Oxygen therapy patient Holly Lockwood takes to the mountains.

What is new with home oxygen therapy? Not much, despite the many new options for home oxygen equipment that meet the needs of a changing market and the challenge of economic pressures. Home oxygen equipment is not therapy, it is only the tool used by a knowledgeable person to accomplish appropriate oxygenation of a patient at all activity levels. Home oxygen therapy is an outcome, not a product or process; and the current trend in the home is to provide the lowest cost device, which might appear to be meeting the oxygen therapy needs of a patient, yet probably is not. We really do not know if the patient is oxygenating at all activity levels, as no one checks; and if someone does check, it is only sporadically and only at one activity level—usually rest.

As reimbursement decreases, home oxygen providers look for ways to reduce expense to stay financially viable. This often means new technology that does not require frequent service at the patient’s home. This is presenting a problem, as the oxygen providers are lobbying in Washington that home oxygen is a service-intensive business, yet are acting just the opposite. Home oxygen devices that can refill a portable in the patient’s home without a delivery, or a portable oxygen concentrator that can act as both the stationary and the portable, are gaining popularity. These devices are labeled nondelivery systems. With the lack of attention to the patient’s clinical needs from the payors, who reimburse only for equipment, the respiratory professionals working in the home are not recognized or paid. Many home oxygen providers have found that they do not need the respiratory professional to do patient care, since it is not requested or reimbursed; so they either have eliminated that position or have transferred the respiratory therapist to a sales or administrative position. This action will lead to a disaster for the patients, payors, and the profession. Let me explain.

Originally, a patient was treated for hypoxemia in the hospital, as that was the only location available for the oxygen service. Home oxygen equipment was developed that could provide the therapy at home, which is a lower cost environment. Fifty years ago, the first patients discharged requiring oxygen were at the end of their disease process. These patients required only stationary oxygen, a portable for emergency backup, and a once-a-month trip to the physician. These original systems were expensive, with the stationary having the highest cost and the portable being the least expensive. Initial reimbursement from Medicare was based on this model, with 80% reimbursement for the stationary (with a very high equipment cost) and 20% for the portable. This model and methodology has not changed except for the cost of the equipment, which is the subject of the current controversy and debate regarding reimbursement. In today’s home oxygen market, this reimbursement methodology is severely flawed.

Today, patients are diagnosed and treated earlier in their pulmonary disease, with a quick intervention eliminating the trigger of the pulmonary disease and appropriate therapy that can improve the patient’s quality of life and reduce the overall health care expense. The current long-term oxygen therapy (LTOT) patient is by far healthier, younger, and more informed and motivated than LTOT patients of 50 years ago.

These patients want to be informed of their options, be provided education on how they can be involved in their care, have access to devices that allow them to maintain activities of daily living, and be encouraged to live with the disease the best they can.

Example of maximum Fio2 delivery of various oxygen-conserving devices. 2007 Guide to Understanding Oxygen Conserving Devices. Reprinted with permission.

A knowledgeable clinician needs to understand respiratory diseases, products, available resources, options, and the home environment. This is a challenge, as the overwhelming burden of the cost associated with LTOT has caused a narrow focus on how to control equipment costs as opposed to treating the patient. As stated earlier, the disaster associated with this focus on cost is preventing patients from receiving the products and procedures necessary to keep them active. If patients are placed on oxygen systems that do not encourage or allow them to be active, they become sedentary. A sedentary patient does not stay in condition; does not deep breathe; fills with secretions; has exacerbations; develops pneumonia; and is rushed to the hospital, placed in an intensive care environment, treated with professional respiratory services, gets better, and goes home. The price tag for this scenario is enormous. If the patient is placed back on the same limited-capability oxygen system that caused the hospitalization, the process will repeat over and over again. The savings associated with the lower cost home oxygen system is overwhelmingly countered with the astronomically expensive hospital stay—the definition of a disaster.

If the respiratory therapy professional knows this is happening but does not react, there is an assumption by payors that the reduced payment for the oxygen therapy equipment is the right answer. Many respiratory organizations are lobbying in Washington for better reimbursement for home oxygen therapy with models and options that are negotiated and renegotiated. What is the basis for the negotiations? If evidence-based medical practice demonstrated the value of products, methodology, and practice, it would seem reasonable that there would be only one way to do LTOT; and this evidence would identify procedures, equipment, and skill levels necessary to accomplish the objective. This evidence would create the foundation for a fair and reasonable reimbursement plan for services and products. Since this evidence does not exist, one opinion on the right way to do LTOT in the home is just as good as another opinion; usually the payors win the opinion war. We need to establish the science—both clinical and practical—for the use, benefits, and overall cost of effectively providing LTOT in the home.

So, What Is New with Home Oxygen Equipment?

There are many products entering the market that claim to offer the best options for patient care. Many of these products are really targeted at the home care providers and promise lower operating costs, which allows the possibility of staying profitable within the new reimbursement models. These new LTOT products offer patient mobility with lower overall provider costs. The nondelivery systems and portable oxygen concentrators are the most popular of these new options. The best new home oxygen system for patients is the one that will keep them oxygenated at all activity levels. Historically, patients were tested for oxygen needs at rest and the oxygen system delivered to their home was capable of oxygenating a patient at rest. Some patients were given an exercise prescription for activity, yet these patients were rarely tested at all activity levels to see if a portable oxygen system would keep them saturated.

Oxygen-conserving devices were introduced more than 20 years ago with the claim that they would reduce the weight of a portable oxygen system and extend operating time by eliminating the waste of oxygen associated with continuous flow delivery. This was a significant breakthrough for efficient use of oxygen, yet the main focus was on conservation, not oxygenation. Many manufacturers targeted savings and developed their conserving devices with a very low dose of oxygen per setting, which allowed the claims of greatest savings ratio. Unfortunately, no standards were developed for the amount of oxygen per dose, so each manufacturer came up with their own dose volume and labeled it equivalent to continuous flow at the same setting.1 This confusion created the problem that when a patient did not oxygenate on one conserving device, the assumption was that the patient did not tolerate any conserving device and required continuous flow. If the clinician would have placed the patient on a different conserving device, with a greater Fio2 delivery, the patient might have been able to oxygenate and get the benefits of a longer-lasting, lighter portable oxygen system.

Oxygen-conserving devices are not a commodity product, yet used appropriately with patient oxygenation as the outcome, they can be valuable tools for both the oxygen provider and the patient.

The Greatest Breakthrough in LTOT

Interestingly, it is not a product, rather an understanding of oxygen therapy. More and more home respiratory therapists and manufacturers are starting to understand the complexities of oxygen therapy and look at the patient as the greatest variable in LTOT. Most oxygen-delivery systems are stagnant in the delivery of oxygen. Continuous flow blows a lot of oxygen past the patient’s airways, and the amount of oxygen the patient receives at gas exchange units in the lung is dependent on inspiratory time, inspiratory flow rate, tidal volume, position of the delivery, dead space, and the Fio2 from the delivery device. As stated before, a complex situation.

The unsophisticated approach of setting a dial on 2 and seeing what happens with patient oxygenation really is not scientific, clinically effective, or appropriate. Many patients receiving this type of therapy do not gain much benefit from their LTOT and unfortunately suffer consequences associated with ineffective LTOT. One of the best conserving devices available is a knowledgeable clinician titrating the patient to an appropriate oxygen saturation at all activity levels.2 With this approach, the patient would probably be at a very low setting with rest (conserving oxygen) and a higher setting with activity—usually at short bursts. The average might be significantly lower overall oxygen delivery over a 24-hour period as opposed to 2 lpm for a 24-hour period. Research would need to prove this theory, yet the premise is sound.

Selecting the right oxygen therapy equipment requires an understanding of a device’s capability—not the method of storing or making oxygen. A device that has the capability to supply a patient’s needs at all activity levels and is practical for the patient to use is the right device. If a device has a low maximum amount of oxygen-delivery capability, in other words, if the device is set on the highest setting and still provides minimum amounts of oxygen, it may not meet the needs of an active patient.3 Conserving devices that target savings ratios may not provide much oxygen per setting, which allows for the savings of oxygen claims. Portable systems present the greatest challenge for economic savings for providers and clinical benefits for patients. It does not matter if the portable is a compressed gas system, liquid oxygen system, or portable oxygen concentrator. If the device can meet a patient’s oxygenation needs with all activity, any of the devices can be used. Unfortunately, at this time, technology has limitations. Patients want the lightest-weight, longest-lasting portable oxygen system. There are two reasons for the desire: esthetics and physical capabilities. Home oxygen therapy equipment has had a very poor compliance response by patients; they do not want to lug around a bulky, industrial-looking oxygen system. These patients have a compromised pulmonary system, so a heavy portable system is not feasible. Conserving devices allow for a more efficient use of oxygen, so lighter portable systems became a reality. Once again, conserving oxygen at the expense of oxygenation does not make sense and will cost both the patient and the payor in the long run. New conserving devices need to be developed that can give a maximal dose of oxygen if necessary to meet the peak demands of an active patient. This still can be done by providing the dose of oxygen efficiently and offering the benefits of a smaller, lighter-weight system than the comparable continuous flow system. Hopefully, the future of LTOT will focus on effective oxygenation of patients at all activity levels with the most efficient use of dosing technology.

So there is really something new in home oxygen therapy: knowledge of what is impacting effective therapy and patient outcomes. We can make a difference in how patients receive LTOT by encouraging and conducting practical research in the home. The increased use of personal oximeters, with appropriate education on their use, can help patients participate in the effectiveness of their care. Greater education of everyone associated with LTOT is necessary—education that emphasizes that oxygen products are not a commodity and do not accomplish therapy on their own. Finally, the payors of LTOT need to realize that the effectiveness of LTOT depends on appropriate use of clinical skills as well as the utilization of appropriate devices in creating a positive outcome for the patient and a lower overall cost of care.

Robert McCoy, BS, RRT, FAARC, is owner and managing director, Valley Inspired Products Inc, Apple Valley, Minn. For further information, contact [email protected].

References

  1. Bliss PL, McCoy RW, Adams AB. A bench study comparison of demand oxygen delivery systems and continuous flow. Respir Care. 1999;44:925-31.
  2. Recommendations from the 6th Consensus Conference on long-term oxygen therapy. Respir Care. 2006;51:519-22.
  3. McCoy R, Carlin B. Product performance variability with home portable oxygen systems may impact patient performance outcomes: it may be the device, not the disease. Respir Care. 2009;54:324-6.