By Denise Williams | News & Views
That pulmonary rehabilitation has been undervalued since becoming a covered Medicare benefit is no secret in payer and provider communities. However, programs may not realize until it’s too late how the cycle of under-billing and under-payment can leave them in a precarious financial position within their hospitals. If they’re seen as a strain on the bottom line, PR services may be vulnerable when times get tight and the budget axe falls, warns Chris Garvey, FNP, MSN, MAACVPR, who’s already caught wind of some program closures in the United States.
As chair of an American Thoracic Society working group with representation from AACVPR and other national organizations and clinical stakeholders, she’s honored to be part of a mission to improve PR awareness, access and reimbursement. A major piece of progress on that front, Garvey shares, comes gift-wrapped from a group of high-profile study authors. Their research, showing for the first time that pulmonary rehab is not only cost-effective but cost-saving, promises to open eyes to the true value of the specialty and, hopefully, open doors to lasting change.
Christopher L. Mosher, MD, MHS, of Duke Clinical Research Institute served as lead investigator for the analysis. Previously published work had demonstrated a clear survival benefit in Medicare beneficiaries who initiated PR within 90 days of discharge for a COPD hospitalization. Mosher’s team subsequently scrutinized similar data from a cost-benefit standpoint. What they calculated, Garvey reports, was cost savings of approximately $5,700 per patient over their lifetime, based on fewer hospitalizations and skilled nursing facility days among those who participated in pulmonary rehab. These savings are realized within the first year; and while longer survival among pulmonary rehab participates attenuates the lifetime savings, pulmonary rehab remained a significant cost-saving intervention. “The takeaway message is that if all Medicare beneficiaries with COPD who were appropriate for pulmonary rehabilitation received it following a COPD admission, Medicare could save more than $1 billion annually,” Garvey says, in summary. As an example, she notes that PR programs are paid about $57 per hour of rehab but, according to the research, charges as high as $170 per hour would still represent a cost savings. “It’s another strong suggestion that we’re significantly undercharging for pulmonary rehabilitation,” she emphasizes.
The unfavorable payment trend is prevalent across the discipline, Garvey notes, even though pulmonary rehab represents a highly complex model of care that caters to a clinically challenging clientele. These patients are frequently frail and often require treatment with oxygen, she explains; and those with COPD tend to bear a high burden of comorbidities, including cardiac trouble and lung cancer risk. Coupled with that fact that only about 3% of patients who should receive PR actually do, Garvey laments that “we’re under-dosing a treatment that is one of the most, if not the most, effective treatment for improving function, symptoms and quality of life in COPD.”
Catalyst for Change?
Garvey and other pulmonary rehab advocates envision Mosher et al’s findings as a wake-up call for Medicare, whose fee-for-service model currently pays for charges rather than for effective care that produces favorable outcomes and cost savings. “We hope these results may help elevate awareness that there are opportunities for cost savings that also represent effective care in a large population of patients – 24 million Americans,” she proposes. Savings in the neighborhood of $1 billion represent “a very strong endorsement,” she adds.
Ideally, Garvey suggests the new study might also position clinicians and administrators to acknowledge the money-saving potential within their own hospital systems. “Medicare penalizes hospitals for readmissions within 30 days of a COPD admission,” she notes, “and if we’re seeing better survival after pulmonary rehab, that suggests this service is a higher priority for patients with COPD.”
To realize the proper value of their services and start helping their hospital achieve what Mosher et al have proven is possible, Garvey directs PR professionals to AACVPR’s pulmonary rehab landing page. There, providers have access to a recently updated PR reimbursement toolkit as well as links to two summaries. One offers a quick one-and-a-half page synopsis of the toolkit as an alternative to reading the full 20-page document. The other, shorter briefing delivers key points that providers can share with billing leads or hospital CFOs to increase their understanding of how, as Garvey puts it, “we’re working hard to be part of the solution, where we can contribute effectively to the hospital’s bottom line by supporting equitable payment for pulmonary rehab.”
PR Reimbursement Toolkit
PR reimbursment summary for PR providers 6 24 22.pdf (aacvpr.org)
PR reimbursement one page CFO Billing Director resource 6 24 22..pdf (aacvpr.org)