Trial seeks to promote respiratory therapists

Friday, May 16, 2014

LOS ANGELES – A new trial is examining the value of respiratory therapists, but its sponsor hopes it will lead the HME industry to think more about clinical services than reimbursement.

Industry veteran Vernon Pertelle’s company StratiHealth is behind a trial to determine the benefit of education and case management by respiratory therapists on improvements in health outcomes and quality of life for COPD patients. Enrollment by invitation began in March, and StratiHealth wants 100 patients to complete the yearlong study.

“This is the beginning of something I think has to happen throughout the HME industry in that the dollars devoted to lobbying have to be shifted to research,” Pertelle said. “We haven’t done a good job of demonstrating value through evidence and that’s beginning to affect us in the home care and acute-care environment.”

With healthcare reform set to require hospitals to reduce readmissions within 30 days for COPD starting in 2014, or face penalties, it’s a good time to try and swing that pendulum the other way.

“The respiratory therapist, being very knowledgeable of COPD and really all respiratory conditions, helps empower the patient with the information and knowledge that they can use to care for themselves,” said Pertelle. “If we look at the foundation of where patients will improve with self management, the answer is education.”

Pertelle said the study will form the basis for developing a standardized, comprehensive model to fit the needs of various organizations, based on things like population density or location.

“This study will be a landmark in that it will now create the framework for more discussion and expedite the use of respiratory therapists,” said Pertelle.


There are a lot of people out there doing many creative things to create job opportunities and this push to enlist the hiring of Respiratory Therapist on DME suppliers is a good example.  There are many very good Respiratory Therapy Clinicians out there, however there are a number of reasons hiring Respiratory Therapist is an unnecessary expense to DME Suppliers with no patient benefits and in fact possibly creating devistation to the Supplier. 

1.  The fact that no one pays for Respiratory Therapist should be the evidence, as insurers say, they are  "not medically necessary".  Medicare for instance will not pay DME Suppliers for Clinical Care and maintains DME Suppliers are "Suppliers" and not "Providers".  There is a big difference in billing a HCPCS code verses a Procedure code. 

2. Also, In over 25 years I have never received an order from The ordering Physician or anyone to assess a patient for Respiratory equipment.  Why, because the ordering Physician already understands the patients needs and understands the home medical equipment required to meet those needs.  The assessments have already been done in a clinical setting by the Physician or staff. 

3. Further, I am unsure about other states but in North Carolina, Virginia, and South Carolina, the DME Permit does not permit for the provision of clinical care.  A DME Supplier would have to obtain another license to provide such.  

4. Further the Liability Insurance DME Suppliers maintain covers only those services the Suppliers are licensed or permitted for and since they are not licensed or permitted for clinical services there is no liablity insurance covering such.  For those liability reasons, Clinicians should not wear name tags or hold themselves out as clinicians when working for a DME Supplier to prevent incurring liabilities which would not be covered under the Suppliers liability insurance.  That is devistation just waiting to happen.

5.  And of course the reimbursement issues insuring no Supplier can afford to incur unnecessary expenses in today's reimbursement enviornment..  The focus is cutting expenses and increasing productivity to meet todays anti-business and anti-healthcare enviornment.  

Just look at the VA mess where hundreds have died waiting on healthcare.   That my friends is where our healthcare system is heading.


John Kight  RPh

CEO and President




I, and many people familiar with your business model, could not disagree more.  Our company employs several full time respiratory therapists and we are almost always asked to perform "clinical assessments" of our patients from our referring physicians.  It is true that the ordering physician knows the general type of equipment needed by their patients, but not necessarily the best way to apply it or if there are other factors that preclude it's use.

You are correct in stating that states requre addidtional certifications to provide clinical services, namely that we be accredited for "clinical respiratory service".  This is a valuable service offering to many patients, and most physicians I interact with not only agree, but expext that we do so when we take care of higher accuity patients such as those who have artificial airways, use high flow oxygen or are on ventilators.  To provide any of this equipment without qualified and licenced RTs is not only irresponsible, but I suspect is also in vilolation of state respiratory care board regulations.

I think you have completely misssed the point of this article.  The author is trying to promote added value to what we do in this industry to secure our future.  If we are simply providing a commodity, then we will forever be subjected to payment according to the lowest bidder, and rightly so.  If we add real value and service to what we do, then those who pay us will be less likely to scrutinize how much they pay for a simple device.  Anyone can deliver a piece of equipment.   What makes one company better is the offering of complete service to a high level that satifies both the referring physician and the patient.  How do you optimize the use of anything by simply delivering it without knowlegeable staff to support it and properly educate the end user while ultimately observing that they are using it as directed?

Respiratory therapy is new relative to other proffesions such as nursing, pharmacy, etc.  Funding for it is not yet available, but given time and effort, it certainly will be.  There is a bill being reviewed in congress that would recognize respiratory therapy in a similar fashion to these other allied health professions.  Clearly this is a step in that direction.  As to liability insurance, there most certainly are policies available to those who are commited to what they do and are interested enough to get them.  To compare our industry to the current VA scandal is reckless and incorrect.

Chris Burgess, BS, RRT, RCP

Charlotte, NC


To follow up on my most recent email regarding Respiratory Therapist employed in a DME Supplier setting, I mistakingly left out one important point. 

Neither a DME Supplier nor a Respiratory Therapist can write an order to assess a patient or assess a patient on a Medical Equipment or to provide any clinical services.  All orders must be written by a licensed Physician.   Also as stated earlier, neither the DME Supplier's permit nor their Liability Insurance allow for the provision of clinical services even if a Physician writes an order for such, which I have nerver seen.


Thank you

John Kight RPh

CEO and President

Having been a hospital RT, then having worked for a National HME company, then owning my own company in the past I think I understand the value of RT services when the patient is in their home setting. Physicians and other healthcare providers depend on the expertise of Respiratory Therapists to Setup, Follow Up, and Support the patient in their homecare setting.

Properly used for this expertise a RT works with patients to reduce their risk for visits to emergency rooms and recurring hospitalizations. Physicians in our area greatly appreciate these efforts as well as our referral hospitals and Homecare Nursing Agencies.

Companies that do not employ respiratory staff or do not use their skill set properly simply do not know what a respiratory therapist real value is. Equipment setup can and is done by non-respiratory staff. Follow up and support is where true value lies for the patients and a company’s bottom line profitability. 

To the suppliers out there... your Respiratory Staff following a best practice strategy can reduce your overall cost of oxygen delivery by matching patients up to appropriate equipment and increase compliance with CPAP patients which leads to continued rental revenue and recurring replacement supplies profits.

Final thought on "Payers" not paying for Respiratory Services. Many do not pay for delivery (delivery staff); nor do they pay for good customer service, efficient routing staff, effective billers, or good managers, but many of us employ people specialized to make this happen for us. If you are going to employ Respiratory Therapist do so to increase your company’s value to patients, referrals, and your own bottom line by using them as described above. 

Thanks...Matt Metzger, RRT, Manager

I am a practicing pharmacist and member of a cross-continuum team charged with reducing readmissions for patients diagnosed with COPD.  While, I don't normally write comments to articles, I feel compelled to set the record straight regarding the importance of conducting research to create evidence on the value and benefits of using Respiratory Therapists in non-traditional roles and the need to have clinical trials such as the one referenced in the article ( to establish the role of Respiratory Therapists (RTs) to improve health outcomes and reduce costs.  

Beginning in October 2014, Chronic Obstructive Pulmonary Disease (COPD) will be included in the Hospital Readmission Reduction Program (HRRP) for penalties associated with frequent or excessive readmissions.  The fact is that many organizations are rapidly trying to develop programs and services to mitigate the potential impact of the penalties; however the reality is most will likely be affected.  While I can appreciate that many individuals and organizations may lack the knowledge and foresight to create viable and lasting solutions, it is necessary to develop strategies and the tactics that work. 

So let me share with the readers and those interested in understanding the solutions to the problem of managing patients with COPD. Contrary to what has been noted in previous comments, Kaiser Permanente and quite frankly Carolinas HealthCare System are currently using RTs in non-traditional roles. 

Both organizations are innovative and have the vision to use Respiratory Therapists in non-traditional settings to help improve the treatment and management of patients with COPD. 

However, before I get into the details, the profile of both organizations follow to set the stage and give the readers a better frame of reference regarding my knowledge of what has worked:

Kaiser Permanente

Founded in 1945, Kaiser Permanente is one of the nation’s largest not-for-profit health plans, serving approximately 9.3 million members, with headquarters in Oakland, Calif. It comprises:

Kaiser Foundation Hospitals and their subsidiaries

Kaiser Foundation Health Plan, Inc.

The Permanente Medical Groups

At Kaiser Permanente, physicians are responsible for medical decisions. The Permanente Medical Groups, which provide care for Kaiser Permanente members, continuously develop and refine medical practices to help ensure that care is delivered in the most efficient and effective manner possible.  While RTs are not licensed to write prescriptions they are in fact guided by Respiratory Driven Protocols that are evidence-based and practiced throughout the continuum of care (inpatient and outpatient).  The outcomes from the programs at Kaiser Permanente are far better than many organizations that do not use RTs as physician extenders. 

The organization serves will over 8 million members and has locations in Colorado (590, 241 members); Georgia (254,630 members); Hawaii (229,690 members); Mid-Atlantic States including VA, MD and DC (229, 690 members); Northern California (3,527,274 members); Northwest including OR and WA (497,123 members) and Southern California (3,719,193 members).  

In addition we have 38 hospitals, 618 medical offices and outpatient facilities and approximately 16,942 physicians, representing all specialties.  The annual operating revenue for 2013 was $53 billion.  So believe me when I share with you that our organization understands full well what has worked and what has not worked to improve outcomes for patients with COPD.  What has worked includes using Respiratory Therapists in non-traditional roles. 

Carolinas HealthCare System

Before I profile the Carolinas Health System, let me lead of by stating emphatically that Respiratory Therapists are in fact used in non-traditional roles at this organization as well.  The reality is that the concept has not been embraced by and large because of the barriers of reimbursement and lack of evidence, however that does not stop these two organizations from doing the right thing and doing what works.

Carolinas HealthCare System, was originally founded in 1940. Since that time Carolinas HealthCare System has grown into one of the nation’s largest and most comprehensive systems, with more than 60,000 full-time and part-time employees, more than 7,460 licensed beds (acute care and post-acute care), and an annual budget exceeding $7.7 billion.

Carolinas HealthCare System is one of the nation's leading and most innovative healthcare organizations, and provides a full spectrum of healthcare and wellness programs throughout North and South Carolina. The network has more than 900 locations, which includes academic medical centers, hospitals, healthcare pavilions, physician practices, destination centers, surgical and rehabilitation centers, home health agencies, nursing homes, and hospice and palliative care.

Their facilities include Levine Cancer Institute, Levine Children’s Hospital, Sanger Heart & Vascular Institute, Carolinas HealthCare System Neurosciences Institute and The Transplant Center. 

Unfortunately many individuals and many of the readers may not be aware of the fact that the Carolinas HealthCare System has identified the value of utilizing Respiratory Therapists in non-traditional roles.  In fact, the organization was recently highlighted in the Healthcare Financial Management Association (HFMA) April 2014 journal based on results that they presented at the Institute for Healthcare Improvement (IHI) Conference in December 2013. (See the link:

Now clearly this should be information that everyone is aware of; but obvious, that is not the case.  So let me highlight the specifics regarding the use of Respiratory Therapists at Carolinas HealthCare System:

1.       Respiratory Therapists assigned to Inpatient COPD Care Management:  Patients diagnosed and admitted with COPD were identified on admission by “both” a case manager and respiratory therapist.  Both experts followed the specific patient’s treatment and established a discharge plan that was reviewed daily.  All patients were assigned a medical home and received education on their disease and inhaler use; which by the way as a pharmacist, and most of my physician colleagues, do a poor job.  The patient had a follow up appointment scheduled within two to seven days of discharge among other activities to prevent readmission.

2.       Respiratory Therapists assigned to Key Primary Care Physicians in their Office:  Respiratory Therapists were embedded one day a week in five employed physician practices that had the highest number of COPD patients.  While at the primary care offices, the respiratory therapists took specific steps to identify, enroll and treat patients under the direction and evidence-based protocols and visited patients.  (See the Protocol below)

As far as not having heard of the use of RTs in non-traditional setting for many years; Graybill Medical Group (a member of the Sharp Healthcare Pioneer ACO) located in San Diego County, CA has been using RTs as primary case managers since 1996.  Their model is similar to the one used by the Carolinas HealthCare System; although includes a "Chest Clinic" run by a Respiratory Therapist alongside a primary care physician and home visits performed as needed - - for patients at risk for exacerbations.  

The fact is that the examples do not include DME/HME RTs; is frankly because there exists no reimbursement for their services.  However, DME/HME providers that employ RTs should explore opportunities to align with progressive organizations such as Kaiser Permanente and Carolinas HealthCare System to create programs to improve health outcomes, reduce costs and prevent readmissions for patients that are diagnosed with COPD.  

The New Healthcare Normal however, has created the opportunity to now explore the value of developing comprehensive programs that involve home care RTs.  The new models of care (Accountable Care Organizations - ACOs) and Patient Centered Medical Homes (PCMHs) do in fact include RTs in their methods to improve outcomes and reduce costs.  

Durable Medical Equipment - Physician Knowledge

Physicians that prescribe home oxygen therapy often find it difficult and time consuming to identify a unique oxygen system, which provides therapeutic benefits for patients that require Long-Term Oxygen Therapy (LTOT).  The reality is that the vast majority of physicians rely on the DME provider, case manager or nurse to figure out the equipment details and often times do not have the time or focus on that level of detail - - that is the reality.  Most important is they really do not know the difference because they were never trained nor do they have an interest in understanding the differences in oxygen delivery devices.  

So, all this to say that while evidence regarding the use of RTs in non-traditional roles is lacking; important research that quantifies the value and expertise of RTs as viable cost-effective solutions to improve outcomes and reduce costs is needed.  In the meantime, some organizations have begun integrating RTs in non-traditional roles because it makes practical sense.  The clinical trial ( referenced in the article will help to highlight the role of the RT and provide evidence of the cost-benefit to improve outcomes and prevent readmission of patients diagnosed with COPD.