Worries Remain over Beneficiary Care under Competitive Bidding

FORD CITY, Pa. — Three birds in a cage positioned over a
nebulizer and an oxygen concentrator — that’s what was
causing the patient’s distress.

“He was inhaling bird droppings,” said Kimberly S. Wiles, BS,
RRT, vice president of respiratory services for Ford City,
Pa.-based Klingensmith Healthcare.

It’s likely that patient’s condition would have continued to
worsen had it not been for the respiratory therapist from
Klingensmith who visited his home to assess the situation —
and quickly determined it was a bird problem.

“No one would have known that over the phone,” Wiles said.

But “over the phone” is how much clinical assessment might have
to be done in the new world of competitive bidding. That
worries Wiles, whose company garnered Round 1 rebid contracts in
several product categories, including oxygen, and who fears that
the slashed Medicare reimbursement will result in sicker patients
and more hospital readmissions.

“At $100, not a lot of companies are going to be able to have
respiratory therapists working on titration,” Wiles said. (The
Pittsburgh CBA charted the lowest Round 1 oxygen concentrator
reimbursement at $102.84.) She added that will be so even though it
is well documented that 40 percent of all oxygen patients are not
properly titrated.

It’s a problem for companies like Wiles’ that have a tradition
of closely monitoring patients to ensure they are getting proper
care. Klingensmith, in fact, has a singular goal for respiratory
patients: to keep them from being readmitted to the hospital.

Last December, the provider initiated a program designed to
capture outcomes showing that with high-end service, the rate of
hospital readmissions within 30 days of discharge can be affected.
That service includes frequent visits from clinicians to help with
disease management, such as ascertaining the correct titration
level. It will not be a service that is available to Medicare
patients, according to Wiles, because the funding will not be
there.

“The Medicare patient is the one that is put by the wayside,”
she said, adding, “The government is paying for a delivery service.
That is all.

“We are looking at how we are going to handle this. We will
always have respiratory therapy capability there. Will it be as
often, will it be as frequent? Probably not. Will you have it
initially? Always.”

It is the ongoing contact, the visits that keep patient care on
track, that will suffer, she believes. “I am not saying you need a
therapist every day, but initially, you need to visit to see what
you are working with,” Wiles said. “It’s that face-to-face contact,
looking at their home to see what you can do there. We’ve got to
find ways to look into that patient’s home.”

Most patients would have a difficult time monitoring themselves,
but that appears to be where Medicare is headed, according to
Wiles. “We’re putting a lot of trust in the patient being a
respiratory therapist,” she said. “I know patients are not being
oxygenated, which leads to the whole cycle of patients being
readmitted [to the hospital]. So we are taking a setback.”

The importance of monitoring the patient’s situation was
underscored recently when Klingensmith got a call from a physician
that an oxygen patient had a new, drop-shipped oxygen concentrator
and needed the old one to be picked up. As a precaution, the
company sent out an RT, who discovered that, although the patient
needed a minimum five titrate level, the concentrator only went to
level three.

“You can get anything cheaper on the Internet if you look hard
enough. But you have to look at the service that goes along [with
the equipment],” Wiles said. “You’ve got to provide the service
that patient needs. How can you do that with a flyer, a phone call
and a website?

“We don’t want to be that Internet provider that just throws
equipment at patients,” she added.

Wiles is also concerned that patient confusion will help push
Medicare beneficiaries back into the hospital. For example, one of
Klingensmith’s current patients will have four different providers
under competitive bidding, she said.

“It’s really difficult trying to keep the continuity of care and
trying to make the patient understand who they need to call for
care,” Wiles said. Patients could become so confused that they
simply call 911 and end up back in the hospital.

“And that is just what we do not want to happen,” Wiles
said.

So how will Klingensmith service its Medicare beneficiaries
under the constraints of competitive bidding when it goes into
effect Jan. 1? Wiles is not sure what that new service will look
like, though she said the company is exploring the possibility of
starting a home health agency. That would allow Klingensmith to
“bring in respiratory therapists as a consult and try to get them
in that way,” she said.

In the end, she said, “We still have a mission and we still have
a goal and we’ve got to do whatever we can to … keep that
patient out of the hospital. We’ll just have to readjust and
realign and see how it goes.”

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