Respiratory service vendors have seen a boom in business due to the pandemic, with respiratory therapists sometimes filling in when COVID unit staff on a nursing home campus became scarce.
RTs became indispensable when facilities were experiencing a surge in COVID-19 cases, and continue to be needed to treat virus “long-haulers,” administering high-flow oxygen without having to transfer a resident to the hospital.
But specialty services like respiratory therapy still aren’t eligible for direct reimbursement at a nursing home, vendors say.
The ‘ugly stepchild’ of reimbursement
Instead of being assigned a code linked to a particular fee per encounter, like a primary provider, cardiologist or nurse practitioner, RTs are usually compensated on a salaried or per shift basis in a nursing home.
“There’s no [direct] reimbursement from Medicaid, Medicare insurance for respiratory therapists for the labor or the equipment. That’s all out of pocket for the nursing facility,” said Lance Tossell, vice president of business development and strategy for Peoria, Ill.-based Petersen Health Care.
Respiratory services work relatively well with the Medicare Payment-Driven Payment Model (PDPM), Tossell conceded, explaining that certain “respiratory components” are reimbursable through the value-based payer model.
If a patient receives seven consecutive days of respiratory therapy for at least 15 minutes a day, and intravenous (IV) feeding, for example, he or she is qualified for the “special care high” category under PDPM, Dynamic Respiratory Services told SNN in an interview last fall.
“I think that’s helped strengthen respiratory care in nursing homes, [certain] payer models reward for that care and good outcomes, with the pandemic over the last year-and-a-half,” said Tossell.
John Anderson, vice president of sub-acute services for respiratory vendor Pulmonary Exchange, called respiratory therapy the “ugly stepchild” of the reimbursement world as it is considered an ancillary service.
RTs aren’t required to be part of a facility’s therapy team, Anderson said, adding that oftentimes the licensed practical nurse (LPN) or registered nurse (RN) fill that role depending on acuity.
Symphony Care Network’s Donna Sroczynski believes the problem is more broad: “No payment model really recognizes acuity as well as it should. And it doesn’t ever pay you, dollar for dollar, what your expenses related to that service was; it’s just part of the per diem, and it’s up to the provider to try to manage that as best they can.”
Sroczynski serves as president of operations for the Chicago, Ill,-based operator, leading its post-acute care network.
RT Compensation Post-COVID
The way in which respiratory therapists are compensated in the skilled nursing sector doesn’t appear to be changing, despite RTs becoming more of a vital role in the acute-care and long-term care sectors because of COVID.
Currently, SNF post-acute care patients are experiencing longer stays because of lingering COVID effects on the body, translating to longer hours for Pulmonary Exchange’s therapists and increased usage of its rental equipment.
“With COVID … they could be there for longer. [Operators] slowly get back to normal with what the standards are,” said Anderson. “Respiratory comes in there because we can evaluate patients on a purely cardiopulmonary level and really look at the patient and the key for us is education with the patient and the patient’s family, and then also with the nursing staff.”
Moving into the second half of the year, it’s unclear if respiratory reimbursement is headed in a positive or negative direction.
Respiratory therapy’s most promising path toward direct reimbursement — PDPM — may still be recalibrated after the Centers for Medicare & Medicaid Services (CMS) in April found the model increased payments to nursing homes by 5% last year, a $1.7 billion gain.
But earlier this month, CMS’ 2022 Medicare physician fee schedule proposal included coverage of outpatient pulmonary rehabilitation services under Medicare Part B. Beneficiaries would need to be hospitalized with COVID-19 and exhibit “persistent symptoms,” including respiratory dysfunction for four weeks after hospitalization, CMS stated.
Hospital Care in a Nursing Home
Sometimes having the equipment available, like Continuous Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP) machines within a facility helps care for higher acuity COVID patients.
“It’s very easy for [hospitals] to do. Skilled nursing facilities can do it but they have to do it in a different way, using different modalities,” said Anderson, referring to the treatment of COVID-19 patients in a hospital compared to a nursing home.
Oak Lawn, Ill.-based Pulmonary offers respiratory and cardiopulmonary support in the form of equipment and clinical staff, and has seen the business grow greatly during the pandemic.
Pulmonary has added between 20 to 30% new business over the course of the past year, Anderson said.
“We’re getting a lot of calls from places that weren’t partners with us before that are now like, we need this stuff and we need to change this so that our patients still get what the physician’s orders are,” added Anderson.
Existing clients like Petersen increased RT hours for its residents and signed multi-month agreements last year.
“When there was an outbreak, it was so bad and we just felt like that this was the best thing to do,” said Tossell. “[Pulmonary] would have suppliers within our team for the buildings that were having an outbreak and [they’d] be there 40-plus hours a week, helping. They would also bring all the extra equipment that we would need.”
Sroczynski told SNN Symphony has historically been a high acuity provider, and although there was a definitive leap in respiratory services last year, she believes their facilities will always have a high usage of this type of service.
“Between pneumonia and [chronic obstructive pulmonary disease, or COPD], we do take a lot of those patients, we run a lot of oxygen for those kinds of things, so it’s hard to say. I would think it’s always going be a high usage area I think it’s always gonna be an area of need,” noted Sroczynski.
Petersen has used Pulmonary as a respiratory service vendor for five-plus years, Tossell said. Symphony has partnered with the respiratory vendor for 8-plus years.