(Part 2 of a 2-part series)
Last month we examined global trends in health care, now let us take a look at the specific forces in our health care system and examine what opportunities exist for respiratory therapy managers and respiratory therapists.
Increase in Cost Without Concomitant Increase in Quality
The question nearly everyone is asking is this: If we are paying more for the health care system in the United States, why don’t we have the best health care in the world? As a report on the National Coalition on Health Care Web site documented,1 there is a disconnect between the dollars and the outcomes. More fuel was added to the fire in a recent Harvard School of Business article published in January 2009.2 In a telephone survey, the respondents listed health care reform as the third highest priority, only trailing improving the country’s economic situation and fighting terrorism. While the complete overhaul of the health system is being debated by various parties throughout our nation, what can the respiratory therapist do? In my opinion, respiratory therapists need to be able to document the value of each of their interactions to diagnose, treat, and manage the care of their patients. Regardless of the payment methodology—whether we enter an era of socialized medicine or retain the system we have in place today—respiratory therapists will make their mark and define their value by demonstrating positive patient outcomes as a result of the various means by which we interact with our patients. A recent posting on the Houston Chronicle Web site3 reported that the Texas Senate passed a sweeping state Medicaid bill that would create more patient-focused, quality-based systems. In short, should this legislation become law, it would base insurance payments to doctors and hospitals on patient outcomes. In the words of Sen Jane Nelson (R-Flower Mound), “This legislation brings us closer to a modernized system that prioritizes quality of care over quantity of treatments.” This philosophy should resonant with all respiratory therapists and their managers.
Since the inception of our profession in the 1940s, respiratory therapists have been at the vanguard of developing or assisting with the development of technology focused on improving patient care. With increasing scrutiny of how we spend the nation’s health care funds, it will become even more important to document the value of each technology that we utilize. We must scrutinize the equipment and ask the question: “Does this technology improve patient care and outcomes?” We need to do this with every piece of equipment that we use, from humidifiers to treatment nebulizers to mechanical ventilators. This is not simply a question that forces us into the corner of selecting the least expensive equipment, but one that asks us to consider the unit cost, operating cost, and labor cost. Sometimes, using a product that is more expensive in the short run will be less costly in the long run. Using treatment nebulizers as an example, Do we know what particle size each nebulizer produces and then utilize this knowledge to tailor the nebulizer to the particular patient condition? Do we consider the labor cost in delivering a medication treatment in the same manner as we consider the treatment time, dosage, etc? For mechanical ventilators, of the seemingly myriad modes of ventilation available to respiratory therapists, which makes a difference in time on the ventilator, days in ICU, weaning success, and overall morbidity and mortality?
For more information on pulmonary rehabilitation legislation, access the AARC’s governmental affairs Web page at www.aarc.org/advocacy, or contact Cheryl West, director of governmental affairs at the AARC, at (972) 243-2272 or via e-mail at .
The AARC Web page for protocols is www.aarc.org/resources/protocol_resources/ main_protocol_resources.asp.
For information on ethics, access the online ethics course provided by the AARC at www.aarc.org/ethics_course/welcome.
For information on S 343 or HR 1077, in regard to both patient access and quality of care, contact Cheryl West at the AARC at (972) 243-2272 or via e-mail at , or contact your state society leadership.
For managers desiring to promote our profession, contact Tom Kallstrom, AARC chief operating officer, at the AARC office at (972) 243-2272 or via e-mail at .
In short, more attention is being paid than ever, both as a result of the economic environment as well as the concern over the relationship between manufacturers, big pharma, and the users of these products. Respiratory therapists possess the didactic knowledge and the clinical acumen to both pose the questions and provide the answers as to which technology to apply in each situation, how to measure the value of the technology, and how to document the value in terms of patient response.
You’ve read the news: We are getting older—both individually and collectively. The aging issue is more complex than ever, because we are seeing more “older sick” and “older well.” For both conditions, the respiratory therapist is positioned perfectly to add value. For the sick, we provide diagnostic evaluation to determine the presence and severity of disease. Once it is diagnosed, we can determine the most effective therapy regimen to achieve the optimum patient outcome. We have the knowledge and skills to assist patients in maintaining and/or improving their health. With the passage of the national coverage policy for pulmonary rehabilitation this past year, respiratory therapy managers who do not currently have pulmonary rehabilitation programs should be organizing this service so that they are prepared for the January 1, 2010, start date. An excellent resource can be found in the March 2009 AARCTimes.4 It provides a valuable checklist for respiratory therapy managers to prepare for starting a pulmonary rehabilitation program.
Society’s View of Health and Life at Any Cost
Much of our population—certainly that part not working in health care—simply does not understand the magnitude of the cost of health care. I have heard various projections about the cost of health care toward the end of life, and while the figures vary somewhat, what is clear is that we spend nearly half an individual’s lifetime health care cost in the last year of life. The respiratory therapist is not the health care professional who decides to continue or terminate life support devices but is intimately involved in this care. What is the role for the respiratory therapist?5 First, the department manager should be involved with the hospital’s ethics committee, ideally by having a seat on the committee. Second, the manager should have in place protocols to support the respiratory therapist to ensure compliance with law and ethical standards in those instances where life support is ordered to be discontinued by the physician. Readers are encouraged to access the AARC’s Web site protocol section for assistance in developing this and other protocols (see sidebar above right).
Third-Party Payor System Removes Economic Responsibility from Consumers
For many Americans fortunate to have health insurance, the incentive is to request as much as possible, particularly since there is no economic disincentive to do so. By some accounts, this is one reason that we have arrived at the point where many of our antibiotics are no longer effective for some relatively benign maladies. In short, the third-party payment system either distances or removes economic responsibility from the consumer. Over the past decade, we have seen the power of direct-to-consumer marketing that puts physicians in an uncomfortable position with their patients who come armed with a wealth of scientific evidence about the treatment or medication that they want the physician to prescribe. At a recent state respiratory care society seminar, the speaker showed a slide that indicated that Americans spent more out of pocket for alternative medicine than for all of their co-pays and deductibles. While I have not found the source to confirm this, I have heard this repeated by numerous individuals. With all of these pressures, what is the role for the respiratory therapist? In my opinion, it is quite simple. We must demonstrate the value of our knowledge and services to the general public such that they are willing to pay out of pocket for our services just as it is done for alternative medicine. With a growing body of evidence that respiratory therapists increase quality while saving money, what respiratory therapy managers must do is to communicate this value as part of your marketing program for your services.
Malpractice Insurance and Defensive Medicine
There is not a health care professional who does not know that malpractice insurance and defensive medicine play significant roles in our health care system. Health care professionals privately admit to ordering more tests and procedures simply to lessen or eliminate the potential for a lawsuit. It is clear that our patient-care volume has increased as has that of other disciplines. The best resource for the respiratory therapy manager is to have established clinical protocols governing the appropriate use of all diagnostic and therapeutic modalities.
High Cost of New Facilities and Equipment
Before the current economic crisis, and certainly intensified by our current economic environment, hospitals and other providers were faced with what a colleague of mine called the health care arms race. If the neighboring hospital purchased the newest CT or MRI, there was pressure on your organization to purchase the same technology. In addition to clinical technology, the burgeoning cost of information technology (IT) has strapped hospital capital budgets to the extent that greater limitations were placed on other capital-intensive endeavors in order to fund the IT needs.
For managers, what opportunities exist in this capital-intensive environment? First, they should become experts in IT, such that the value to the department, staff, and ultimately the patient is absolutely verifiable. Second, managers must investigate the opportunities to use IT to accomplish desired services and do so in a manner that minimizes the need for additional expensive facilities. Telemedicine and “hub-and-spoke” sleep laboratories are on the rise and appear to be adding value in demonstrable ways, both financially as well as in customer service.
Fragmentation of the Industry
While electronic medical records (EMR) promise quantum improvements in managing the wealth of health information, for most of us EMR is in its infancy. In many areas of the country, there is little coordination between providers, which results in duplication of services and unnecessary costs. An example of this occurs far too frequently when individuals get x-rays at family physicians’ offices; but when their physical condition worsens, and they require further testing and/or hospitalization, the x-rays are repeated. Pulmonary function tests (PFTs) done in the physician’s office are likewise repeated in the pulmonologist’s office and the hospital. This occurs because we have a payment methodology that pays for the tests and procedures and does not mandate coordination of care and information. For the respiratory therapy manager, one goal would be to investigate the ability to coordinate diagnostic tests, therapeutic care, and patient education among a group of physicians, the pulmonologists office, and the hospital as a prelude to a complete EMR that is down the road several years.
Anyone who reads management journals and health care publications knows that hospitals must maintain an average occupancy, predicated on their reimbursement stream, somewhere in the 65% to 70% range. Interestingly, according to various reports, the average occupancy rate is below this for many US hospitals. What this means is that unless a hospital has significant nonpatient revenue (eg, investments), they are on the brink of not being able to invest in equipment, staff, and physical plants for the future to the extent that they need to do to survive. Compounding this is the loss of significant revenue from ambulatory services to physicians moving their surgeries and other services outside of the hospital. Even for those hospitals that have joint-ventured with the physicians, this is a net loss to the bottom line. Respiratory therapy managers should consider developing relationships with their community physicians to assist them in performing pulmonary function tests, sleep studies, and other services for which respiratory therapists have a long and solid history of providing high-quality, cost-effective care. With the increasing burden of asthma and chronic obstructive pulmonary disease (COPD) and the attendant concern over unnecessary admissions, the respiratory therapist is actually positioned quite well to collaborate with their physician colleagues.
The AARC, through its leadership and the Political Action Contact Team (PACT), has been communicating steadily with the federal leadership to adopt the expanded role of the baccalaureate registered respiratory therapist to function under the general direction of a physician. This legislation, S 343 and HR 1077, can be found on the AARC Web site on the governmental affairs Web page.
Over the past two decades, we have seen health care under the knife to reduce operating costs in response to various factors. From what we are seeing across the nation, the impetus for cost reductions is far greater than previously witnessed. What managers must do is leverage their administrative skills, knowledge, and competencies to advocate for the continuing or expanding role of the respiratory therapist. In some hospitals, the opportunity exists for managers to assume leadership for other similar departments, such as cardiology and neurodiagnostics. With the increasing body of evidence documenting the value added in terms of quality and cost for utilizing protocols, providing asthma and COPD education, and providing timely diagnostic testing to validate the appropriateness of bronchodilator therapy, the time has never been better for respiratory managers to document and communicate the value of their departments.
Growing Number of Underinsured and Uninsured
Somewhere in the neighborhood of 40 to 50 million Americans do not have access to the most appropriate form of health care. While it has been stated by numerous politicos that this number does not have access to health care at all, those of us working daily in the health care industry know that their protestations are directed more toward getting elected or re-elected than to the facts. The fact is that all of these “underserved” have access to care—it is called the emergency department for the vast majority of them. While the care in the ED is top-notch, it certainly is not the proper delivery method in terms of cost. The respiratory therapy manager would be well served to investigate the feasibility of providing respiratory therapy services in a federally qualified health center, in an asthma/COPD clinic, or, as noted previously, in collaboration with community physician colleagues.
As if the issues of cost, quality, and customer service were not enough, almost every health care profession is confronting current and/or future shortages. From physicians to therapists to nurses, there are few professions that seem to be ready for the onslaught of the Baby Boomers entering their Medicare years. The AARC and state societies have been collaborating on a number of endeavors to raise awareness of the RT profession in order to attract the attention of high school students considering their future career as well as those individuals displaced from their jobs and looking for a new career.
In my list of current and future challenges and the attendant opportunities for respiratory therapy managers, I have listed consumerism as the last issue, because it appears to most individuals to be the smallest current concern. Having said that, I believe that the Baby Boomers will move this issue far up the list as they begin to utilize a wealth of information on the Internet to determine which hospitals and physicians to use. The generations that never questioned the doctor are being replaced by much more involved and invested generations that will not just accept the latest marketing verbiage as a sign of high quality and reasonable cost. The fairly recent upsurge in health savings accounts, urgent care centers, and retail medicine is only the first wave of a new way of evaluating and selecting health care and health care providers. For managers, it is critical that they document the value, in terms of customer service (hours of operation, satisfaction scores), quality (clinical outcomes), and finances (cost per case, not just unit cost of service), if we are to retain our valued position as an integral part of the evolving health care system.
I suggest that every respiratory therapy manager and every respiratory therapist learn what the AARC is doing to support our profession. An important endeavor is currently under way: “2015 and Beyond.”6 While the value of this endeavor exceeds the limits of this article, what this series of three conferences will provide for us is a comprehensive analysis of how patients will receive health care services, how respiratory care services will be provided, what knowledge/skills/attributes and credentialing systems will be needed, and how we get from here to there.7 Readers are encouraged to visit the AARC Web site for more information.
Garry W. Kauffman, RRT, FAARC, MPA, FACHE, is director, strategic implementation, Lancaster General Hospital, Lancaster, Pa, and adjunct faculty, Harrisburg Area Community College.
- National Coalition on Health Care. Health Insurance Costs. Available at: nchc.org/issue-areas/cost. Accessed May 27, 2009.
- Health Provisions Among Public’s Top Priorities for Economic Stimulus. Available at: www.hsph.harvard.edu/news/press-releases/2009-releases/health-provisions-publics-top-priorities-economic-stimulus.html. Accessed May 27, 2009.
- Bunch D. Ready, set, go: 10 things to do right now. AARCTimes. 2009;33(3):48.
- So, you want to be a successful RT manager? AARCTimes. 2009;33(3):56-64.
- Bunch D. 2015 and beyond. AARCTimes. 2009;33(4):50-56.
- Kacmarek R, Durbin CG, Barnes TA, Kageler WV, Walton JR, O’Neil EH. Creating a vision for respiratory care in 2015 and beyond. Respir Care. 2009;54:375-87.