Which Way? 1. Understand where you came from and lessons learned The RCP GPS - Recalculating Roadmap for the Future Richard M Ford BS RRT FAARC Administrative Specialist UC San Diego Medical Center 2. Anticipate internal and external factors that may alter your path 3. Key strategies to consider 4. SB 525 and Telehealth recalculating 5. Always follow VALUE- PACE GPS Guidance As RCP s Where are We Going? Respiratory Therapist Early Role/Value (1947) Technician (O2 Technician) Provision of cylinder gas Delivery of aerosol therapy Provision of IPPB Assistance with operating ventilators Performance of diagnostic tests 1960 State of the Art Respiratory Care Bread and Butter for Respiratory Care 1960-1975 1
Vapor Oil At 40% alcohol plus 3 grams of opium per dose. It didn't cure you... but you didn't care! Early Aerosol Therapy Sugarloaf Conference on the scientific basis of respiratory therapy 2
Sugarloaf - Recalculating On May 2 4, 1974, the National Heart and Lung Institute and the American Thoracic Society sponsored a Conference on the Scientific Basis of Respiratory Therapy. The conference was held at the Sugarloaf Center in Philadelphia and became known as the Sugarloaf conference. Finance Reforms DRG and Capitated Shift from Revenue Center to Cost Center no convincing rationale for the use of IPPB in patients with COPD has been demonstrated and there is little data in the literature on which to base any conclusions as to whether IPPB is effective Reimbursed per Disease Encounter or per Day Less is Best Opportunity for a Scientific Basis The profession responded with a new focus on evidence driving the provision of Respiratory care. A set of instructions or interventions that are driven by the patient s condition or response to therapy in which the practitioner is allowed to initiate, refine, transition, discontinue, or restart therapy. (AARC) Emergence of Therapist Driven Protocols, RC Consult Services, and PDPs Judy Tietsort and George Burton MD (Wheatridge CO) Lucy Kester and Jamie Stoller MD (Cleveland) Jan Phillips Clar and David Burns MD (San Diego) Protocols The Intent The use of clinical protocols allows health care providers to offer appropriate diagnostic treatment and care services to patients, variance reports to purchasers and quality training to clinical staff Protocol based care enables staff to put evidence into practice by addressing the key questions of what should be done, when, where and by whom This standardization of practice reduces variation in the treatment of patients and improves the quality of care Communication is enhanced and timely response assured UCSD RC Protocols 3
12000 10000 Treatments 8000 6000 4000 Impact of PDPs on Routine Treatment Trends 2000 0 Jul-82 Jul-84 Jul-86 Jul-88 Jul-90 Jul-92 Jul-94 Jul-96 Jul-98 Jul-00 Your Staffing Programs Demand Based Flexible Cross Department Cross Site Beyond Acute Unique Value Minute Based RVUs = How Many Activity Frequency RVU(min) Time (total) Therapist Workday per Hour per Area Total: 6.12 Patient Care Hours Assessment 10 15 150 Setup 1 20 20 Med Aero 6 15 90 CPT 3 25 75 Suction 4 11 44 Blood Gas 3 11 33 Total 412 Direct Variable Time = 6 hours 52 minutes Minutes of Therapy 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 Hour of Workday Total 6W 5W 11W 7W BICU 5W SICU 4
Value Plus - Productivity UCSD Thornton Respiratory Care Productivity Trends July 2004 through December 2011 Cost Saving Programs The AARC Has the Answer 4000 3500 3000 Hours Worked Hours Required Procedures/Activities How long do they take Staffing statements Staffing worksheets 2500 Hours 2000 1500 1000 500 Over 30 Protocols Policies and flowcharts References and CPGs How to start 0 Cost Saving Initiatives by UCSD RC Protocols and Cost Initiation of Patient Driven Protocols $600,000 Initiation of PDPs Thornton $180,000 Incorporation of Inpatient EKGs $150,000 Incorporation of Bronch Services $157,000 Incorporation of Bronchs Thornton $77,000 Consolidated RCS (PFT, PR,Clinics) $250,000 Vent Liberation Protocol $180,000 Creation of an Extern Program $24,000 Med Substitution $497,000 Nitric Oxide Protocol $1,200,000 All would agree that regardless how productive your staff is, that time spent in providing treatments that are not medically necessary is not productive, is a waste of time and materials and can possibly result in harm. You may be 100% productive in performing 10,000 Med Aerosols per month, but if only 4,000 are indicated, you have wasted resources to provide 6,000 interventions, thus only 40% effective productivity. 5
The Cost of Inhaled Meds Today The Hospital Bill in 1968 for a Tonsilectomy The Patient Protection and Affordable Care Act (PPACA), commonly called Obamacare- Shift from Volume to Value THE PATIENT PROTECTION AND AFFORDABLE CARE ACT (aka Obamacare ) Beginning in FY 2013 ACA was enacted and first phases implemented: Value Based Purchasing Patient Experience/Clinical Domain 30 Day Readmissions HF, MI, Pneumionia, COPD, CBG, Major Joint Bundled Payments Hospital Acquired Conditions 6
Hospitals Brace for New Medicare Payment Rules (4/1/16) Comprehensive Care for Joint Replacement Model The new rules will hold hospitals accountable for all the costs of hip and knee replacements for 90 days. If patients recover and go home quickly, hospitals could reap savings. If patients have complications or need lengthy stays in a rehab facility, hospitals could owe Medicare instead. The so-called bundled-payment initiative is the first mandatory program under the Obama administration s plan to shift at least 50% of Medicare spending to alternative-payment models by 2018. 430,000 hip and knee replacements Medicare covers annually. The Centers for Medicare and Medicaid Services, or CMS, estimates the program will save $343 million on the $12.2 billion that Medicare will spend on the procedures over the next five years. Tim Wolters, Director of Reimbursement, Citizens Memorial Hospital, Bolivar, MO 7
Pulmonary Impairments on the Rise Recent studies indicate that in 2009, 40.3 million Americans were diagnosed with asthma or COPD (chronic bronchitis and emphysema). Of these, 25.1 million had asthma and 15.1 million had COPD. These numbers are increasing and are expected to increase to 43.9 million by 2016 While other major causes of death have been decreasing, COPD mortality has continued to rise. COPD is the 3rd leading cause of death. 12 million Americans are diagnosed with COPD; research shows that many do not get optimal treatment. An additional 12 million Americans may have COPD and remain undiagnosed. Recent advances in treatment for COPD offer real opportunities to improve your patient's quality and length of life COPD and 30 Day Readmission Fourth leading cause of 30 day readmission Significant cost, over 11 billion annually Readmission cost of $20,757 30 day readmission rates as high as 28% Assessment of care based on adherence to guidelines suggest numerous opportunities exist to improve COPD outcomes Gary Brown, Patrick Dunne, COPD In Patient Care: Time for a New Paradigm. AARC Times November 2011 The COPD Expert RCP Disease Management in the Acute Care Setting The single most important initiative to provide unique and clear value with VBP reform is the ability of the RCP to reduce COPD readmissions! Identify Patients Treat per Protocol Patient Driven Education Condition Driven Referral Pulmonary Rehab and Post Discharge Care The COPD Expert RCP Disease Management Beyond the Acute Care Setting RCPs in Clinics and MD offices Physical exam and history Home evaluation and family capability Action Plan to contact the MD, report to ER Coordinate care encounters Application of guidelines and protocols Measure outcomes across the continuum Telehealth California SB 525 and Congressional bill HR 2948, Medicare Telehealth Parity Act Ammendments to the Respiratory Care Practice Act No regulatory amendments since the Respiratory Care Practice Act was enacted 33 years ago in 1982. Lack of clarity through expert opinion review can often be a road block for the institution Complaints to the board of educators not liscensed to provide such instruction Scope pursued for unlicensed practice 8
SB 525 Amendment to the Respiratory Care Practice Act (Signed Sept 2, 2015 by Gov Brown) The therapy, management, rehabilitation, diagnostic evaluation, and care of patients with deficiencies and abnormalities which affect the heart and cardiovascular system Administration of medical gases and pharmacological agents for the purpose of inducing conscious or deep sedation under physicians and surgons supervision and the direct orders of the physician SB 525 More Educating students, health care professional, or consumers about respiratory care, including, but not limited to, education of respiratory core courses or clinical instruction provided as part of a respiratory care education program and educating health care professionals or consumers. The treatment, management, diagnostic testing, control, education and care of patients with sleep and wake disorders. SB 525 More All forms of extracorporeal life support, including, but not limited to ECMO and extracorporeal carbon dioxide removal (ECCO2R) Mechanical or physiological ventilator support as used in paragraph 4 subdivision (a) of 3702 includes, but is not limited to, any system, procedure, machine, catheter, equipment, or other device used in whole or in part, to provide ventilation or oxygenation support. SB 525 More The therapy, management, rehabilitation, diagnostic evaluation, and care for non-respiratory-related diagnosis or conditions provided a health care facility has authorized the RCP to provide these services and the RCP has maintained current competencies in the services provided. 525 New Navigation for RCPs Medical staff and executive team awareness of enhancement in scope Move forward with programs in which lack of clarity regarding scope has prevented or delayed initiatives Refine and update institutional policies related to both allowable scope and competencies Incorporate required competencies within formal education programs and forums Incorporate skill sets in Licensing Exams Develop roles in which RCPs can add value Partner with nursing and medical staff Medicare Telehealth Parity Act What does HR 2948 do for me? HR 2948 redefines Respiratory Therapists (RCP s) as healthcare professionals. This elevates our status as defined by the Medicare Act and statues. This makes it possible for RCP s to get reimbursed not only for telemedicine services, but also qualifies RCP s for reimbursement for services at levels similar to nursing and other healthcare professionals. This promotes the growth or our profession now and for the future 9
4 Reasons to Embrace Telemedicine Can help reach approximately 80 million people in federally designated underserved areas Can bring timely services and even some followup therapy (speech therapy) to recently discharged patients unable to leave their homes Engages patients who would otherwise leave their condition untreated due to transportation issues related to medical appointments. Half day of travel in 15 minutes. Offers providers the opportunity to hold virtual visits with patients being referred and improved followup to optimize the patients and provider time. HR 5380 Now and Future RCPs as qualified provider RCPs into Medicare Statute Coverage of remote patient management (COPD) Expands existing coverage Calls for studies on readmission * Adds other OP services * Adds home as a telehealth site for hospice, dialysis, DME Telehealth Services Professional consultations Patient Monitoring Patient Training Clinical Observations Assessment Treatment RCPs could perform this services within their scope of practice, however the act does not change current payment policies in which billing remains through the MD. http://www.americantelemed.org/home Benefits of Telemed and Virtual Visits Providers protect market share Facilitates additional capacity Reduce expense Patient access Patient engagement Patient convenience Early identification and referral 39.5 Billion US Adults Using Wearables FDA approved 33 digital health solutions in 2014 FDA to approve 100 more by 2018 433 devices available today RCPs are ideally positioned 10
RCPs and Telehealth Congressional bill HR 2948, Medicare Telehealth Parity Act Covers RCPs as qualified telehealth providers Incorporates RCPs into Medicare Statutes (billed by MD/Facility) Adds remote patient monitoring for patients with COPD Expands coverage in 2 and 4 year phases April 12, over 40,000 messages California well represented! Are You Ready Roadmap for Respiratory Services Must differentiate respiratory care from other services in the hospital RT orders are not static, but dynamic, thus often need to change using protocol driven care and MD extenders Physicians rely on the assessment and documentation of RT in which duplication is minimized and teamwork exist Focus on the added value, do you make a difference? Unique advanced expertise and competence for new roles Data driven managers with a focus on value will create environments where RCPs thrive Plan Your Road Trip with Your Staff Don t Leave Home without Them Recalculating the Value Proposition Revenue Cost Value 1960 1980 2000 2013 11