Ch-Ch-Ch-Changes
Last week was a big one for transitions in the chronic lung disease world. AARC President Brian Walsh shared his latest article (written with one of the godfathers of our profession, Dr. Robert Kacmarek) about how respiratory care stands at a crossroads. COPD Foundation founder and Chair-Emeritus John Walsh passed away after a lengthy struggle with injuries sustained in a fall last year. Congress has started marking up bills to repeal various parts of the Affordable Care Act. Here in Michigan, our almost-daily weather transitions seem to be wreaking havoc on those with allergies, asthma, and COPD. And, of course, most of the US just switched to Daylight Savings Time (for better or for worse). So this is as good a time as any to reflect on where we are as a profession, and where we're going.
I first wrote about respiratory care being at a crossroads just over two years ago. In that article, I wrote about the need for adapting to a more outpatient-focused model, because of changing reimbursement models and the push for evidence-based practice. I've been a part of this transition, building on work and evidence from programs like the innovative, respiratory care-driven care management initiative led by Dr. Jean Wright at Carolinas HealthCare and the UC-Davis ROAD Program (led by two respiratory therapists), which focuses on education and self-efficacy. At the 2016 AARC International Respiratory Congress, I was able to meet several other practitioners from around the country, working on similar projects. Whether it's a full cross-continuum approach, improved care coordination, or increasing our presence in primary care, momentum is building, and it WILL transform our practice.
How can I be so sure? Two reasons: Money and expert recommendations.
You see, 2015 not only saw my first prognostication, it also ushered in a new era of Medicare payments. The Medicare Access and CHIP Reauthorization Act of 2015, also known as MACRA or the "permanent doc fix" was signed into law in April of that year. MACRA did away with the wildly-flawed "Sustainable Growth Rate" calculation that, in theory, determined how much physicians got paid for various Medicare services (but in reality got altered every single year, because the supposed adjustments were just silly)(and yes, this is a vast oversimplification). It also provided for two new payment frameworks, the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs). Both of these frameworks start moving Medicare reimbursement away from the traditional fee-for-service model (an environment where respiratory therapists have had limited success fighting to have our services covered) and toward a more inclusive quality-based system that rewards providers for efficiency and improved outcomes. I'm sure it's not news to anyone reading this that respiratory therapists have a history of providing both, which provides us with a compelling argument to start performing as true therapists and disease managers right in physician offices. On top of increasing penalties as COPD continues to get phased in under the Hospital Readmissions Reduction Program, it's clear that disease management WILL save practices and healthcare systems money. The only question is whether RTs do it, or whether we cede this to other disciplines (as we did for nurses with tobacco cessation).
The expert consensus has been longer in coming, but it is definitely on our side. The latest Global Strategy for the Diagnosis, Management and Prevention of COPD (#protip: Don't call them the "GOLD Guidelines"...they don't like that) calls for an increased focus on patient education programs with an eye on improving self-management and self-efficacy. The recommendations have an overall bent toward outpatient management, as it is becoming more and more clear that if we can keep people out of the hospital, not only for readmissions but for INDEX admissions, we can save money and improve the quality of life for those living with chronic lung disease. This philosophy is also backed up by the upcoming COPD National Action Plan, which will similarly be calling for outpatient management rather than episodic acute treatment, and will likely be suggesting enhanced, ongoing pulmonary fitness and exercise regimens. Both of these certainly suggest a larger role for respiratory therapists, IF we mobilize enough to take advantage of these opportunities.
How can we do that? That's a story for next week. Stay tuned...
Respiratory Care Services Assistant Manager, NY, NJ at The PromptCare Companies
7 年I work for a high tech durable medical equipment company, on the eastern seaboard, where we do this. We provide the home care patient the high tech, life support equipment, education and clinical follow up to provide them sustainability and improved health by reducing their re-hospitalizations. We, as a company, continue to document our patient compliance, due to our due diligence, and demonstrate the effects of our service on reduced hospitalizations. They may be COPD'ers, have SMA, ALS, Cystic Fibrosis, or many other conditions which are improved by invasive, or non-invasive ventilation, thereby improving their quality of life. At the same time, we're reducing demands on the healthcare finances for caring for these patients. After all, that's what it's all about! Isn't it????
Clinical Manager at Hahnemann University Hospital
8 年Well said Tim
Leader in respiratory therapy, educator and cardiopulmonary researcher. Co-founder of FluidIQ.
8 年Bravo! Well stated.
Senior Director of Advocacy and Regulatory Affairs / Respiratory Therapist
8 年Every life is full of crossroads. We are often presented with opportunities to change our course. Sometimes, we're prepared for these. Sometimes, we make the right decisions. Other times, well... The lives of professions are no different. That we've been at a particular decision point in the past does not preclude that point from arising anew. Chronic disease management may not be the newest kid on the block as a theory, but we have been ill-prepared to make the decision to move into that space over the course of my decade in the field for a variety of reasons. The biggest of these is reimbursement; as we all know, Medicare does not reimburse many of our services directly, and does not consider us a true profession. We have made many efforts to change this, but we were very tardy in recognizing that Congressional action would be unlikely, and wasted many resources tilting at that windmill until finally redirecting our efforts. (There are of course many other issues, but if I discussed them all here, what would I have to write about?) However, I believe that game is changing. I, too, have been long advocating for a change in how we sell ourselves. We must switch from a focus on providing a service that gets paid for to providing a service that saves resources and improves outcomes. Now the payer stars are aligning in that same direction, C-suites around the country appear ready to listen to this logic, and we must be flexible enough to ride the wave. As I mentioned in a direct reply earlier, this MUST be an all-hands effort. Rank-and-file therapists do indeed have to stop relying on the kindness of others and engage, but The Choir must also be more creative and proactive in reaching out to those breakrooms and social media groups to re-recruit those who have been disheartened by our nearly-unbroken record of legislative failure at the national level, and our reluctance to enforce the professional goals we ourselves set. We cannot afford to simply write off these folks as hardcases who believe they are entitled to respect without work. We must do a better job at delivering the tools they need to BUILD that respect. Not top-down, not bottom-up, but a true team effort. We can achieve a bright future, but it starts with taking a serious look at each and every one of ourselves, our messages, and our structures. Only then can we start rowing the boat in the same direction.
Regional Director Of Operations at Family Allergy & Asthma
8 年I was once told by a very wise mentor, that "if you stick around in healthcare long enough, history will repeat itself". Outside of technologic advancements, very few concepts are new or innovative. They have been discussed and broached in the past by many. The problem has been in convincing the profession to reinvent itself and move forward. Chronic disease management is not a new concept to the profession of respiratory care, it is an ideology that has been promoted in public venues and plenary lectures at AARC Congress (https://rc.rcjournal.com/content/58/8/1377) for well over 15 years. Since that time, we have seen many respiratory therapists gravitate to physician, and more importantly patient extenders. Disease management, prevention and wellness are being done efficiently and effectively by respiratory therapists around the country. Just not in the volumes we need them to occur. Unfortunately, most of these messages are preached to the "choir". The innovators, the adaptors and the progressive thinkers of the profession that are too few in numbers when we need them in masses. The profession of respiratory care prospered in the 70's and 80's by creative people and groups that were not afraid to "Think Outside the Box" and look to expand their impact on patients and families with chronic respiratory conditions. The profession is not currently at a "crossroads", we were there over a decade ago and chose to take the path of comfort at that fork in the road and not explore the adventures and opportunities that laid ahead along a different path. Now we commiserate in break rooms and social media groups to lament that others have blazed these trails ahead of us and we get no respect. I have always been told and believe that respect is "earned and not an entitlement". For years, too many have ignored the tools and resources to promote best practices, evidence-based medicine, protocols, patient-centered care and to eliminate unnecessary care, treatment and procedures that drive cost and not quality. But it is not all doom and gloom. There are new adventures and opportunities that await us at the next fork in the road that is here today. If we choose to stay the path of comfort and ease, healthcare will pass us by very quickly. But if we choose to network and be creative in the opportunities that are before us across the entire continuum of care, the future will be bright. It is time to get off the "professional welfare" train and facilitate networks and synergies with your state and national organizations to develop the tools, resources, networks and strategies to move this wonderful profession that many of us love to its next level of opportunity and success. The opportunity to be difference makers in the lives of patient with cardiopulmonary disease and their families is here. The question really becomes...Is the profession ready to leave tradition, biases and comfort behind to take advantage of the opportunities before us today?