From the President
What we need you to do
From the Editor
N.S.R.C. Therapists in the News
NBRC Changes
A Summary of Respiratory Therapy and PPS and SNF's
Respiratory Care at Madonna
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The state meeting is fast approaching. This year's conference promises to offer somthing for everyone. Jane Matsui and her program committee have worked very hard to offer a wide array of educational topics. New this year is the pre-conference workshop. This workshop is free to AARC members. Not only is this a great benefit for your membership, it offers you the opportunity to receive four additional C.E.U's. Tthe state meeting also means the board members will change. I want to remind everyone to vote. The opportunity to vote means you have a choice on who represents you. The newly elected officers will begin their terms immediately following the state meeting. Volunteers are also needed to serve on a variety of committees: publications, public relations, sputum bowl,etc. If you are intrested, please contact any board member.
As members, I need your help. I need you to contact your Representatives and Senators to oppose a proposal that would tax the AARC's investment income as unrealated business income. This means that for every AARC member, $5.00 of membership fees would go to cover this tax. This means that AARC would need to raise our membership fees. I have included a copy of what you need to include in your letter. Please do this to support our national organization.
As I come to the end of my term as President, I want to thank everyone on the board that worked with me. I thank you for the opportunity to represent you the last year. Bruce Couillard will resume the role as President. Bruce has vast knowledge at the state and national level. He will be an asset to our state society. I look forward to renewing acquaintances and meeting you in Kearney.
The address are:
The Honorable ____________
US. House of Representatives
Washington, DC, 20515
The Honorable ____________
United States Senate
Washington, DC, 20510
Important points to make, in your own words are:
1. I am a [member/director/officer/employee] of the American Association for Respiratory Care and a [member/director/officer] of [your state affiliate].
2. The AARC is a 501c(6) association serving 36,000 members and the respiratory care community.
3. The AARC relies on investment income to help us complete our tax-exempt mission.
4. I urge you to oppose a proposal in the Clinton Administration budget plan that would tax association investment income as unrelated business income.
You may also contact your Representative or Senator by phone, and most of them can be contacted by e-mail via www.house.com or www.senate.com.
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I would like to take this opportunity to ask for everybody's assistance in getting material for this newsletter. This is your newsletter, it is an opportunity for you to test the water being a writer and to share information that you have a first hand knowledge of. You don't have to commit to writing a monthly column or to doing an in depth report, but everyone of you have ideas and issues that could easily be included in this newsletter. I know we all hve time constraints, but I understand that this newsletter has had some real problems getting material. How easy is it to contribute? Really easy, all you have to do is write something and send it to me at:
Inspiration
c/o Bernice Butler
2025 South St.
Lincoln, NE 68502
That is it. I will edit and do all the other stuff, you get all the credit and some heartfelt thanks from me. You can provide the information on a disk, please make it Window's 95 compatible, you can type it out, you can write it in long hand, it doesn't matter to me, just send me something and you too can see your name in print.
I am looking forward to all of you input and to seeing you get the best newsletter I can put together, but I need your input. Shane is going to help me get through a few newsletters with his expertise, then he will remanin active as apublications chair. What is going on in respiratory care outside of Lincoln? I would like to see more input from outside of Lincoln, I would like to see input from everywhere.
This issue has a lot of information about the upcoming state conference. The conference will be held in Kearney, NE from 11-13, May 1999. The details are inside. The conference is offering a noninvasive ventilation workshop worth 4 CEU's this year and the planning committee has been working hard to bring us this confernce so mark you calendars and attend.
by Sue Waggoner, RRT, RPFT, President
I want to start a column that will congratulate those therapist that have been published, interviewed, quoted, tec. Those Respiratory Therapists that promote the profession throught advancement should get recognized. If you or someone you know has been recognized, please send the information to me. My address can be found on the back of this newsletter.
Tressi Liverhouse RRT and Steve Jesus CRT were selected to present their scientific abstract in Denver, Co at the annual American Association for Cardiovascular and Pulmonary Rehabilitation (AACVPR) conference in October. Both therapists work at NHS Pulmonary Rehabilitation in Omaha. Tressi presented results of a freestanding maintenance program. Steve presented study results comparing rate of perceived dyspnea (RPD) and rate of perceived exertion (RPE)scales in patient populations with COPD and IPF. Steve's study was selected as one of seven outstanding research articles at the national meeting. Congratulations to both Steve and Tressi.
Jan Matsui, RRT appeared on Lifequest, a health promotion television program sponsored by NHS and UNMC. Jane discussed patient compliance with bronchodilators. The episode has aired several tiems in the Omaha viewing area. Jane works in the Respiratory Care department at NHS-University Hospital. Congratulation to Jane for promoting Respiratory Care and helath maintaince.
AARC took issue with the Interim Fianl Rule for PPS primarily in two areas:
1. Those rules do not contain minimum competencey standard for care givers, as described above.
2. These rules do not faily and accurately recognize the costs associated with the provision of safe and effective respiratory therapy.
To provide that second point, the AARC commissioned a study that included an analysis of Medicare's own database. The Executive Summary of this study can be found at http://www.aarc.org/govt_affairs/Muse_summary.html. The bottom line was that respiratory therapist do make a difference from a clinical standpoint, and the services of a respiratory therapist are required by at least 100,000 skilled nursing facility patients.
But here now is what is happening: Medicare payment is not considered adequate, thus there tends to be a retreat on the part of providers from offering that service. So we are witnessing HMO's retreating from providing services to Medicare patients; lidewise, we are seeing skilled nursing facilities eliminate respiratory therapy services in many institutions. This move, even though it's just beginning, will foretell a significant decrease in access to respiratory therapy services in skilled nursing facilites.
Those of you who work in hospitals be advised that you will find ever-increasing difficulty in discharging certian patients (especially those who are ventilator dependent) to sillled nursing facilities. This means that you hospital will suffer a negative financial impact because of Medicare's new payment system. Here's how it will work:
Under the DRG system, Medicare pays your hospital a fixed amount based on the patient's diagnosis. Since this is a prospective payment system, your institution is placed at financial risk for the cost of care that exceeds the amount paid by Medicare. Barring these patients having supplemental insurance, there is no way for you institution to recoup it's cost. Furthermore, without a SNF to accept this patient, there's no place to discharge the patient to. Many of you may recall a smiilar situation that existed in the early and mid 80's. hospitals were absorbing enormous costs related to ventilator patients for no other reason han an inability to place these patients in less expensive skilled nursing facilities.History will repeat itself.
While some SNF's have reacted to PPS in a knee-jerk fashion by withdrawing respiratory therapists from the equation, a few others have remembered that their resident census is comprised of persons other than Medicare beneficiaries. In order to keep census higher, those institutions continue to use respiratory therapists and continute to accept our patients. If you work in an institution that needs to discharge patients to skilled nursing facilities who require respiratory therapy services, especially ventilator support, you should encourage your institution and your medical director to examine the impace to the SNF/PPS system on transfers or discharges from acute to subacute care facilities.
The AARC has been involved in numerous meetings with numerous Medicare officials. We have provided the hard evidence that respiratory therapists are the only professionals qualified to provide respiratory therapy sevices by virtue of their formal education and validated competency testing. Statements from the American Society of Anesthesiologists, The National Association for Medical Direction of Respiratory Care, and the American College of Chest Physicians bolster our evidence. AARC has brought expert witnesses to several of the Medicare meetings, including respiratory therapists, pulmonary physicians, and registered nurses who are also RRT's. In each and every instance, our key message has been that other caregivers cannot be considered qualified to provide respiratory services on the basis of the traditional education they receive. Moreover, all care providers wishing to become proficient in respiratory therapy must undertake a validated educations experience and submit to a validaged credentialing examination.
AARC provided Medicare with sample language to be included in the SNF Resident Assessment Instrument Manual. The gist of our input was that in order for anyone to be deemed qualified in respiratory therapy, they must undertake formal education and validated competency testing that is considered on par with that of respiratory therapists. The AARC believes that there is only one standard when it comes to pronouncing caregivers qualified to perform respiratory therapy. That standard is the same one you subscribe to.
Even though many HCFA officials have stated their agreement with our position, they have yet to develop a remedy for the problem. So to turn up the heat on this issue some more, AARC is engaged in meetings with various members of Congress, with special attention to key Committee Staff. Recently, we met with staff representing the Senate Committee on Aging and the powerful Senate Finance Committee.
Here's what else the AARC is doing:
1. We continue to be involved in coalitions that are attempting to remedy the SNF/PPS payments, especially as they pertain to ancillary services.
2. We are also communicating with consumer groups in an effort to get these powerful groups to embrace our cause and, therefore, assure safe and effective repiratory therapy. We want these groups to help us push for minimum competency standards.
3. Even though key physicians and key physicins organizatins have been helpful, we will continue to work with them to drive home the point that respiratory therapy must be provided safely and effectively only by person deemed qualified by appropriate education and competency testing.
4. We will alos measure the impact on access to respiratory therapy services in skilled nursing facilities since the implementation of SNF/PPS.
5. Perhaps the most important aspect of our strategy is to obtain outcome information. Several of our members have responded to our request to provide us with examples of unsafe and ineffective respiraroy therapy when provided by persons other than qualified respiratory therapists.
As we fight through this latest problem, we should bear in mind that the need for experts to deliver respiratory therapy services has not changed, but rather the reimbursement system has. Ultimately, after this initial reactionay period, SNF operators will realize that they provide services to more than just Medicare patients. They are in the business of maintianing a high census and cannot do so if they have to turn away patients who require respiratory therapy. Futhermore, it is imperative to decrease misallocation of treatment. Of course the only way to do that is to employ persons who possess a comprehensive knowledge of respiratory therapy services and possess indisputable documentation of their competency to provide said services.
Madonna's most widely know porgrams are the ventilator assisted unit and the complex medical unit. The ventilator assisted unit consists of 18 beds dedicated to ventilator dependent patients. The complex medical unit has 30 beds dedicated to those patients who are often faced with going home, but still need a great deal of care. These two units offer many of the same types of care as an acute care facility, the difference is greated patient and family involvement. Madonna has been able to reduce ventilator weaning time from an average 35 days, just 5 years ago, to today's average 21.6 days. This reduction in weaning time has been do in large part ot a flexible weaning protocol, based on patient needs.
In addition to the flexible weaning protocol used at Madonna, aggressive rehabilitation programs have contributed to shorten stays. It si not nuew anymore that managed care companies want to reduce the number of dollars spent per illness, this combined with Medicare denials have caused a greated team managed approach to care, from which everybody benefits. This team managed approach has helped contribute to employees at Madonna working more closely together to provide better patient care. Madonna's respiratory care departemnt now porcides assessments and input into patient care and discharge planning from the time the patient is admitted, and participates in team meetings throughtout their stay.
Altough patients at Madonna are admittedly more stable than patients in acute care facilities, that can and does change rapidly. Often patients can and do go from being stable to being critical in a matter of hours. Although Madonna's respiratory therapists are not involved in emergency room care, they are called on to provide emergent care, this emergent care is limited in scope and often means attempting to stablize a patient until the ambulance team can arrive. In addition to emergent care more and different types of procedures are being done at Madonna, giving staff therapists opportunity to assist in procedures that patients were previously sent out to have done.
Changing health care reimbursement and advances in in technology have lead to a real patient need that Madonna fills. Dave Gross, Madonna's respiratory care manager, believes that the future of respiratory care at Madonna and rehabilitation hospitals nation wide looks good due to the increasing number of aging patients combined with shorter acute care stays. There are still problems with reimbursement, but these are problems that will hopefully be solved in the not too distant future. although the environment is different, the need for quality respiratory care in facilities like Madonna is real and growing. This need is giving respiratory therapists a new setting to practice in.