In mid-September, NAMDRC, along with the American Thoracic Society, the American Association for Respiratory Care, the COPD Foundation, the American Lung Association, and others met to discuss the components of a legislative agenda for the coming years. The primary purpose behind the meeting was the premise that IF the current Republican majority would shift in either the House or Senate after the 2018 election, the community should be prepared to move an already agreed upon legislative agenda. CHEST was involved in the preliminary discussions, as well as follow-up, but was not in attendance at the meeting due to a scheduling conflict. There was also tacit agreement that as these policies are fleshed out and crafted into specific legislative language, the community would re-evaluate the current political climate to determine the value of pushing an agreed upon agenda prior to the 2018 elections.
Various patient groups were also invited to participate, but scheduling conflicts precluded some societies from participating but signaled their desire to work with the broad pulmonary medicine community to pursue common goals.
NAMDRC brought three specific Medicare coverage and payment issues to the discussion: home mechanical ventilation, payment for high flow oxygen therapy, and site of service/Section 603 issues.
Home mechanical ventilation is admittedly a complex issue, but it is moving forward in at least two political directions. First, Senator Bill Cassidy (R-LA) and a physician by training, has signaled his desire to move this issue forward, either legislatively or giving CMS one last chance to move forward through the regulatory structure. He agrees that a payment system that inhibits access to appropriate bi-level mechanical ventilators and encourages access to more complex life-sustaining ventilators, regardless of documented medical need, is appropriate. While CMS does have the authority to act, it has chosen to ignore repeated requests for action over the past 4 years.
Ironically, the House Energy and Commerce Committee, which shares jurisdiction on the House of Representatives with the Ways and Means Committee on Medicare issues, has sent a request to the Congressional Budget Office to provide a cost estimate (a “score” in Washington vernacular) of likely savings from a legislative solution to this matter. In the current political climate, a legislative proposal that actually saves $$$ is politically attractive, and we are working both the regulatory and legislative pathway to seek a workable solution.
On the oxygen therapy issue, there is growing evidence that, for a small group of Medicare beneficiaries who need high flow oxygen therapy as their disease progresses (pulmonary fibrosis, end-stage COPD, etc), there are no oxygen systems readily available to meet that need outside the home. At home, numerous concentrators can meet that need, but outside the home, the ideal solution, liquid systems, is not readily available because of the payment system tied to competitive bidding. CMS payment data indicate that a very low percentage of oxygen users need more than 4 liters per minute, and current law would make a payment adjustment unique to certain patients a very difficult hurdle, particularly in the era of competitive bidding, a legislative change is the best solution facing the community. The challenge is to craft legislative language that addresses the need but would preclude abuse by suppliers who might jump at the chance for higher payment for liquid, well above current payment levels. And because liquid systems fit into a “delivery model” business plan, contrary to portable oxygen concentrators and transfill systems, the solution is not as easy as a payment bump to make provision of liquid systems more attractive.
Site of service regulations are hitting pulmonary rehabilitation particularly hard, and CMS concedes that the only solution is a legislative one. Under current policy, a pulmonary rehab program that is located off campus but needs to expand or move from its current location (losing a lease, for example), if the expanded program is NOT within 250 yards of the main hospital campus, the program is then reimbursed at the physician fee schedule rate, a rate cut of approximately 50%. Needless to say, hospitals are not pursuing that approach. Likewise, a hospital that chooses to open a NEW program is also constrained, needing to locate within 250 yards of the main campus or face the dramatic cut in payment.
As these issues evolve and the political climate perhaps opens unique opportunities, we can expect the broad pulmonary community to pursue these and other issues.