January 20, 1999
Ms. Linda Ruiz
Regional Administrator
Health Care Financing Administration-Seattle RO
2201 Sixth Avenue
Mail Stop RX40
Seattle, WA, 98121-2500
Dear Ms. Ruiz:
The American Association for Respiratory Care (AARC) received the enclosed December 16, 1998 letter (Attachment No. 1) from Ms. Barbara Riley, RN of the Medical Review Branch of Blue Cross of Washington and Alaska.
The AARC has grave concerns regarding resident safety within the nursing home as it relates to the provisions of respiratory therapy services. We have sought reassurances from the local Intermediary, your office, and the HCFA Central Office that coverage policy, as set forth in Local Medical Review Policies (LMRP), is consistent with the provision of safe and effective respiratory therapy.
The AARC is receiving an increasing number of consumer inquiries regarding the suitability of persons, other than respiratory therapists, providing respiratory therapy services to nursing home patients. We have not received from the aforementioned agencies the objective evidence to support the policies in question. Therefore, we have been unable to provide consumers the reassurances that they seek.
We disagree with the contention by the Intermediary that discrete respiratory therapy services are, in fact, "routine nursing services", and that all nurses are competent to provide these services. The LMRP for Alaska contained a verbatim list of respiratory therapy services that originated as part of an opinion letter from one individual (Declaration of Jann Robinson, Attachment No. 2). The Declaration states that the listed respiratory therapy services should be considered routine nursing nursing rather than respiratory therapy services, moreover, all nurses are qualified to perform the listed respiratory therapy services. On what objective evidence, does the Intermediary base its policy? In two previous letters, we have requested this information and, to date, have not received an answer.
Within Ms. Robinson's Declaration, the statement is made:
"The following services are routine nursing services which can be and should be provided by a skilled nursing facilities nursing staff".
No supporting evidence for this statement was provided within the Declaration.
We would point out that HCFA's Resident Assessment Instrument Version 2.0 (Attachment No. 3) used by nursing homes to complete the required Minimum Data Set (MDS) states:
"Question 110". . . . What is the definition of a "trained nurse?"
A: "Trained Nurse" refers to a nurse who received specific training on the administration of respiratory treatments and procedures. This training may have been provided at the facility during a previous work experience or as part of an academic program. Nurses may not necessarily learned these procedures as part of formal Nursing training."
HCFA's RAI Manual directive clearly states that nurses must receive additional training in order to provide respiratory therapy services. Nowhere within the Alaska LMRP, nor within the Ms. Robinson's Declaration is any acknowledgment that nurses providing respiratory therapy services require additional training and education. Both the Declaration and the Intermediary's LMRP are in direct conflict with HCFA's own RAI manual. How does the Regional Office reconcile this?
The AARC disagrees with the contentions made within the Declaration that the listed respiratory therapy services are routine nursing services and nurses, by virtue of their license, without additional education and training, are qualified to provide respiratory therapy services.
We are not alone in our position regarding this issue.
Many health care providers who are duly credentialled as both registered nurses and registered respiratory therapists recognize the differences in the educational experiences of nurses and respiratory therapists. These experts also observe the differences in competency testing between the two professions to provide respiratory therapy services. As an example, we are enclosing (Attachment No. 4) a copy of a recent letter to the editor, which was published in the January 1999 issue of the American Journal of Critical Care. If you would like additional examples, we would be more then happy to provide them.
Moreover, the pulmonary medical community shares our position on the unique qualifications of the respiratory therapist as evidenced by statements made by the American College of Chest Physicians, the American Society of Anesthesiologists, and the National Association for Medical Direction of Respiratory Care (Attachment No. 5).
We are very concerned about the following statement by Ms. Riley in her December 16, 1998 letter:
"We consider the Declaration from Ms. Jann Robinson, CRRN of the HCFA Regional Office, to be relevant, and as with all HCFA directives, it is to be followed."
It is our understanding that the Declaration of Ms. Robinson was admitted as part of a single claims denial appeals case in 1997 for one nursing home in the Pacific Northwest. We were unaware that this opinion statement was elevated to a HCFA coverage policy directive. Please provide us with information concerning the effective date of this significant change in respiratory therapy coverage policy and what steps were taken to provide a period of public comment as is required under the Administrative Procedures Act.
Medicare coverage policy changes that are as sweeping as those contained within the Declaration will affect the provision of respiratory therapy services for significant numbers of Medicare beneficiaries. Surely, you would agree that Medicare beneficiaries, the medical profession, the respiratory therapy community, and facilities providing the care, have a right to provide comment prior to such a policy becoming final.
In the past, revisions to HCFA coverage policy and directives have been accompanied by ample justification and documentation that has been made available for review and comment by the public. As mentioned above, the AARC has repeatedly requested that we, along with the public at-large, be provided with the objective evidence and documentation that was used by Ms. Robinson to derive her list of "routine nursing services". This request for objective evidence becomes more important now that, according to Ms. Riley, the Declaration of Ms. Robinson has been elevated to a HCFA directive.
Therefore, we request that you respond specifically to the following questions:
- On what date was the Declaration of Jann Robinson elevated to a HCFA directive?
- What opportunity for public comment was provided regarding this significant coverage policy change?
- What is the objective evidence and documentation that justifies reclassification of specific respiratory therapy services as routine nursing services?
- Please provide the objective evidence that documents the competency of persons other than respiratory therapists to provide respiratory therapy services.
Your prompt responses to these questions are critical in reassuring both the respiratory therapy community and the consumers who require respiratory therapy services in nursing homes, that HCFA has followed both the appropriate regulatory procedures in amending the coverage policy and that the policy changes have been based on documented objective evidence.
Sincerely,
Sam P. Giordano, MBA, RRT
Executive Director
SG/bd
Attachments
cc: Thomas Hoyer
Senator Ted Stevens
Senator Frank Murkowski
Senator Gordon Smith
Senator Ron Wyden
Senator Patty Murray
Senator Slade Gorton
