Developing a pediatric home ventilation program is a tremendous endeavor that can be intense, challenging, and, most of all, rewarding for a respiratory care practitioner. Both the clinical and financial aspects require a highly dedicated and structured staff within a home medical equipment (HME) company. Because the chronic pediatric ventilator patient population is relatively small in the scope of care reimbursed by Medicaid and private insurance companies, the importance of funding its special needs seems to have been all but ignored in the recent past. Bringing together the required clinical excellence and sufficient reimbursement to finance such a program is the very essence of opportunity to be an advocate for both chronically ill children and the respiratory care profession itself.

Gathering the Evidence

My background in respiratory care had been in the critical care and chronic care setting for more than 12 years. Home care was completely new territory when I was approached in 2003 to develop a pediatric respiratory program for an HME/oxygen company (Hastings Home Health Center, Cleveland). The owners asked me to explore the need for this service and to prepare a formal presentation based on my findings. I met with respiratory therapists, physicians, nurse case managers, and social workers and representatives from the area’s pediatric hospitals: Children’s Hospital Medical Center of Akron; Cleveland Clinic Children’s Hospital for Rehabilitation, which accepts chronic ventilator patients from MetroHealth Medical Center in Cleveland; and Rainbow Babies and Children’s Hospital in Cleveland. The answer was clear: All of these facilities reported that there was a definite need for another company to offer pediatric services, since there were not many HME companies in the Cleveland-Akron area that offered ventilator programs. Furthermore, those companies that did offer such programs could not consistently accept new ventilator patients if their staffing could not support them. Bottom line: The hospitals needed more options for discharging their patients. The reason the current options were so few was quite clear: Ohio Medicaid reimbursement for the required HME, especially mechanical ventilators with pressure support/pressure control capabilities, was entirely inadequate and had been for many years, although most of the pediatric chronic ventilator patients have Medicaid coverage: A large number live in poverty and are born prematurely due to a number of factors, including poor prenatal care or parental drug abuse.

I scheduled additional meetings with the hospitals’ respiratory therapists and physicians to learn their current protocols for discharging a ventilator patient, including the home ventilators currently in use, ventilator circuits, heated humidity, family education, and patient monitoring with pulse oximetry and apnea monitors. We also discussed the intermittent need for therapeutic modalities such as aerosol machines and IPV (intrapulmonary percussive ventilation).

It was during these meetings that I realized that I could attempt to offer a program that would be an extension of the hospital interdisciplinary team. For years, I had worked on the hospital side of the situation: weaning the children to home-going ventilator settings and teaching tracheostomy care to families, for example. I felt I could develop a plan that would offer a seamless transition to the home to support their plan. As a pediatric-neonatal specialist, I believed I could be a unique liaison between the hospital and the child at home, ensuring that these young patients would get the best care, but always keeping in mind that the bottom line for the company was no less important.

Just the Facts

I then presented this information to my employer, a family-owned HME company that had never worked with pediatric patients or Ohio Medicaid but had a strong adult ventilator clinical program in place. This undertaking would be huge and somewhat daunting both financially and clinically, but it was also an opportunity to take the company to a new level by offering a unique program. The owners and vice president agreed that this was definitely worth pursuing and that I could develop the program that would reflect the standards of the company’s already-existing adult clinical program. Beyond that, I could tailor it specifically to the needs of the patients and use my years of pediatric experience in order to be a true resource for the families and their children at home.

The Ohio Medicaid reimbursement issue was addressed from the outset. We knew the only way to determine the bottom line would be to do the calculations ourselves. Pursuing changes within the Medicaid system would be futile until we could support requests for higher reimbursement with our own concrete experience.

Several months into development of the program, we received our first referral and quickly expanded the program to a maximum of 21 pediatric ventilator patients at the 2-year mark. The capital equipment investment was enormous, but the pediatric program gained the attention of private insurance companies. After presenting my program to their administrators, Anthem Insurance agreed to add Hastings to their provider list, having rejected requests in previous years because doing so would have been “duplication in services” provided by other HME companies already contracted with Anthem. We realized that providing this program would bring value to the company in ways other than attempting to make a marginal profit from Medicaid reimbursement.

After accepting 21 ventilator patients and hiring the necessary respiratory therapists and nurses to provide clinical support, the owners made the decision to “cap” the pediatric program. Until a ventilator was discontinued from a current patient, we could not accept new patients. Because we consistently offer heated humidity with heated wire circuits in conjunction with the newer ventilators, capping our services placed a strain on the referring facilities. According to our referral contacts, patient discharges were delayed as a result of capping our program.

Facing Medicaid

We at Hastings felt it was time to contact Ohio Medicaid regarding the E0463 ventilator code pertaining to invasive ventilation with a ventilator that had pressure support and pressure control capabilities. At that time, reimbursement for those ventilators was $750 per month and was intended to cover the cost of the machine and its maintenance, the circuit, and the required monthly equipment check of the ventilator by a respiratory therapist. If it was financially impossible or very difficult at best for HME companies to offer this type of program, the result would be that the pediatric patients would be forced to wait in the hospital. Paying the costs of delayed hospital discharges would be even more costly to Ohio Medicaid in the big picture. Presenting this predicament to Ohio Medicaid was therefore crucial to everyone involved: the patients and their families, the hospital physicians and staff, and the HME companies attempting to provide this service.

I then organized the effort to contact Ohio Medicaid and put together the formal presentation. On December 1, 2005, I sent a letter to the Bureau of Health Plan Policy (BHPP) (within the Office of Ohio Health Plans, which is part of the Ohio Department of Job and Family Services in Columbus). It was sent “To Whom It May Concern” and described our program, why we needed to “cap” it, and the dramatic changes in medical technology (ventilators) requiring the reevaluation of reimbursement levels to accommodate those changes.

In January 2006, I received a phone call from Brenda Lucas, deputy director, Office of Ohio Health Plans, asking that we schedule a presentation to the BHPP. To prepare for the February 17 presentation, I made countless phone calls to hospitals (physicians, respiratory therapists) and HME companies around the state so that I could fully understand what had transpired previously in the history of Ohio Medicaid and confirm that statewide, this was a dire situation for everyone involved.

This presentation was truly a group effort in the name of providing a solution for these children at home. I was joined in this effort by Ann-Marie Brown, MSN, CCRN, CPNP-AC/PC, critical care nurse practitioner coordinator, Children’s Hospital Medical Center of Akron, who presented “Quality of Life: With the Ventilator, and Beyond.” Also joining our effort was Daniel Pavlik, RRT, vice president of operations, Hastings Home Health Center, who presented “Current Medicaid Reimbursement Levels vs DME-Company Costs. Proposed Reimbursement Levels with Associated Documentation of Patient Qualification for E0463 Code.” Karen Lidsky, MD, pediatric critical care, MetroHealth Medical Center and Rainbow Babies and Children’s Hospital, provided crucial support to the ventilator presentation and quality of life presentation. (Letters of support were submitted by Dr Karen Lidsky and by Kathy Fedor, CPFT, RRT, RRT-NPS, manager of pediatric respiratory care, Cleveland Clinic Foundation.)

I presented a ventilator concept of pressure support and how it requires less work of breathing overall; the patient’s energy can instead be used for growing, playing, talking, developing muscle mass, and weaning from the ventilator. Together with Dan Pavlik, we provided a breakdown of the costs of these patients: clinical support, equipment, and soft supplies. We divulged the costs that were provided by Cleveland Clinic Children’s Hospital for Rehabilitation: The average daily cost for a stable, ready-for-discharge patient is more than the monthly amount that a HME company would be paid even with our proposed increase ($1,406.38/month = Medicare’s present reimbursement for this E0463 ventilator). We stressed that this presentation was on behalf of the patients, the medical facilities, and any/all HME companies that would offer this ventilator program. Together, we asked that Medicaid consider paying a higher reimbursement rate so companies could feasibly provide this service and facilitate hospital discharges, thereby lowering the cost of the hospital stay and the overall cost to Ohio Medicaid.

The attendees had many questions regarding the ventilators and the pressure support mode of ventilation. They stated that they did not realize that these kids were out there, living productive lives, and that for many, the ventilator was only a temporary support measure.

Success

In May 2006, Edward Amaya, Medicaid Health Systems administrator, sent a letter informing us that reimbursement would be increased to $900/month, effective July 1, 2006, which was the amount reimbursed by Anthem, the lowest payor from the private sector; $900 per month is a 20% increase, a considerable success given that reimbursement has been at $750 for many years. I did present to Medicaid the fact that I was proposing an increase to Anthem at the same time I was presenting to Medicaid, though. Since then, I have received notice from my contact at Anthem that they had made the decision to increase reimbursement to $1,265.74 (an increase of 26.5% over the current rate) for the Blue Traditional (YRT) and Anthem Senior plans (YRA); for the managed care plans (PPO, HMO, POS), the new rate is $1,139.17 as of July 1, 2006. My employers and I view this as a huge success!

I have contacted Ohio Medicaid, informing them of this change, with hopes of convincing them that $900 per month is still not enough to fund a pediatric program and that they would reevaluate their figure.

Whatever the final result with Ohio Medicaid, true progress has been made in this area—with even the $900 per month reimbursement level for the E0463 code. As a neonatal-pediatric specialist, being a committed respiratory therapist has afforded me the opportunity to make a difference in the lives of these children and their families.

Sue Percival, RRT-NPS, is manager, pediatric clinical services, Hastings Home Health Center, Cleveland. For more information, contact rtmagazine@allied360.com.