CQRC members provide patient-centered care in the home to individuals who require home oxygen, home sleep, and home non-invasive ventilation therapies. During the pandemic, CQRC members expanded access to these home therapies to enable more beneficiaries to receive their care at home instead of in the hospital. As the country moves beyond the pandemic, the CQRC has prioritized protecting continued access to individuals who continue to need these therapies by strengthening the Medicare benefit.
Provide a Clear eClinical Template for Prescribers Ordering Home Oxygen to Support Patient Access
- More than 99 percent of beneficiaries who receive home respiratory therapy meet CMS requirements, according to Medicare's CERT contractor.
- Yet, contractors, deny 80-90 percent of claims denied as improper because they do not find the physician's notes sufficient, even though the objective test results support the patients' medical need.
- Home respiratory therapy suppliers win the overwhelming number of appeals through Administrative Law Judges relying upon a document CMS has indicated it will eliminate.
- Given that Medicare coverage establishes objective criteria that do not require the medical record notes to determine medical necessity, the Medicare program can support access to home respiratory therapies by streamlining and adopting a template as the only required to documentation to support medical necessity.
- The CQRC recommends that CMS adopt a clear template for use in lieu of physician medical record notes for establishing medical necessity for home oxygen therapies.
- To view the CQRC infographic Standardize Documentation for Ordering Home Oxygen, CLICK HERE.
Protect Patients who First Received Home Respiratory Therapy During the COVID-19 PHE
- During the pandemic, the number of beneficiares who required home oxygen therapy increased substantially. For example, between January 2020 and the end of June 2020, the percentage of new start acute patients in Medicare increased by 229 percent, while the percent of new start chronic patients in Medicare decreased by 25 percent.
- During the pandemic, CMS rightly waived some of the documentation requirements to ensure patient access to therapy. Once the pandemic public health emergency (PHE) ends, it will be important to streamline the documentation requirements to make sure these patients continue to receive the therapies they need.
- CQRC suggests allowing these patients to continue receiving the benefit without having to "restart". This patient-friendly policy would ensure they do not have to relinquish their equipment or have additional copayment obligations.
- To view the CQRC infographic America’s Home Respiratory Patients Can’t Afford to Lose Access to Care, CLICK HERE.
Update Payment Policies to Reflect Patient Need
- CMS removed home respiratory therapy equipment and supplies from the Round 2021 DMEPOS Competitive Bidding Program (CBP). While there were some anomalies in product areas in select competitve bidding areas. Round 2021 data support the CQRC's concern that the previous methodology drove rates below what the market would have set.
- Medicare reimbursement rates for home oxygen stationary units have been cut by nearly 63 percent since 2010. The CBP has done its job and substantilly reduced the rates for home respiratory therapy.
- Non-invasive ventilation (NIV) is a cornerstone of treatment for COPD patients with severe exacerbations, where it has been shown to reduce the need for intubation, hospital lenght of stay, and mortality. NIV also allows patients with restrictive thoracic disorders and neuromuscular diseases to remain at home with their families.
- CMS appropriately has not included NIV in the CBP to prevent reimbursement rates from cremating a barrier to patient access.
- CQRC encourages CMS to maintain policies that enable patient access to NIV equipment by allowing the rates to stabilize. This can be accomplished by continuing to exclude home respiratory therapy from the CBP. CMS should allow the rates to increase annually by the CPI-U inflation factor.
Address Unanticipated Cost Increases Due to the Pandemic
- While COPD incidences have increased, Medicare claims for home respiratory therapy for COPD patients have decreased, even though there have been no medical advances to replace home respiratory therapy. This suggests that payment policies could be creating barriers to access.
- Increased costs due to workforce shortages and supply chain issues have outpaced the traditional update mechanisms CMS relies upon.
- CQRC encourages CMS to work with the community to address the unanticipated and substantial increases in costs due to workforce issues and supply chain shortages that have driven costs above what the CPI-U can recognize.
Retain the Blended Rate for Beneficiaries Living in Rural Communities
- Rates in rural areas were set at the competitve bidding rates in 2016, which are dramatically below the cost of providing services to patients in these areas.
- Congress provided relief to rural rates during the pandemic by setting a 50-50 blended rate. In the CY 2021 DMEPOS Fee Schedule final rule, CMS maintained the blended rate for rural Americans but raised doubts about whether it would retain the blended rate in the future.
- CQRC recommends maintaining this blended rate to protect patient access to home respiratory treatments in rural America.
Support the Establishment of a Sustainable Reimbursement Rate for Liquid Oxygen
- GAO reported in 2011 that beneficiary needing liquid oxygen had difficulties accessing it because of cuts in payment rates for liquid oxygen equipment.
- A peer reviewed study in the Journal of the American Thoracic Society found that beneficiaries have lost access to important modalities, such as liquid oxygen, because providers simply cannot afford to provide the equipment and supplies necessary under the Medicare rates.
- ATS reiterated this concern that Medicare payment rates create a barrier to patient access in the guideline on home oxygen therapy for adults with chronic lung disease published in 2020 in the American Journal of Respiratory and Critical Care Medicine.
- While technology advances have lessened the need for liquid oxygen for some patients, it remains a necessity for others who require high liter flows. Providing liquid oxygen, however, requires complying a series of regulatory requirements, storing and maintaining liquid oxygen, and increased services for patients. Current Medicare rates are too low to support providing liquid oxygen.
- The CQRC urges CMS to eliminate barriers to care by increasing the reimbursement rate for liquid oxygen.
- To view the CQRC infographic CMS Payment Must Reflect the Unique Role of Supplemental Liquid Oxygen, CLICK HERE.
Promote a Long-Term Vision for Home Respiratory Care
- The CQRC believes that lessons learned during the pandemic can help improve patient outcomes and quality of life. Specifically, CQRC is urging CMS to:
- Maintain telehealth policies related to home respiratory therapies.
- Work with the industry to address exponential costs increases resulting from workforce shortages and supply chain issues.
- Establish a respiratory therapist payment system to fairly reimburse professionals not currently paid under the Medicare program.
- Work with Congress and stakeholders to address alternative payment models that may be considered for home respiratory therapy.