 pounds, the FreeStyle is the lightest POC.

We believe that although this is a relatively new market (only 6 years old), the next 5 years will likely yield only slight and gradual improvements to these technological marvels in the areas of oxygen capacity, battery duration, sound level, and maintenance intervals. The one boundary that is going to be extremely challenging going forward is in the area of weight reduction from the 4.4-pound bar that has been set. Our experience, confirmed by patient focus groups, reveals that the single most important consideration from the patients' perspective is the overall weight of the portable oxygen system; second is the duration time. FreeStyle incorporates this critical feature along with excellent internal and external battery durations.

HME Today: Among providers, what is the biggest misconception about the POC business?

Jacobson: There is a misconception regarding the POC's ability to keep patients saturated during sleep. This is understandable since the POC incorporates an oxygen-conserving device (OCD), and although these devices are widely used during the daytime, their use for sleep has not really been promoted until the invention of the POC. There can be substantial differences in OCD technology and functionality, including delivery methodology, sensitivity, delivery speed, size of the oxygen bolus, and the alarm system. The most important aspect of keeping patients saturated during sleep is the unit's sensitivity. AirSep OCD technology is extremely sensitive and allows for up to 25 feet of tubing to be used with our POCs. The alarm system does incorporates a cannula disconnect alarm, something that is not found on any stationary, continuous flow system. This alarm brings awareness to mouth breathers during sleep, when a chinstrap is often desirable.

OCDs can use a per-minute-volume methodology for oxygen delivery in which the device adjusts the size of the pulse of oxygen according to the number of breaths it detects. Essentially, this means that the faster someone breathes, the smaller the size of the oxygen pulse. Because AirSep uses a fixed-pulse methodology for the oxygen delivery—so that our device keeps the size of the pulse constant—as someone breathes faster, they actually receive more oxygen, a desirable feature for patients when ambulating. HME providers need to explore the features of the POC devices and select ones that meet the clinical needs of their patients, while providing the required features.

It is worth remembering that when stationary concentrators and OCDs were first introduced in the mid 1970s and 1980s, they were met with great skepticism for a number of years until they proved their value and advantages to the marketplace. Today, these two types of devices are considered mainstream, and are widely accepted and used all around the world. The POC is moving in this same direction, proving its value in the marketplace daily and gaining acceptance each year. This is not unnoticed by a few of the respiratory equipment manufacturers who are planning to launch POC models, even though they have other non-

delivery technologies. More competition in the POC market is a sign that this technology is here to stay and has genuine advantages over other oxygen technologies.

HME Today: How can POCs help providers combat relentless respiratory reimbursement threats (including competitive bidding)?

Jacobson: The most valuable service we can provide to our customers during these difficult times of reimbursement is what we refer to as a Medicare Model, although we realize other insurance companies are also participating in this unfair attack on oxygen reimbursement. In this model, we stipulate a combination package of two products, a portable and a stationary oxygen concentrator. So that it can be used appropriately, given the current reimbursement schedule, the combo must be priced economically as a duo to the HME provider.

Our concept allows HME companies to provide a lower cost stationary oxygen concentrator designed and able to absorb the bulk of the hours, while the more expensive POC is used only during travel or ambulation (4 to 6 hours per day). Used this way, the POC will have much longer life expectancy with lower maintenance and service costs, as compared with those oxygen products promoted as a single solution.

This combo package also has the benefit of redundancy whereby a concentrator "backs up" a concentrator. The POC is an excellent device in the event of mass power outages during storms, since the patient can easily move the device to another location where power is unaffected.

POCs can stabilize and sometimes greatly reduce companies' operating costs, by eliminating contents-based oxygen deliveries to certain patients. There is still going to be the need for patient follow-up and maintenance, but visits to these patients will be less often than with routine oxygen deliveries.

Before the stationary oxygen concentrators were developed, oxygen patients were provided either liquid or cylinders for home stationary use. These deliveries were virtually eliminated when the oxygen concentrator came into use. Today, with AirSep's experience with oxygen-generating technology in more than 100 countries, we know that oxygen concentrators are the most popular way (worldwide) of administering stationary home oxygen. Portable oxygen is following in the same pattern. Before the POC was invented, liquid or cylinder oxygen was exclusively used for ambulation. Depending on reimbursement and logistic costs, HME companies can begin to evaluate the cost-effectiveness of a POC oxygen system, which doesn't require liquid or cylinder deliveries, versus other nondelivery oxygen systems that are contents-based. Contents-based systems do not afford the patients all the advantages provided by POCs.

HME Today: AirSep has two distinctly different POCs on the market. Why did you deem it necessary to have two?

Jacobson: LifeStyle was the first POC, and offers settings from 1 to 5. Knowing how important it is for the oxygen patient to have the lightest device possible, we determined it feasible to accommodate the highly ambulatory patient group, those who are on 1 to 3 LPM, with a device designed specifically for them. The FreeStyle, with its 1 to 3 settings, gives these patients the oxygen they require in the smallest POC package.

LifeStyle is affordable and represents the most economical POC in the market. Due to its popularity and endurance in the worldwide market, we have been able to greatly reduce its selling price to less than half of what it was when first introduced.

By offering two POCs, we offer flexibility to our customers and choices that reflect individual patient needs and requirements. FreeStyle continues to impress the growing segment of highly ambulatory oxygen users. As production quantities of this product go up in the future, we fully expect to be able to reduce manufacturing costs and our selling price to our customers, as we have with LifeStyle.

Today, a number of HME companies in the United States and throughout the world have justified the use of the POC and find that it is economical to replace contents-based systems in working within the framework of insurance or reimbursement. As the costs of our products come down, the model of a portable and stationary oxygen concentrator becomes more attractive, especially when juxtaposing this with the logical costs associated with contents-based systems, which are predicted to even further increase. POCs will continue to garner market share away from contents-based portable systems for years to come, while providing users with unsurpassed ambulation opportunities.

HME Today: What type of support from manufacturers should providers be looking for when selecting a POC?

Jacobson: It might be said that POCs create new pathways for oxygen patients and their respiratory equipment companies. These devices allow patients to chart a new course or explore new frontiers while "pushing the envelope" with faraway travel. With this unbridled travel comes risk, and everyone has a different tolerance and comfort level as to what is acceptable. In reality, it is just as easy for a patient to run out of oxygen when at home or while ambulating around town, but what happens when there is a problem far from home, even out of the country of residence?

AirSep, along with our extensive customer base, uses its widespread reach in more than 100 countries to provide fast assistance and support for patients traveling with POCs. Combined with our CareFree program for POC replacement, easy and comfortable travel is achieved today. Purchasing from an experienced manufacturer with a long history in design and production, as well as marketing and supporting innovative oxygen concentrators, helps ensure that the product will be durable, reliable, and operational for years to come. Product training and support, along with marketing materials, are critical components for the successful implementation of POCs.