Prominent Physicians Support RTs

Letters in Response to Proposed PPS Regulations for SNFs

Health Care Financing Administration

George G. Burton, MD
Professor of Medicine,
Wright State University
Medical Director, Respiratory Services

July 8, 1998


I am writing to express my concern over the proposed above-referenced HCFA regulation, which appeared in the Federal Register of May 12, 1998.

I have been in the practice of pulmonary medicine since 1961; a copy of my resume is attached. Much of my career has been spent in education as well as practice, specifically in the area of training of allied health personnel who provide minute-to-minute care required by patients who suffer from respiratory diseases. Among my publication, I have authored seven textbooks and numerous peer-reviewed scientific articles on the subject of respiratory therapy. It is in the spirit of supporting the work of respiratory care practitioners (RCPs) and requiring their presence at my patient's bedside, that I am writing you at this time.

I am an expert in the field of respiratory therapy, and am extremely conversant with the knowledge and skill of RCPs. For ten years, I have served on the Committee for Accreditation of Respiratory Care Education (CoARC), for four years as its Chairman. I am founding President of the National Association of Medical Direction of Respiratory Care (NAMDRC), and most recently have served as Chairman of the Board of Councilors for the American Thoracic Society (ATS). In all of these roles, I have done my best to support the training, credentialing, and practice of respiratory care personnel, and have championed the care of patients with respiratory disorders, irrespective of the site where their care may be delivered.

My concerns about the proposed regulation are two-fold. First, I am concerned that the MDS-II, which is the engine that drives the RUGs-III groupers, is badly flawed in that it gives short shrift to the complex needs of patients suffering from heart and lung diseases. Secondly, I believe that financial pressures brought about by the PPS will encourage the practice of respiratory care by individuals with little or no competence to do so. Allow me to discuss these concerns separately.

MDS CONCERNS: Careful analysis of the MDS Version - 2.0, which are core to determination of the level of SNF reimbursement, reveals that cardiopulmonary issues are not given much emphasis in drafting the proposed RUGs-III classifications. Common cardiopulmonary complaints such as dyspnea, cough, spectrum production, hypozemia, and chest pain are mentioned only briefly, if at all. The manner in which the classifications are tied to only the severe ADL classifications is the most worrisome of all. In my view, it is ludicrous to require 5 inches of documentation regarding wound and foot care, and only 1 inch for cardiopulmonary concerns! Anyone who visits a SNF, and sees that as many as 30% of patients there require respiratory care services, will see the irony in this misplaced emphasis.

A "Don't ask; Don't tell" mentality with respect to patient's cardio-pulmonary symptoms and findings results in a downward emphasis on the required competency of those who treat such conditions (see below). Today's RCPs who work in SNFs are goal-oriented with respect to their patients, every bit as much as their other colleagues in health care (nurses, physical therapists, speech therapists, etc.). Recent years have seen RCPs become proficient in physician-ordered protocols which select only appropriate, needed respiratory services, the minute-to-minute selection of which is based on comprehensive patient assessment and use of physician-approved clinical practice guidelines. (1-5)

This type of respiratory care pays off in terms of patient improvement by application of the RCPs rehabilitative skills, exactly, as that of other health care workers, and it is for this reason that I have concerns about just who delivers these services in SNFs today and in the PPS-driven future.

COMPETENT, CREDENTIALED RESPIRATORY CARE PRACTITIONERS SHOULD NOT BE REGULATED OUT of positions of importance in the service mix of SNF allied health care professionals. Manual provisions set forth types of respiratory care services which are covered under Medicare. These provisions do not limit coverage of respiratory care services that are provided by respiratory care practitioners as prescribed by physicians. There is no language in the Medicare Manual provisions which suggests that respiratory care services performed by respiratory care practitioners should have any limited coverage.

The current Medicare SNF, Hospital and Intermediary Manuals (6-8) interpret what is reasonable and necessary and provide examples of the application of these provisions. They note that there is a distinction between respiratory care services and routine nursing, and instruct the intermediaries to "make a distinction between respiratory therapy services and routine nursing services." The manuals further interpret the distinction between routine nursing care and respiratory care services as follows:

"When appropriate, setting up of respiratory equipment, instructing and monitoring patient progress in the use of equipment or on postural drainage, and breathing exercises by respiratory therapist or technician are considered reasonable and necessary even though the direct patient supervision may be the responsibility of the nursing service" 8

WHERE OUR PATIENTS ARE CONCERNED, PHYSICIANS EXPECT RESPIRATORY THERAPY TREATMENTS TO BE PROVIDED BY RCPs. National Association for Medical Direction of Respiratory Care (NAMDRC), the American Society for Anesthesia (ASA), and the American College of Chest Physicians (ACCP) have all issued position papers supporting this position. These documents have already been supplied to you by those organizations. While it is true that some respiratory care procedures can be performed by alert, oriented patients or their non-RCP caregivers (e.g. oxygen therapy, peak flow measurements, even chest percussion and drainage), the facts are that in old, frail disoriented patients, this is generally not the case. (9-13)

The competency of nurses and other health care professionals to provide respiratory care services is simply not as high as RCPs, as the peer-reviewed literature demonstrates,(9,10) Further, in most SNFs, registered nurses are stretched to the near breaking point, in order to deliver the global therapies that the aged require. Indeed, where "The Nursing Service" delivers respiratory care, it is often done by licensed vocational nurses and aides, not the competent registered nurses (RNs) who are described in the nursing profession's own standards. (14)

In this light, I am very concerned for my patients when RCPs are left out of the higher levels of RUGs-III (rehabilitation) categories. I believe that such oversight, deliberate or accidental, will result in less than optimal care, and in increased readmissions to acute care hospitals. Indeed, many forms of aggressive respiratory care (e.g. incentive spirometry, deep breathing and coughing, exercise conditioning, chest physical therapy) are not even mentioned in the Extensive Services portion of the RUG's categorization.

On-the-job training of nurses and other non-RCP allied health personnel cannot hope to be as comprehensive as that of today's highly trained, nationally credentialed (e.g. RRT, CRTT), and state licensed RCP's. Indeed, individuals who have been cross-trained as nurse-therapists can testify to the relatively limited training that nurses receive in respiratory assessment, treatment selection, and treatment performance.

A 1994, a University of Indiana study demonstrated that respiratory care instruction was extremely limited in standard nursing curricula, not surprising given the scope of nursing practice and the time constraints of a crowded curriculum. Indeed, in every respiratory subject area surveyed, RCP's were noted to receive more instruction than did nurses.

Another method used to compare the competency of RCPs and nurses who provide RCS has been to evaluate the number and scope of respiratory content questions on each of their respective certification/licensure examinations. Examinations such as the NBRC entry level and advanced practitioner level examinations for RCPs and the NCLEX licensure exam for RNs are putatively designed to ensure that RCPs and nurses are adequately prepared to provide a core set of RCS safely and effectively. A recent report by the Lewin Group, analyzing these examinations, demonstrated that there was a five to ten-fold greater number of respiratory questions in the NBRC examinations compared to the NCLEX examination. Thus, in addition to training differences, RCPs would appear to be tested more thoroughly than RNs on their certification examinations in respiratory content areas.

With these considerations in mind, and with the expectation that in the immediate future, SNFs will have a financial incentive to utilize least costly personnel, I am hoping that HCFA will revisit its RUGs-III database, recognizing the deficiency in its recognition of patients with heart and lung disease, and rework the service classifications accordingly.

Additionally, it is my expectation that RCPs will be recognized as the most qualified allied health workers in the delivery of respiratory care, and that the need for their services will be appropriately acknowledged in the final PPS regulations.

I would be honored to respond, in written or verbal form, to any questions you may have.


George G. Burton, MD
Professor of Medicine
Wright State University
Medical Director, Respiratory Services

Enc. C-V


  1. 1. BURTON GG: A Short History of Therapist-Driven Respiratory Care Protocols. Resp Care Clin NA 2:15, 1996
  2. 2. ZBRAK JD, Rossetti P. and Wood E: Effect of Reductions in Respiratory Therapy on Patient Outcome. N. Eng J Med 315:292, 1986
  3. 3. STOLLER JK, Skiginski Cl, Giles DK et al: Physician-Ordered Respiratory Care vs. Physician-Ordered Use of a Respiratory Therapy Consult Service: Results of a Prospective Observational Study. Chest 110:422, 1996
  4. 4. SHRAKE KL: A Respiratory Care Assessment-Treatment Program: Results of A Retrospective Study. Resp Care 41:703, 1996
  5. 5. KOLLEF MH, Shapiro SD, Silver P et al: A Randomized, Controlled Trial of Protocol-Directed Versus Physician-Directed Weaning From Mechanical Ventilation. Crit Care Med 25.567, 1997
  6. 6.Medicare Skilled Nursing Facility Manual (HCFA-Pub. 12)("SNF Manual")230.9; see also Medicare Intermediary Manual (HCFA-PUB. 13) 3133.8.
  7. 7. Skilled Nursing Facility Manual 230.10.B.4; Intermediary Manual 3101.10.E; Hospital Manual 210.10.D.
  8. 8. SNF Manual 230.10.C. (emphasis added); see also Intermediary Manual 3101.10.B; see also Hospital Manual 210.10.A.
  9. 9. GUIDRY CG, Brown WD, Stogner SW et al; Incorrect use of Metered Dose Inhalers by Medical Personnel. Chest 101:31, 1992
  10. 10. INTERIANO B, Guntupali KK: Metered Dose Inhalers: Do Health Care providers Know What to Teach? Arch Int Med 153.81, 1993
  11. 11. O'Connell MB, Lackner TE, Pastor III JD et al; Short- and Long-Term Retention of a Nursing Home Education Program on Metered-Dose Inhaler Technique. Ann Pharmacother 26:980, 1992
  12. 12. ARMITAGE JM, Williams SJ: Inhaler Technique in the Elderly. Age Aging 17:275, 1988
  13. 13. DANIELS S and Meuleman J: Importance of Assessment of Metered-Dose Inhaler Technique in the Elderly. J Am Geriatrics Soc 42:82, 1994

Health Care Finance Administration

Neil R. MacIntyre, MD

May 18, 1998

I am writing to you to strongly encourage your inclusion of Respiratory Care Practitioners (RCP) in your regulations on the skilled nursing facility prospective payment structure. I am a Professor of Pulmonary Medicine at Duke University Medical Center and for 18 years have cared for respiratory patients in outpatient facilities, long term care facilities, and the intensive care unit. In all of these areas, I have constantly relied on the assessment and treatment skills of properly trained RCPs, to deliver appropriate care. Moreover, in this era of fewer resources and less subspecialty trained for physicians, I have been focused on developing an advanced respiratory care practitioner as a physician extender in order to provide cost effective care to patients with respiratory disorders.

The properly trained RCP is uniquely suited for this role. Their educational process focuses on cardiorespiratory physiology and the management of cardiorespiratory diseases. They alone among the allied health professions have the necessary skills to both assess patients with respiratory conditions and then apply appropriate therapies that can range from inhalational treatments to the use of life support systems. At the Duke University Medical Center, these skills are being enhanced with our advanced RCP program which will allow these professionals to manage airways, deliver aerosolizing medications, operate ventilators, and inset arterial lines under physician directed protocols. As a number of physicians in the United States with expertise in respiratory diseases continues to decliner, RCPs are the only ones who have the skill and training to reach this level of expertise.

These skills of the properly trained RCP will be increasingly needed in sites outside the acute hospital. Specifically, patients with respiratory diseases are being discharged to long term care facilities at an earlier stage, often with complex cardio-respiratory problems (including dependence on mechanical ventilators). In these settings, the properly trained RCP will clearly be the only non-physician who can posses the assessment and treatment skills necessary to care for these patient's respiratory problems properly. Simply stated, nurses and other allied health professionals do not have the expertise to provide quality care required in this increasingly cost conscious environment.

I strongly urge you to add the RCP to the reimbursement schedule for skilled nursing facilities. Their expertise is clearly cost-effective and deserving of proper reimbursement.


Neil R. MacIntyre, MD
Professor of Pulmonary Medicine
Director of Respiratory Care Services

Cheryl A. West, MHA

Thomas L. Petty, MD
Professor of Medicine
University of Colorado Health Sciences Center
Chairman of NLHEP

April 28, 1998

Dear Ms. West:

The purpose of my letter is to make a strong public comment about the qualifications necessary for non-physicians who carry out respiratory care procedures and therapies directed by a physician's order. I am aware that there is some confusion over the definition of the term, "trained," when other than non-certified or licensed respiratory care professionals are involved in the provision of respiratory care services. Certainly, nurses and other healthcare providers can acquire the skills equivalent to respiratory care professionals, but only with equivalent training, certification, and licensure, where required.

The commonplace on-the-job training of otherwise qualified healthcare professionals is simply inadequate to deal with the details and complexities of modern respiratory care, including devices such as mechanical ventilators, complex pulmonary function testing equipment, and the use of potent pharmacologic agents which are ordered by attending physicians. Thus, I urge that the term "training" be specific to formalized training, pursuant to certification of registration in respiratory care, and appropriate licensure.

My qualifications in the field of respiratory care are extensive and include over 600 articles, books, editorials, and chapters on the topic, which are too numerous to cite in this brief letter. My present position is Professor of Medicine at the University of Colorado Health Sciences Center, and simultaneously Professor of Medicine at Rush University, in Chicago. On the national scene, I am currently the Chairman of the National Lung Health Education Program (NLHEP), a new healthcare initiative directed to the problem of chronic obstructive pulmonary disease (COPD), and related disorders.

Enclosed is a brief summary of highlights of my career, which allows me to be recognized as an authority in the field.

Sincerely yours,

Thomas L. Petty, MD
Professor of Medicine, University of Colorado Health Sciences Center
Chairman, National Lung Health Education Program (NLHEP)