For more than 20 years, the home care profession has pleaded with lawmakers and private insurers to increase oxygen reimbursements. But instead of more money, providers have been offered less. And less. And less.
Robert McCoy, RRT, owner and managing director of Valley Inspired Products, Apple Valley, Minn, believes one possible alternative—an approach that might put oxygen on course for higher rates of reimbursement—would be to promote much more aggressively documented, evidence-based home care science. “We’re sending our lobbyists to Capitol Hill unarmed,” McCoy asserts. “We are not equipping them with the proofs necessary to convince Congress that the industry needs to be better paid.”
A reason for the ineffectualness of earlier persuasion is that the home care profession appeared to be crying wolf: “Our message since 1986 has been that people will die if the latest round of proposed cuts is approved,” McCoy says. “But what’s happened? The dealers responded by finding ways to adapt. And every time they adapted, no one died. So lawmakers have learned that the warnings of death and disaster issued by our side ahead of a reimbursement cut are not credible. As they see it, we have not yet reached the point of cutting so deeply that patients will actually suffer for it.
“The remedy is to present to Congress the strongest scientific evidence possible to demonstrate that, when you cut reimbursement, you cause specific, concrete negative results on human lives. For example, cutting ambulatory oxygen reimbursement by x-percent demonstrably sends y-number of home care patients back into the hospital.”
McCoy’s Valley Inspired Products—VIP for short—is a research outfit involved in the testing of respiratory technology. Says McCoy, “We look at respiratory products of all types—oxygen-delivery systems, oxygen-conserving devices (OCDs), high-flow oxygen devices, sleep therapy devices and accessories, CPAP, line humidifiers, auto-adjust systems, masks and nasal interfaces, compressor nebulizers, volume ventilators, you name it.”
VIP also provides education, mainly in the form of seminars touching on matters such as the fundamentals of respiratory care, oxygen-delivery systems, oxygen-conserving devices, sleep diagnosis and treatment, the economics of oxygen delivery, and the economics of home respiratory care. The company is known as well for its consumer-oriented guide to oxygen-conserving devices. “Our first edition came out in 2003, and the newest one became available in May,” McCoy reports. “The idea behind it is to provide oxygen patients, clinicians, and dealers with an all-inclusive tool that they can use when considering use or purchase of OCDs. The guide stresses that not all oxygen-conserving devices are the same. It also emphasizes that pulse volume, maximum dose, delivery flow patterns, and many other factors affect oxygen delivery. The guide describes the fundamentals of oxygen delivery and conservation. And it delves into the function of 19 commercially available oxygen-conserving devices, without recommending or endorsing any.”
McCoy conducts these varied activities from a 2,000-square-foot industrial space with the help of two employees—one full-time, the other part-time. VIP debuted in 1997, started by McCoy and design engineer Pete Bliss (the creative mind behind Respironics’ new Ever-Go travel oxygen concentrator). “We realized there was a need for a company with independence that could take a totally objective look at product performance capabilities,” says McCoy, who previously had been in charge of sleep-group marketing for Nellcor Puritan Bennett.
|Robert McCoy, RRT (left), shown here with his patient “Marty,” predicts a “tidal wave of problems” when patients own their own oxygen equipment.|
Originally, VIP was set up to develop product prototypes, demonstrate their viability through extensive testing, and then sell the patents to manufacturers. Two such products emerged from this process, but neither attracted a buyer. The first was dubbed Air Buddy, and it was intended for use by laymen confronted with an adult or child who has stopped breathing. “We designed it as an add-on to automatic electronic defibrillators,” McCoy says. “Our research showed that giving ventilation to a heart-attack victim in the minutes before paramedics arrived on the scene would greatly increase his chances of survival, but that people standing nearby are reluctant to attempt artificial resuscitation on a stranger because of the requirement that they put their mouth over his. Air Buddy solved that problem. Fitted over the victim’s mouth, it provides ventilation for 5 minutes—enough time for the paramedics to show up and take over.”
That the patents for Air Buddy and the second product (a critical care product used in conjunction with mechanical ventilators) remained unsold had nothing to do with McCoy and Bliss deciding in 2003 to dissolve their partnership. “We realized that by both designing and testing a product, we were hurting our credibility as a source of objective assessments,” McCoy says. “Pete sold me his interest in VIP and is now on his own, focused solely on designing.”
HANDLE WITH CARE
In addition to VIP, McCoy operates a durable medical equipment (DME) business, started in 2006, called ValleyAire Respiratory Services. While the business is small, that is not a source of worry for McCoy. “I’m focused on solving patient problems, not making money,” he says, adding that ValleyAire’s cash shortfalls are for now covered by VIP. “I’ve set up ValleyAire mainly so that I can validate the clinical effectiveness of the care being provided using the products available to us. One of the frustrations I have is that these new products are wonderful, but no one is really checking to see if they’re actually helping the patients. That is what has been missing in all this.”
Still, McCoy has not completely blocked from his mind the young venture’s thirst for black ink. How else then to explain his move to reduce the company’s expenses by outsourcing oxygen deliveries. “That’s being handled for us by the same company that supplies the gas and fills the tanks,” he says. “Outsourcing is helpful in that it frees us from the equipment provision responsibility.”
Today, DME providers, McCoy says, are functioning as an equipment delivery service in the mold of UPS, the package delivery service. “With UPS, the driver pulls up to the home, dashes out of his truck with a package, drops it off, races back to the truck, and leaves in a hurry,” he elucidates. “It’s a race to see how fast the driver can run and how short a time he can stop. Home care providers are doing almost the exact same thing, only not anywhere near as efficiently as ‘Big Brown.’ ”
McCoy gives oxygen providers credit, though, for branching into clinical services. “The therapy component was a nice add-on that some companies started to give themselves a competitive advantage—showing themselves to offer more than the competitor down the street—or that they introduced simply out of the goodness of their hearts,” he says. “But the value of that add-on was never recognized by any of the payors, and that was in part because there was never any documented evidence to demonstrate whether and to what extent the clinical service was able to favorably affect outcomes.”
When not at the bench of his testing facility or behind the counter of his DME shop, McCoy can be found making presentations at home care symposia and industry meetings. He occasionally is joined by longtime friend Tim Buckley, RRT, director of respiratory services for Deerfield, Ill-based Walgreens Home Care. “We’ll sometimes take the point-counterpoint approach,” McCoy says. “We gave one such presentation in California, where I spoke from the position of the respiratory care idealist who wants to provide care no one can afford to deliver, while Tim spoke from the viewpoint of the realist whose job was to explain how we can offer good care despite the economic restrictions we all face.”
McCoy and Buckley both went to respiratory therapy school at Triton College in River Grove, Ill. “Bob has a reputation of being an advocate for the patient,” Buckley says. “He asks questions that we should all be asking when we see a new piece of equipment on the market. I have worked to develop the role of the respiratory therapist in home care, and it is complementary to Bob’s work. I believe RTs need to first have an understanding of how the equipment works to apply the correct technology to improve the patient’s condition.”
MAN BEHIND THE NAME
Articles McCoy has written for RT have dealt with issues in long-term oxygen therapy (February 2006), obesity and oxygen therapy (October 2006), various oxygen modalities (March 2005), and the difficulties faced by long-term oxygen therapy patients when they fly (March 2005).
A common feature of articles on respiratory care that McCoy has written is a COPD patient known simply as Marty. “I keep discussing Marty because he’s so different from other patients who have gone high-visibility with their disease,” McCoy explains. “Most of them are presidents of or consultants to patient-advocacy groups and, by extension, very political. Not Marty. He has no political affiliations at all. He’s just an average Joe oxygen patient trying to make the most of every day of his life. I find that to be well worth writing about.”
And indeed, it is an active life that Marty leads. Golfing, snowmobiling, and being towed on an inflatable tube behind a ski boat are among his favorite recreational pursuits. However, Marty recently underwent surgery and is showing signs of slowing down. “Marty’s COPD is clearly progressing—his oxygen needs are increasing,” McCoy says .
McCoy first became acquainted with Marty 8 years ago. “I gave a presentation to a meeting of the local Lung Association chapter; Marty and his wife came up to me at the conclusion and started asking me questions about COPD,” he remembers. “They felt I offered good answers, because then they started coming to my shop. Before long, I was testing equipment Marty brought over for evaluation. He was so helpful that later, whenever I came across equipment on my own that I wanted to test, I would ask Marty to stop in.”
Grandfatherly Marty devotes much time speaking to school-age kids about the dangers of cigarette smoking. The nasal cannula he wears helps to visually reinforce that the consequences of tobacco use are real and unpleasant. Says McCoy, “Marty’s warnings hit home, especially when the students hear him talk about his life on oxygen.”
TIDAL WAVE TO HIT
McCoy criticizes the home care field for its failure to appropriately counter the reimbursement cutters. Yet, were the profession to adopt his advice today, would it be a case of too little too late to make a difference? “No,” he insists. “An embrace of evidence-based science is something that’s never too late to do.”
Unfortunately, such a shift would not and could not avert the disaster McCoy predicts for Medicare’s 36-month rental cap rule, now in effect. “There will be a tidal wave of problems when patients own their oxygen equipment,” he says. “Mainly, you can expect a sharp rise in the number of patients experiencing exacerbations of their respiratory problems as a result of dealers no longer having any incentive to periodically check the equipment and make sure it’s functioning properly. Many of these patients will be forced to go to the hospital because of the exacerbations they’re experiencing. If each patient sent back to the hospital spends just 1 day there, the costs of that alone will be enough to demolish the entire economic model on which the 36-month cap is based. As a result, the system will soon enough implode.”
Angriest of all at that collapse will no doubt be the patients, who are plenty mad as it is for other reasons. “I monitor patient Listservs over the Internet,” McCoy says. “What I’m observing in those forums is patients are going off and doing their own research—they request or buy products they’re interested in and then do their own testing. They post comments along the lines of, ‘I tried this and it didn’t work, and finally I tried this and it did work.’ Through the process of elimination, they’re finding what works, but, basically, they’re playing a guessing game.”
McCoy also worries whether home care providers, physicians, and payors will ever truly come to grips with the fact that patients’ needs are dynamic, while the equipment supplied to them is static. He elaborates: “When we drop off a liquid system, you set the flow control on 2. But the patient’s needs may actually call for more or less flow throughout the day as they engage in various activities, as they are at rest, and as they get up and move around.
“Ultimately, in the future, you could have patients buying concentrators at Wal-Mart. To me, that’s not a big issue. But if you have an oxygen product that you’re selling and distributing like a commodity, someone still needs to pay for professional services that go along with that product. There must be clinical intervention because still what you’re selling and distributing is a medical process. So, at bottom, the end point is not the equipment—it is appropriate patient outcomes.”
Rich Smith is a contributing writer for RT. For further information, contact firstname.lastname@example.org.