August 26, 1998


Health Care Financing Administration
Department of Health and Human Services
Attention: HCFA-1913-IFC
P.O. Box 26688
Baltimore, MD 21207-0488

To Whom It May Concern:

The American Association for Respiratory Care (AARC), has reviewed and analyzed the interim final regulations on the Prospective Payment System (PPS) and Consolidated Billing for Skilled Nursing Facilities (SNFs), published in the Federal Register on May 12, 1998, and respectfully submits the following comments. The AARC is a professional association representing 37,000 respiratory therapists, or respiratory care practitioners, across the nation.

OVERVIEW

On July 1, 1998, the Medicare structure for Part A SNFs began a dramatic transition from a cost/charge reimbursement system to one of prospective payment. The prospective payment transition, which will occur over 3 years, includes a Federal rate and a facility-specific rate. The Federal payment rate will cover all the costs of furnishing covered skilled nursing services with the exception for educational costs. This includes Part B services furnished under an arrangement with the SNF to SNF inpatients. Thus, except for physicians’ services, and other practitioners exempted under the law, unbundling of services allowed under the previous payment mechanism will no longer be permitted.

The data used to develop the rates were taken from the cost and claims reports of 1995, a wage index, a case-mix index, and a market basket inflation index. The facility-specific rate is based on the 1995 cost report (which includes routine, ancillary and capital related costs) plus an estimate of the amount that would be payable under Part B for covered SNF services. Version III of the Resource Utilization Groups (RUG—III) case-mix classification system will capture resource use (nursing and treatment time) of nursing home patients and is intended to provide an improved method of tracking quality of care. The RUG-III groups are used in determining the payment scheme. SNFs must prepare a Minimum Data Set (MDS) clinical assessment by day 5 of a patient’s admission to a SNF, as well as ongoing assessments within certain time frames. The outcome of all the patient data derived from the extensive MDS fields will determine what RUG—III category the patient will fall into, and therefore, what the per diem rate will be during that time frame.

In today’s complex and ever-changing health care system, the need for more cost effective measures in the delivery of health care, while preserving the quality of care to patients, is ever-present. The AARC recognizes the need for prospective payment for SNFs and commends HCFA staff on it efforts to develop such as system, including consolidated billing provisions, as required by the Balanced Budget Act of l997. However, we have serious concerns regarding the treatment of respiratory services in the development of this significant new Medicare payment mechanism.

While we are committed to implementing prospective payment for SNFs, we are concerned that there are no separate cost calculations for respiratory therapy services included in the cost of ancillary services. The new per diem PPS squarely places the financial risk of providing services on the individual nursing facility. Individual facilities will have the discretion to determine what professional will provide a given health service. Because the new PPS will result in the overall reduction in SNF reimbursement, nursing homes will have an apparent financial incentive to utilize the least costly and unqualified personnel. The AARC has serious concerns that the use of persons with inadequate training and competency testing in respiratory care to provide respiratory rehabilitation services to SNF inpatients will contribute to inadequate quality of care for such patients.

ISSUES

In its overall assessment of the new SNF PPS rules, the AARC has identified several substantive issues that HCFA needs to address: 1) respiratory therapy as a rehabilitation service; 2) outlier policy in developing Federal rates; 3) quality issues affecting patient care; and, 4) time frame for implementation. In addition to these substantive comments, AARC has also two areas of concern relative to resource materials that long-term facilities use in evaluating patient assessments; namely the Long Term Care Resident Assessment Instrument (RAI) User’s Manual, and the MDS. With respect to these issues, we have provided additional technical comments which relate to the definition of "respiratory therapy" and MDS assessment fields. The discussion that follows identifies the issues, provides a summary of AARC’s concern and sets forth recommendations and/or options for HCFA’s consideration.

 

 

 

SUBSTANTIVE COMMENTS

1. RESPIRATORY THERAPY AS A REHABILITATION SERVICE

Issue:

The new SNF PPS rates do not include specific cost calculations for respiratory therapy services. The RUG—III case-mix classification system, which is used, in part, to develop the Federal prospective payment rates, designates only physical therapy, occupational therapy, and speech therapy as rehabilitation services. Respiratory therapy has been omitted without apparent reason or adequate justification.

Comments:

The preamble of the interim final rules describes the data sources used in developing the Federal SNF PPS rates. One data source is the Medicare Provider Analysis and Review (MEDPAR) case mix analog (Section II., A, 2, e., 63 FR 26257). HCFA concludes that, although there are certain limitations in using this data source, the MEDPAR file is a reasonable tool to use in approximating the RUG—III categories related to Medicare SNF claims and appropriate for use in rate standardization. One limitation in using MEDPAR data is the fact that rehabilitation therapy provided in the SNF is covered under Part A (thereby having claims data in MEDPAR), but such services provided by an independent agency may be billed under Part B. Thus, the MEDPAR proxy may not reflect a complete record of all the services a SNF patient may receive during a course of stay. For example, respiratory therapy is not specifically identified as a rehabilitation therapy service.

Access to Quality Care

In other benefit categories, the Medicare payment does provide for respiratory rehabilitation. The Comprehensive Outpatient Rehabilitation Facility (CORF) benefit recognizes the clinical appropriateness and efficacy of respiratory rehabilitation by including this service as a Medicare benefit. Further, in order to assure that quality care is given, the CORF conditions of participation specify at 42 CFR 485.70 the qualifications a respiratory therapist and a respiratory therapy technician must meet. Thus, by not including respiratory therapy within the RUG—III rehabilitation category, HCFA will, first and foremost, deny access to quality respiratory rehabilitation services to persons with respiratory impairments. But more importantly, persons with the potential to benefit from these services to improve the length and quality of their life, and to decrease the incidence and cost of these illnesses, will not have access to the beneficial effects of respiratory rehabilitation. For some patients, this may also contribute to longer hospital stays.

The RUG—III system is the clinical assessment tool which will be used to classify Medicare SNF patients for reimbursement purposes under the new PPS system. Patients will be required to undergo a detailed assessment within the first 5 days of being admitted to a facility. RUG—III classifies patients by medical conditions, rehabilitation needs, and their ability to perform activities of daily living. The RUG—III rehabilitation category covers physical therapy, occupational therapy, and speech therapy. Reimbursement for rehabilitation services over and above the routine PPS payment is provided for those patients in an amount dependent upon classification into five rehabilitation subcategories. The subcategories are derived from the intensity required for rehabilitation. Respiratory therapy is not included as a RUG—III rehabilitation classification service.

AARC strongly opposes the omission of respiratory therapy services as a designated rehabilitation service as part of the RUG—III system. This omission will disadvantage Medicare beneficiaries with respiratory rehabilitation potential by denying them needed services. For example, under this system, a patient with a broken hip and in need of respiratory services, such as pneumonia or chronic obstructive pulmonary disease (as indicated in the MDS), would be placed in a rehabilitation RUG—III category. Resources for this patient would be high enough to include the provision of physical therapy to care for the broken hip, but not sufficient enough to provide reimbursement for necessary respiratory therapy. Respiratory, physical, occupational and speech deficiencies each impact an individual’s quality of life. However, rehabilitative respiratory deficiencies, much more so than the others, will also directly impact the life expectancy of a patient if untreated or not treated properly.

Data Analysis

The respiratory component of the Medicare SNF rate was estimated by HCFA based on PPS demonstration data collected in 1995. These data included extremely limited instances of respiratory therapy in the Rehabilitation Groups. For example, for new admissions to the demonstration in 1995, it was found that in the Rehabilitation Groups, 65 percent received physical therapy, 49 percent received occupational therapy, and 7 percent received speech-language pathology services, while only 3 percent received respiratory therapy. Because of its minimal use, HCFA apparently concluded that respiratory therapy rehabilitation was insignificant to include it in the RUG-III classification groups as a rehabilitation service along with physical therapy, occupational therapy, and speech therapy.

AARC recently commissioned Muse & Associates, an independent health care consulting firm, to conduct a study which 1) determined the growth, scope and extent of respiratory care services in Medicare inpatient settings using the most recent data; 2) determined if there are significant numbers of Medicare beneficiaries who are intense users of respiratory care services; and 3) speculated on how these intense users might be dealt with in the SNF PPS system.

 

Muse & Associates’ analysis is based on data compiled from HCFA’s 1994 and 1996 Standard Analytical Beneficiary Encrypted Public Use Files. These data bases contain all Medicare services delivered to a sample of beneficiaries and are widely accepted in HCFA as valid data sources. The files contain final action claims data with all adjustments resolved for all Medicare beneficiaries. They capture 99 percent of the claims for a given calendar year. The 5 percent Sample Standard Analytical Files, which consist of 7 separate files, are created by extracting all of the claims for a 5 percent sample of beneficiaries for a particular year. All files were used for the Muse & Associates study. The findings indicate the following:

to $1.1 billion. The growth in charges paid between 1994 and 1996 was 138 percent. HCFA data show that 24 percent of the 1.6 million Medicare beneficiaries who were in skilled nursing facilities during 1996 received respiratory therapy. This is eight-fold the 3 percent figure HCFA obtained from the 1995 SNF PPS demonstrations.

Summary

The AARC believes that the above discussion clearly demonstrates that respiratory therapy services are:

1) an integral and increasingly used service for many Medicare beneficiaries in SNFs;

2) medically necessary for a subset of Medicare beneficiaries in SNFs who are intense users of such therapy; and

3) cost effective when provided to SNF patients by qualified personnel.

Therefore, we strongly recommend that HCFA recognize respiratory rehabilitation as a distinct medical service, not a subset of other therapy services. Other therapy providers cannot assume the clinical responsibility of the respiratory therapist when providing respiratory rehabilitation. Respiratory rehabilitation cannot, and should not, be rendered without a physician’s plan of care, which must include measurable improvement goals for each patient.

Currently, nursing homes can and do offer respiratory rehabilitation to their patients. Without including respiratory therapy as a category under RUG—III, this valuable service may no longer be available to a Medicare patient unless the SNF provides the service "under arrangement." As a result, nursing homes faced with a limited reimbursement, which will not include respiratory rehabilitation, will be reluctant to accept patients with compromised respiratory systems. We acknowledge that HCFA is revising its rules at section 409.27 (Section VI, 63 FR 26301 - 26302) to permit coverage of respiratory therapy services under an arrangement between the SNF and a respiratory therapist, regardless of whether the therapist is employed by the SNF’s transfer agreement hospital. However, this amendment alone does not go far enough in ensuring patient access to critically needed services by qualified personnel.

Recommendation #1:

HCFA should act immediately to amend the RUG—III classification system to include respiratory therapy in the rehabilitation classification group and develop a factor for establishing the SNF payment rates to appropriately account for respiratory services in all groups.

2. OUTLIER POLICY IN DEVELOPING FEDERAL RATES

Issue:

A significant number of Medicare beneficiaries in SNFs require extensive respiratory care services. Although the proposed regulation deals with some of these beneficiaries through the RUG—III categorization, adequate resources for approximately 80,000 to 90,000 Medicare beneficiaries requiring extensive respiratory services are not provided for by the interim final regulations.

Comments:

Our comments are divided into two sections. The first section documents the existence of those Medicare beneficiaries in need of respiratory services. The second subsection examines the characteristics of the group of intense users whose needs are not dealt with by the interim final regulations. Our comments and the statistics provided below are drawn from the previously mentioned Muse & Associates’ study.

Overall Need

HCFA data show that approximately 4.2 million (33 percent) of the 13 million Medicare beneficiaries who were in a SNF or inpatient hospital setting in 1996 received respiratory therapy services. Approximately 363,000 (24 percent) of the 1.6 million Medicare beneficiaries who were in a SNF setting in 1996 received respiratory therapy services. The top 100 diagnoses account for 98.6 percent of all respiratory care services. The top 10 diagnoses account for approximately half of all respiratory therapy payments and the top five diagnoses account for one-third of all payments.

In 1996, the average length of stay for SNF patients who received respiratory therapy services was 22.6 days. This is significantly less than the 1996 average length of stay of 26.2 days for all

1.6 million Medicare SNF patients. Costs per day for respiratory care services for the top 10 diagnoses ranged from $39 to $85, with the average of all diagnoses being $47. More importantly, within this category, the top 5 primary diagnoses for respiratory care services, which ranged in cost from $58 to $85 per day, were all diseases of the lung. These data clearly show a group of Medicare beneficiaries that have high respiratory care needs and relatively short SNF stays.

Intense Users

The Medicare data base available for commenting on the SNF PPS interim final rule, the Medicare 5 percent statistical file, did not have measures of the number of minutes of respiratory therapy provided to Medicare beneficiaries in the nursing home setting. Hence, it was necessary to use dollars as a proxy for resources. After examining the distribution of allowed payments for respiratory care, $1,000 of respiratory services per stay was selected as the definition of an "intense user."

Medicare beneficiaries with more than $1,000 in paid respiratory therapy claims account for only 18 percent (744,580 out of 4,170,160) of all Medicare beneficiaries who received respiratory services in 1996.

Most importantly, the top four diagnoses (excluding a generic category of "other diseases of the lung") — chronic bronchitis, chronic airway obstruction, pneumonia due to solids or liquids, and pneumonia — average between $75 and $100 per day in respiratory services. This amount of dollars is far more than the dollars available to SNFs in the 42 RUG—III categories that do not have respiratory adjustments. These extraordinary respiratory care needs of the 98,540 Medicare beneficiaries that fall into this category warrant an outlier policy to insure adequate care for these beneficiaries.

Because of the limits of the data base available to Muse & Associates in conducting its study, they were unable to determine how many of these respiratory patients would fall into the two RUG—III categories that have explicit adjustments for respiratory services. Based on some exploratory analysis of the records, it is estimated that no more than between 10,000 and 20,000 of the 98,540 will fall into these two RUG—III categories. Data bases available to HCFA could produce more precise estimates. One data base would be the SNF PPS demonstration data that should soon be available as a Public Use File. Another data base would be the future combined MDS and PPS fiscal intermediary data. We assume that new data bases would not be available until the year 2000.

Recommendation #2:

HCFA should initiate an outlier policy for approximately 80,000 to 90,000 Medicare beneficiaries with specific diagnoses that require intensive respiratory care services, i.e., chronic bronchitis, chronic airway obstruction, pneumonia due to solids or liquids, and pneumonia. This subset of Medicare beneficiaries who have high respiratory needs do not fall within the two RUG—III categories that have explicit adjustments for respiratory services for the four diagnoses identified above. Based on our clinical practice guidelines, it is recommended that the outlier policy should require that nursing homes document patient needs and the provision of respiratory services in excess of 30 minutes per day. The outlier policy could be made budget neutral. The budget neutrality could be made relative to either therapies and/or nursing resources.

Our membership’s technical experts, the AARC staff and our contractor, Muse & Associates, are available to assist HCFA in the data and policy development for such an outlier policy.

3. QUALITY OF CARE AFFECTING PATIENT OUTCOMES

Issue:

The new SNF PPS, as outlined by HCFA in the interim final rules, provides nursing homes with an apparent financial incentive to utilize the least costly personnel who may not be qualified to provide appropriate care to patients. As stated earlier, AARC has serious concerns that this may result in respiratory services being provided to Medicare patients by personnel who may be inadequately trained and who do not have the necessary competency testing in respiratory care to perform such services.

Comments:

The AARC recognizes that the cost-based system under which the Medicare Part A SNF benefit has been reimbursed for over 30 years requires change. The PPS, as proposed, will clearly require the facility to assume financial risk in providing services. However, we believe the flaws in PPS addressed above will have the result of impeding the Medicare beneficiary’s access to clinically appropriate respiratory therapy. Because PPS will result in the overall reduction in SNF reimbursement, nursing homes will have an apparent financial incentive to utilize the least costly respiratory services by unqualified professionals in providing respiratory therapy. In fact, some nursing facilities may fail to provide a full range of services. We believe this translates into use of unqualified personnel which, in turn, will adversely affect the quality of patient care and health outcomes.

In past discussions, HCFA contends that the scope of practice provisions contained in state licensure or certification laws prevent unqualified personnel from rendering health care services without appropriate training or education. However, by design and by definition, scopes of practice are typically non-exclusionary. In certain circumstances, crossover skills among professionals are efficient and effective and do not endanger patient care. On the other hand, some facilities, driven by financial motives to maximize their per diem, may use unqualified personnel and justify their decision as based on open-ended "scope of practice" definitions. HCFA cannot abandon its duty to ensure quality care that maximizes patient outcomes by relying on states’ scopes of practice to provide a firewall against inappropriate personnel decisions.

In the case of respiratory therapy, 42 states, Puerto Rico, and the District of Columbia have respiratory therapy licensure or certification laws. There are 8 states without any state-based regulations. Unscrupulous providers in any state, but in particular those 8 states without respiratory regulations, could very well employ unqualified personnel to assume the duties of the respiratory therapist. It is HCFA’s responsibility to have program safeguards in place that will protect Medicare beneficiaries from receiving services by unqualified and untrained personnel,

whether they be in states with or without licensure laws. There is no basis for including respiratory care services as a "routine nursing" practice. Moreover, we believe the current design of the SNF PPS rules will only continue to perpetuate this problem.

Respiratory Care Services

Respiratory care is a highly specialized allied health discipline focused on the management and treatment of lung disease and illness. Respiratory therapists treat patients with acute and complex respiratory problems in a broad spectrum of settings. They also assess and develop patient care plans as part of their scope of practice. Respiratory therapists initiate, conduct and modify prescribed therapeutic procedures, assist physicians performing special procedures and conduct pulmonary rehabilitation. They select, assemble, and assure that equipment will not contribute to nosocomial infections. Additionally, they verify proper equipment operation and correct malfunctioning equipment. Respiratory therapists maintain patient records and communicate relevant information to other members of the health care team.

Moreover, respiratory therapists utilize clinical decision-making skills to assess resident health, analyze pathophysiology, recommend medications, and design, implement and modify respiratory care treatment plans. They implement protocol-based care, in which respiratory therapists work with physicians to develop the most appropriate treatment plan to meet a resident’s changing respiratory care needs. Respiratory therapists rely upon a combination of intervention and clinical thinking skills developed through experience in actual clinical practice. They utilize their training in and knowledge of the latest complex respiratory care technology to make resident care decisions.

Specialized Training and Education

The key to successful patient outcomes, and protection of the patient, is to ensure that a respiratory therapist is available at the SNF to oversee the diagnostic evaluation, therapy, and education of the patient, family and the public. We acknowledge that there may be cases in which some registered nurses may be able to administer certain rudimentary respiratory procedures after undergoing specialized post-licensure education. However, that is not necessarily an indication that they are qualified to 1) deliver all forms of such care; 2) that the respiratory care they give is of the same acceptable quality as that provided by respiratory therapists, or 3) that they are qualified to assess the appropriateness and continued need for a particular modality of respiratory care. For example, to qualify as a "trained nurse," we believe one should not only receive specific training and education in the administration of respiratory treatments and procedures, but should also be tested for competency based on task performance. Nurses may not necessarily learn appropriate respiratory care therapy as part of their formal nursing training program On the other hand, respiratory therapists undergo more advanced, specialized training and education focused on the provision of respiratory care than any other health professional. More importantly, they are tested on their competency.

For respiratory therapists, "formal training" is defined as a supervised, deliberate and systematic continuing educational activity in the affective, psychomotor, and cognitive domains. The training must be approved by a local, regional, or national accrediting entity. In the allied health field, this training includes supervised preclinical and clinical activities, as well as documentation of competence through tests determined to be valid and reliable. The facility providing the training must also meet accreditation standards.

Respiratory therapists must pass a rigorous examination administered by the National Board for Respiratory Care (NBRC) in order to be credentialed. The NBRC examination is the only examination which tests the competency of health professionals to render respiratory care services. The test is based on job requirements. The NBRC competency examination specifically focuses on skills and knowledge related to respiratory care. (A copy of the examination content outline is enclosed.) Often the national credentialing is linked with state licensure. And, respiratory therapists update their skills and knowledge through continuing education courses, which many states require as a condition of licensure.

The AARC has developed 13 separate competency areas that we strongly believe must be demonstrated prior to providing respiratory therapy services. (A copy of the formal training and competency testing requirements is enclosed for further reference.) However, we would point out that there are several organizations that have standards for developing competency tests. Among those are the Joint Standards of the American Psychological Association and the American Educational Research Association, the Uniform Guidelines on Employee Selection Procedures, and the National Commission for Certifying Agencies (NCCA). The NCCA was originally created as a Federal initiative to develop regional competency tests. Thus, if any competency tests meet the standards established by these organizations, the AARC considers them to be valid in fully meeting the requirements for respiratory therapy.

Respiratory Therapy Treatment

Physicians routinely order respiratory therapy services for patients with severely compromised pulmonary systems. Implicit in the physician’s order is the expectation that the patient will receive high quality specialized respiratory therapy treatment rendered by a credentialed

respiratory therapist. Physicians rely on the respiratory therapist’s expertise not just to carry out their orders, but to assess the continued need and appropriateness of respiratory therapy orders and recommend changes to each patient’s plan of care. This is especially true today with the prevalence of protocol-based care. Under protocols, respiratory therapists work with physicians to develop the most appropriate treatment plan to meet a patient’s changing respiratory care

needs. It is the respiratory therapists’ combination of assessment skills and clinical savvy in respiratory care that allow them to make critical decisions and recommend medications and treatment plan changes.

Support of the Professional Medical Community

The high standards of the NBRC credentialing process have been recognized within the medical community. For example, the National Association for Medical Direction of Respiratory Care (NAMDRC) supports the fact that "The hours of education and the curriculum required for credentialing of a respiratory care practitioner [therapist] should be the standard for all non-physician providers of respiratory care services." (See enclosed statement.) In addition to NAMDRC, several state and national associations and societies have gone on record in support of the continued use of nationally credentialed respiratory therapists working under the supervision of a qualified medical director as being the most highly qualified health care personnel to deliver respiratory care services to patients. These organizations include the American College of Chest Physicians, the American Society of Anesthesiologists, and the California Thoracic Society. (See enclosed statements of support.) We would note that these are all physicians’ groups who are concerned that patients receive quality care.

Lastly, other national associations, together with AARC, have recently expressed concerns to the HCFA Administrator about the effectiveness of implementing a prospective payment for SNFs that does not fully account for the crucial role that respiratory care plays in SNFs with respect to the required professionals, the services and their costs. These organizations include the American Health Care Association, Health Industry Distributors Association, Health Industry Manufacturers Association, and the National Association for the Support of Long Term Care. We are providing a copy of that letter as part of our official comments on the SNF PPS interim final rule to ensure that the concerns expressed therein are considered as part of the record. (See copy enclosed.)

Outcomes Data

Studies have concluded that respiratory care programs spend significantly more time training people in respiratory care than nursing programs and that "many nursing programs provide little or no training in many respiratory care subject areas. Studies have also found that respiratory therapists receive far more classroom instruction on respiratory care than do nurses. The respiratory care certification examinations cover significantly more respiratory care material than the certification exams in other allied health disciplines. Studies comparing the number and the range of content of respiratory-related questions on certification or licensure examinations have found that there are greater numbers of respiratory-related questions on the respiratory therapist examination than on the registered nurse practice exams. These studies demonstrate that respiratory therapists have a stronger educational background in respiratory care services than nurses. Nurse practitioners who studied on-the-job training of nurses for metered-dose inhaler technique found that the registered nurses were unable to verbalize or demonstrate proper technique over time. Metered-dose inhalers are the simplest procedures to use. This suggests that the effectiveness of on-the-job training for registered nurses is inadequate to deliver respiratory care to patients under the guise of routine nursing. Respiratory therapists are the most qualified, and therefore the most appropriate, health professionals to deliver respiratory care services.

Summary

Simply put, respiratory therapists are best qualified to render respiratory care services just as physical therapists, occupational therapists, and speech therapists are superior in their roles. Respiratory patients should expect to be assured that they are going to receive appropriate quality care.

Recommendation #3:

HCFA should recognize that respiratory therapy must be provided by trained, skilled and experienced professionals who have been competency tested, and that the respiratory care service must be fully funded in order to ensure that positive patient outcomes are achieved and savings to the Medicare program are maintained.

4. TIME FRAME FOR IMPLEMENTATION

Issue:

By extending the comment period until September 11, 1998, HCFA has acknowledged the complexity and scope of the interim final rule published in May 1998 and the need for the industry and professional associations to assess adequately its consequences. Thus, the effective date of July 1, 1998, for implementing the SNF PPS provisions does not provide sufficient time for HCFA to properly take into account issues raised by the AARC during the extended comment period. (It should be noted that HCFA has delayed implementation of other BBA provisions due to resource and data systems constraints, including the consolidated billing provisions of the interim final rule.)

Comments:

The major issues, comments and recommendations we have articulated above are based on our deep-seated concern for patient safety, quality of care and equity. While we clearly voice our concerns on behalf of respiratory therapists and respiratory care practitioners, we are no less concerned about the welfare of our patients. The revolutionary changes HCFA is proposing will have a profound effect on the nursing home industry. We believe that the recommendations we have made must be accepted by HCFA and implemented in order to minimize any untoward effect of the new payment and billing procedures that will be imposed upon Medicare skilled nursing facilities. These changes will take time to put in place and we, accordingly, believe it will be time well-spent.

 

Recommendation #4:

HCFA should extend the effective date for implementing the skilled nursing facility prospective payment system for at least six months following the close of the comment period (i.e., September 11, 1998) in order to incorporate fully the AARC recommendations.

TECHNICAL COMMENTS

In addition to the substantive comments discussed above, the AARC has several concerns regarding the RAI User’s Manual and the MDS assessment fields. Our comments are discussed below:

5. DEFINITION OF "RESPIRATORY THERAPY"

Issue:

There are several areas in the RAI Manual that are problematic. First, the RAI Manual fails to define correctly the profession of "respiratory therapy" and the qualifications of a "respiratory therapist." Second, the RAI Manual states that a "trained nurse" can provide respiratory therapy services. However, there is no elaboration or definition of what the term "trained" means. Third, the RAI Manual fails to recognize the qualifications and skills required to perform respiratory therapy assessment and treatment care planning. Fourth, certain competency testing based on task performance is critical to successful patient outcomes in the area of respiratory care services. The RAI fails to take into account the validity of competency testing, in addition to training and education, as a measure of qualification in the administration of respiratory treatments and procedures.

Comments:

The definition of "respiratory therapy" in the RAI Manual is not only inconsistent with general medical practice, it is also inconsistent with the definitions given to the other therapies in the RAI manual — physical therapy, occupational therapy, and speech therapy. Also, because of future planned changes in the respiratory therapist/technician curriculum, we believe the definition of "respiratory therapist" also needs to be updated. Lastly, because there is no definition of "trained nurse" in the RAI Manual, AARC is concerned that some nurses may provide respiratory care services who have not received specific training, education, and competency in the administration of respiratory treatments and procedures. As we have discussed throughout this document, respiratory therapy is a highly specialized skill requiring intensive formal education and training and competency requirements. Therefore, we believe such skills should be reflected in the RAI definitions.

We have had ongoing discussions with HCFA staff over our concern in this area. The primary issue is one of training, education and competency. We believe the most qualified professionals

should perform respiratory therapy services, especially with respect to competency testing. This includes respiratory therapy assessment and treatment care planning. The AARC advocates that all persons delivering respiratory care services be competent to do so in order to ensure that patients requiring such services receive a standard level of care. To that end, HCFA should add a new definition to the RAI Manual that defines "validated competency examination", which incorporates some measure of competency for those professionals providing respiratory care services based on established competency standards. We believe the standards established by the organizations identified elsewhere in our comments represent valid competency requirements one must meet to perform respiratory care services. Also, as mentioned previously, the AARC has developed 13 separate competency areas that we believe must be demonstrated prior to providing respiratory care services.

On a separate track, we intend to pursue similar changes in definitions to the "Interpretative Guidelines" for long-term care facilities regarding the training, education and competency requirements for respiratory care services.

 

Recommendation #5:

HCFA should revise the definitions of "respiratory therapy", "respiratory therapist", and "trained nurse" contained in the RAI Users Manual (Version 2.0) and add a new definition of "validated competency examination" to reflect current accepted medical, educational and competency standards for respiratory care services. These changes should include the requirement that respiratory therapy assessment and treatment care planning be performed by a physician or respiratory therapist. Similar changes should also be included in the "Interpretive Guidelines" for long-term care facilities and HCFA’s published "Questions and Answers" on the MDS.

 

6. MINIMUM DATA SET ASSESSMENT FIELDS

Issue:

The assessment fields in the Minimum Data Set (MDS) (2.0) do not provide categories to adequately document the complex needs of patients suffering from heart and lung disease and their therapeutic, diagnostic, and pharmaceutical respiratory requirements. Also, there are current data items in the MDS that are not considered in the RUG-III classification groupings determination that need to be taken into account in order to appropriately recognize patient acuity and payment.

Comments:

At public briefings and meetings over the past several years, HCFA reported the need for parsimony and efficiency in the final design of the Minimum Data Set (MDS version 2.0). As a result of the efficiency efforts, several sections that document the need for respiratory therapy services were combined or even omitted.

A thorough review of the MDS, which is instrumental in determining the SNF levels of payment, reveals that cardiopulmonary issues are not given much emphasis in the proposed RUG-III classification groupings. For example, MDS items I.2.e., Pneumonia; P.1.a.g., Oxygen Therapy; P.1.a.i., Suctioning; P.1.a..j., Tracheotomy care; and P.1.a.l., Ventilator or Respirator, are the only respiratory diagnoses and services or treatments that are used in the RUG-III classifications methodology out of 109 items. Many forms of aggressive respiratory care (e.g., incentive spirometry, deep breathing and coughing, exercise conditioning, chest physical therapy) are not even included in the Extensive Services portion of the RUG-III categorization.

As was detailed in previous sections, when the MDS was developed in the early 1990s, the volume of respiratory services was very low. Thus, it is easy for AARC to understand that the low volume of respiratory services, coupled with the need for reduction in the number of items in the MDS, resulted in the reduction in respiratory therapy items. However, we believe the

tremendous increase in the respiratory services received by Medicare beneficiaries over the last

several years necessitates modifications on future versions of the MDS. Specifically, AARC requests HCFA consider the following modifications to the MDS.

In addition to the above modifications, there are several data entries in the existing MDS 2.0 that are related to respiratory care but are not considered in the RUG-III classification groupings determination. We believe HCFA must take these items into account and revise the RUG-III classification groupings to appropriately recognize patient acuity and payment for respiratory care services. The data entries include the following:

1.hh. Asthma

1.ii. Emphysema/COPD

2. f. Respiratory infection

2. i. Tuberculosis

1.b. Inability to lie flat due to shortness of breath

1.k. Recurrent lung aspirations in last 90 days

1.j. Shortness of breath

1.a.e. Monitoring acute medical condition

1.a.r. Training in skills required to return to the community

1.b.d.(B) Minutes of Respiratory Care

Recommendation #6.

Any future revisions to the Minimum Data Set (MDS) (2.0) should be modified to expand fields of data collection to capture critical respiratory therapy diagnoses and medication requirements. Also, certain data items in the current MDS related to respiratory care should be taken into consideration in revising the RUG-III classifications so that patient acuity and payment will be appropriately recognized.

 

SUMMARY OF RECOMMENDATIONS

The respiratory therapists and respiratory care practitioners represented by AARC appreciate the opportunity to comment on the SNF PPS interim final rule. The issues we have presented above are those with which we have had ongoing communications with HCFA staff. We appreciate the time and attention given to our concerns. To assist HCFA staff in reviewing our recommendations, we provide the following summary:

Recommendation #1:

HCFA should act immediately to amend the RUG-III classification system to include respiratory therapy in the rehabilitation classification group and develop a factor for establishing the SNF payment rates to appropriately account for respiratory services in all groups.

Recommendation #2:

HCFA should initiate an outlier policy for approximately 80,000 to 90,000 Medicare beneficiaries with specific diagnoses that require intensive respiratory care services, i.e., chronic bronchitis, chronic airway obstruction, pneumonia due to solids or liquids, and pneumonia.

Recommendation #3:

HCFA should recognize that respiratory therapy must be provided by trained, skilled and experienced professionals who have been competency tested, and that the service must be fully funded in order to ensure that positive patient outcomes are achieved and savings to the Medicare program are maintained.

Recommendation #4:

HCFA should extend the effective date for implementing the skilled nursing facility prospective payment system for at least six months following the close of the comment period (i.e., September 11, 1998) in order to incorporate fully the AARC recommendations.

 

 

Recommendation #5:

HCFA should revise the definitions of "respiratory therapy", "respiratory therapist" and "trained nurse" contained in the RAI Users Manual (Version 2.0) and add a new definition of "validated competency examination" to reflect current accepted medical, educational and competency standards for respiratory care services. These changes should include the requirement that respiratory therapy assessment and treatment care planning be performed by a physician or respiratory therapist. Similar changes should also be included in the "Interpretive Guidelines" for long-term care facilities and HCFA’s published "Questions and Answers" on the MDS.

 

Recommendation #6:

Any future revisions to the Minimum Data Set (2.0) should include an expansion of data collection fields to capture critical respiratory therapy diagnoses and medication requirements.

Also, certain data items in the current MDS related to respiratory care should be considered in revising the RUG-III classifications so that patient acuity and payment will be appropriately recognized.

In reviewing the above comments, if additional clarification is needed, please contact Cheryl A. West, MHA, Director of Government Relations, at (703) 548-8506.

Sincerely,

Sam P. Giordano, MBA, RRT
Executive Director

Enclosures

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