In a blend of good news and bad news, Medicare enacted new rules for the reimbursement of pulmonary rehabilitation services effective on January 1, 2010.
For the respiratory care professionals who have lobbied long and hard for changes in how Medicare (and ultimately other health insurers) reimburses practitioners for providing pulmonary rehab services, there is a measure of satisfaction that some progress was made in the new reimbursement rules. On the other hand, the degree to which these dedicated pulmonary physicians and therapists have had to fight in order to get a handful of modest changes enacted has surely been frustrating.
To take a step back, it is important to understand that pulmonary rehabilitation as a practice has been fighting for reimbursement recognition for a very long time. This is mostly due to the fact that there are few "hard data" measurements to demonstrate successful patient outcomes in pulmonary rehabilitation. In this profession, practitioners typically use results of six minute walk tests and patient quality of life surveys to measure patient improvement from admission into a program to graduation (both in research studies and clinical evaluations). Since most of the patients they see have developed irreversible lung damage anyway, the best respiratory professionals can do is help people feel better and better manage their conditions (and if patients stick with it after formal rehab, slow the progression of lung disease and reduce the incidence of future shortness of breath attacks). There is unfortunately no current diagnostic/statistical measure that one could look at and say pulmonary rehab definitively improved Patient X's lung function.
But insurers, including Medicare, want to make certain that they reimburse practitioners only for services that produce a verifiable improvement in patients' health (understandably so). While the body of scientific evidence of pulmonary rehab's effectiveness using the above two measures is substantial and impressive, they are not the same sort of statistics that insurers prefer to validate patient outcomes. Despite this bias, over the last two decades, respiratory care professionals have opened Medicare's minds enough to these measures as descriptive of patient outcome to achieve insurance reimbursement.
So what's changed in the new Medicare rules and how will these changes help people interested in pursuing pulmonary rehab?
Though there were a host of changes in the new ruling the two most important changes enacted in terms of broadening access to pulmonary rehab were as follows:
- A single, nationwide reimbursement category for pulmonary rehabilitation services was established that covers most of the core elements of pulmonary rehab services (known in Medicare speak as a National Coverage Determination). Prior to this change, there was no central, nationwide reimbursement standard/amount for providing pulmonary rehab services. Practitioners had to utilize an array of individual codes for specific services performed during pulmonary rehab sessions and these codes varied from region to region in the U.S. (known as a Local Coverage Determinations). It was cumbersome to track/report on all of those codes and not all pulmonary rehab services were covered. As a side effect of the previous reimbursement situation, many hospitals today do not offer pulmonary rehab services given the combination of coding hassle factor and how low reimbursement levels are compared to the cost of providing these services.
For your information, the amount that practitioners can be reimbursed for a 1-hour rehab session under the new rule is $50. When you consider the cost of outfitting and staffing a pulmonary rehab facility (doctors, therapists, medical equipment, exercise equipment, physical space), this is a very modest sum – but it's a lot better than Medicare's original proposed amount of $19/hour!
Prior to the reimbursement rule change, practitioners could be reimbursed in 15 minute increments of $18 for certain specific/discreet services. So if a practitioner conducted an hour long session that was comprised of 4 reimbursable services, they received $72. As a result, the new all-encompassing reimbursement rate is less than stringing together four individual pulmonary rehab services in a one hour session but at least the new reimbursement category doesn't involve the same amount of hassle in coding/tracking the incremental services and it covers a broader array of services (though a slew of new cumbersome requirements were created to assess patient progress in order to achieve reimbursement under the new rule). By the way, practitioners can still utilize the Local Coverage Determinations if they want to continue to seek reimbursement as they have in the past (and our guess is that many will).
- The number of allowable reimbursed sessions/patient increased from 36 1-hour sessions to 72 1-hour sessions. This allows practitioners to offer a longer course of pulmonary rehab, and/or to provide a maintenance program after patients complete their initial core program. This is a pretty big change. It essentially allows practitioners the ability to double the amount of pulmonary rehab offered to patients. In the past, when a patient had exhausted his/her insurance/Medicare coverage, they graduated and were expected to continue pulmonary rehab on their own or at their own expense. Knowing that it takes more than a few weeks to solidify a lasting commitment to new health habits, this is a very welcome improvement.
Pulmonary rehab services covered by this new Medicare National Coverage Determination are extended only to COPD patients and limits reimbursement to those patients identified as Moderate to Severe (known in the medical profession as Stage II and Stage III COPD). In other words, the new reimbursement rules do NOT cover pulmonary rehab services for nearly any other lung condition nor for patients who have either Mild or Very Severe COPD.
Folks, the reality is pulmonary rehab is an effective treatment for ANYONE who experiences chronic shortness of breath - whether or not you have been diagnosed with COPD or some other form of lung disease/condition (and in our opinion, even if you are a smoker who has yet to be diagnosed with any lung disease but are concerned about chronic or persistent shortness of breath).
The cruel irony of the way that pulmonary rehab services are offered and reimbursed is that you have to be "Goldilocks" to get access to a program that is reimbursed by insurers. You can't be too sick (ala Very Severe COPD) and you can't be too healthy (ala mild COPD) and you can't have nearly any other lung disease other than COPD.
The sad part of this situation is that it is clear that the less lung damage you have when you begin a pulmonary rehab style program, the better off you will be if you stick with such a program. If you already have lung disease, the earlier in the development of your condition you start and maintain such a program, the better chance you have of slowing the progression of lung disease.
From a health care cost standpoint, beginning and maintaining a pulmonary rehab style program earlier in the development of lung disease would lower the number and duration of future hospitalizations associated with COPD and quite likely reduce the need for medications and oxygen therapy (neither of which do anything but relieve short term symptoms) – all very costly medical services that far exceed the cost of providing pulmonary rehab to a wider audience of people who suffer from chronic shortness of breath!
And so while the new Medicare rules are a demonstrative step in the right direction, there is still a significant amount of more work to do to get pulmonary rehab into the lives of more people for whom it can make a substantial difference in how they feel and live.
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