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Point/Counterpoint Editorials |

Point: Should Medicare Allow Respiratory Therapists to Independently Practice and Bill for Educational Activities Related to COPD? YesAllow Respiratory Therapists to Bill for COPD? Yes FREE TO VIEW

Thomas M. Fuhrman, MD, MMSc, RRT, FCCP; Robert Aranson, MD, FCCP
Author and Funding Information

From the Bay Pines VA Healthcare System (Dr Fuhrman); and the White River Junction Veterans Affairs Medical Center (Dr Aranson).

Correspondence to: Robert Aranson, MD, FCCP, 20 Lookout Dr, Freeport, ME 04032; e-mail: aransonr@comcast.net


For editorial comment see page 206

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(2):210-213. doi:10.1378/chest.13-2517
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From the time the first inhalation therapists (as they were known at the time) stepped into the clinical arena in 1943, to the present-day respiratory therapists (RTs), the field of respiratory care has burgeoned into one of the essential ancillary medical professions of today. Because of medical advancements leading to the increased sophistication of respiratory care, RTs no longer provide just oxygen therapy. They perform a multitude of tasks, including measurement of arterial blood gases and insertion of arterial lines, transducer setups in the ICU for hemodynamic monitoring, intubations and extubations, management of increasingly complex mechanical ventilators, chest physiotherapy, administration of bronchodilator therapy, pulmonary function and cardiopulmonary exercise tests, and polysomnography studies, to name just a few. Additionally, they provide outpatient services in pulmonary physicians’ offices and patients’ homes, including education in areas unique to respiratory diseases. As a result, RTs have advanced their titles to that of respiratory care practitioners (RCPs), for they are truly practicing within their field of training.

While inhalation therapy was evolving into the more comprehensive respiratory care of today, other ancillary medical professions were developing. These include, among others, advanced practice registered nurses (APRNs), comprising certified registered nurse anesthetists, nurse practitioners (NPs), certified nurse midwives, clinical nurse specialists, anesthesiology assistants, and physician assistants (PAs).

Today physicians are finding the practice of proper ethical medicine increasingly difficult as they are saddled with more burdensome rules and regulations by third-party payors and legislation, not the least of which is the > 2,000-page Affordable Care Act (ACA). As a result, physicians spend more time satisfying regulatory bodies and less time taking care of their patients. The ACA poses to add another approximately 48 million patients to the roles waiting to see a doctor,1 while there is a projected deficit of 124,000 to 159,000 physicians by 2015.2 Shortfalls in the pulmonary and critical care physician workforce are estimated to be at least 35% and 22%, respectively, by 2020.3

The care of pulmonary patients is labor and time intensive. Presently, approximately 50% of pulmonologists spend ≥ 50 h/wk caring for patients, with approximately 30% seeing 50 to 99 patients/wk and approximately 40% seeing ≥ 100 patients/wk.4 Approximately 60% spend up to 17 to 20 min/patient, and 35% spend ≥ 21 min/patient.4 Additionally, 55% of pulmonologists spend 10 to ≥ 25 h/wk on indirect patient care-related activities, such as paperwork, medical reading, involvement in professional medical organizations, and administrative, managerial, and supervisory chores.4

Consequently, access to medical care is limited, and some essential areas of patient care are being neglected—among them, education. Besides obtaining patient histories, performing physical examinations, and ordering tests and treatment, doctors must teach their patients about their diseases and the treatments to remedy them. After all, the word, “doctor,” comes from the Latin, docere, which means, “to teach,” which doctors should be doing more, not less.

Enter ancillary medical practitioners. They have been lifelines for physicians, both in the inpatient and outpatient venues, in urban and rural areas, filling large gaps in medical care, including patient education. APRNs and PAs are now so entrenched in the medical profession that, according to the Centers for Medicare & Medicaid Services, they are allowed to act as primary care providers (PCPs), managing everything from diabetes mellitus to heart failure.5 Certified registered nurse anesthetists and anesthesiology assistants may act as anesthesiologists, the former authorized to work without anesthesiologist supervision in many states.5 Certified nurse midwives may perform obstetric services in offices, clinics, birthing centers, patients’ homes, and hospitals, without physician supervision, oversight, or collaboration.5 NPs, clinical nurse specialists, and PAs may provide assistant-at-surgery services and outpatient mental health counseling.5

NPs have achieved such unprecedented stature that they are allowed to practice independently in one-third of the United States (Fig 1). NPs are authorized to serve as both PCPs and consultants in telemedicine use for management of Medicare patients in federally designated Health Manpower Shortage Areas, as PCPs on Medicare Managed Care panels, and as attending physicians for hospice beneficiaries.5 They can even perform sigmoidoscopies and colonoscopies.5 Physicians are no longer required to countersign NPs’ inpatient admission history and physical examination notes.5,6 By Centers for Medicare & Medicaid Services standards, however, RCPs have not reached occupational parity with their fellow ancillary medical professionals.

Figure Jump LinkFigure 1. Autonomy for nurse practitioners, by state. (Reprinted with permission from the American Association of Nurse Practitioners.6)Grahic Jump Location

Although the medical literature is replete with studies demonstrating the clinical effectiveness of APRNs and PAs providing inpatient and outpatient services,7,8 so, too, is the literature for RCPs.9-11 There is ample evidence showing that RCPs are effective in managing many areas of respiratory services, such as shortening the duration of invasive and noninvasive ventilation,12-14 ensuring proper use of inpatient respiratory care services,11,15 and educating patients in self-management for all forms of COPD.9,10,16-20

COPD is disabling, deadly, and expensive. It is the third leading cause of death in the United States, killing > 143,000 people yearly.21 Nearly one in five patients ≥ 40 years old has COPD.21 Eighty percent of all health-care dollars in the United States are spent on chronic disease, with COPD accounting for approximately $39 billion yearly.22 The federal government aims to reduce these costs by such means as the ACA, which includes financial penalties to hospitals for early readmissions of such conditions as COPD exacerbations. It is widely acknowledged that not all early readmissions for COPD can be prevented. However, patient education should have an overall positive impact on readmission rates. And, indeed, RCPs can effect beneficial outcomes where they are involved.

One key Medicare priority is training patients to self-manage their diseases. To this end, the American Association for Respiratory Care (AARC) has been active, submitting legislation for patients with chronic pulmonary diseases. Their latest, HR 2619, known as the Medicare Respiratory Therapist Act of 2013, would allow for pulmonary self-management education and training services under Medicare Part B by recognizing qualified, registered, bachelor- or advanced-degree RCPs to provide these services to patients under direct physician supervision. Specific chronic disease management services would include patient education for self-management of their disease, monitoring a treatment plan and developing a patient action plan, appropriate selection of aerosol medications in collaboration with the physician, education and training in proper inhaler techniques and observation and assessment of the patient’s ability to self-administer aerosol medications, smoking cessation counseling, and education and training in appropriate oxygen doses. Ostensibly, the bill would help achieve quality care of the pulmonary patient at an overall lower cost, in large part by reducing hospital admissions and emergency room visits.

During the period 2008 to 2010, the AARC devoted a significant amount of time and effort into looking ahead for the respiratory care profession in a three-part conference series, known as “2015 and Beyond.”23-25 Even without fulfilling all of the report’s prospective goals, the RCP of the not-too-distant future will be educated and trained specifically to practice at a level to maximize care of the pulmonary patient. An RCP will be armed with a minimum of a bachelor’s degree and educated in areas beyond his/her present realm, such as evidence-based medicine, medical literature assessment, research, managerial skills, quality improvement, electronic medical records, and more. The RCP will perform clinical evaluations, periodic testing, and patient education, and then alert the physician about a rescuing intervention, seeking to avert an ED visit or hospital admission. In essence, the RCP will care for the pulmonologist’s patients as a true physician extender, not as a physician alternative. Licensure and scope of practice would be determined on a state-by-state basis.

Despite the conjectural nature of this pro/con debate, we want to emphasize that the AARC has never advocated for the independent practice of RCPs, but instead for the employment of qualified RCPs working under the supervision of physicians. For the sake of this debate, however, the real question may not be if RCPs should be allowed to practice independently, but when. In the interest of best patient care, appropriate physician specialists and RCP educators should form the core group charged with the task of defining the appropriate scope of practice for the independent RCP. An appropriately educated, properly credentialed, independent RCP can follow a thoughtfully delineated scope of practice based upon evidence-based medicine and the needs of the physicians and their patients.

In summary, RCPs deserve the same recognition under Medicare as their fellow ancillary medical professionals. As the great Jewish sage, Rabbi Hillel, stated in his famous aphorism more than 2,000 years ago, “If I am not for myself, who will be for me? If I am only for myself, what am I? If not now, when?”26 Well, now is the time to level the playing field for RCPs.

Abbreviations

AARC

American Association for Respiratory Care

ACA

Affordable Care Act

APRN

advanced practice registered nurse

HgbA1c

hemoglobin A1c

NP

nurse practitioner

PA

physician assistant

PCP

primary care provider

PR

pulmonary rehabilitation

QOL

quality of life

RCP

respiratory care practitioner

RCT

randomized controlled trial

RT

respiratory therapist

SME

self-management education

National Center for Health Statistics. Early release of selected estimates based on data from the 2011 National Health Interview Survey. Centers for Disease Control & Prevention website. http://www.cdc.gov/nchs/fastats/hinsure.htm. Accessed September 6, 2013.
 
Association of American Medical Colleges Center for Workforce Studies. The Complexities of Physician Supply and Demand: Projections Through 2025. Washington, DC: Association of American Medical Colleges; 2008.
 
Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762-2770. [CrossRef] [PubMed]
 
Kane L. Medscape pulmonary compensation report. 2011 Results. Medscape Business of Medicine. WebMD website. http://www.medscape.com/features/slideshow/compensation/2011/pulmonarymedicine. Accessed September 6, 2013.
 
Department of Health & Human Services. Medicare information for advanced practice registered nurses, anesthesiologist assistants, and physician assistants. Medicare Learning Network (ICN 901623), September 2011. Centers for Medicare & Medicaid Services website. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN901623.pdf. Accessed September 6, 2013.
 
State practice environment. American Association of Nurse Practitioners website. http://www.aanp.org/legislation-regulation/state-practice-environment. Accessed September 6, 2013.
 
Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ. 2011;29(5):230-250. [PubMed]
 
Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med. 2008;36(10):2888-2897. [CrossRef] [PubMed]
 
Stoller JK. 2000 Donald F. Egan Scientific Lecture. Are respiratory therapists effective? Assessing the evidence. Respir Care. 2001;46(1):56-66. [PubMed]
 
Spratt G, Petty TL. Partnering for optimal respiratory home care: physicians working with respiratory therapists to optimally meet respiratory home care needs. Respir Care. 2001;46(5):475-488. [PubMed]
 
Orens DK, Kester L, Konrad DJ, Stoller JK. Changing patterns of inpatient respiratory care services over a decade at the Cleveland Clinic: challenges posed and proposed responses. Respir Care. 2005;50(8):1033-1039. [PubMed]
 
Kollef MH, Shapiro SD, Silver P, et al. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med. 1997;25(4):567-574. [CrossRef] [PubMed]
 
Ely EW, Bennett PA, Bowton DL, Murphy SM, Florance AM, Haponik EF. Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med. 1999;159(2):439-446. [CrossRef] [PubMed]
 
Duan J, Tang X, Huang S, Jia J, Guo S. Protocol-directed versus physician-directed weaning from noninvasive ventilation: the impact in chronic obstructive pulmonary disease patients. J Trauma Acute Care Surg. 2012;72(5):1271-1275. [PubMed]
 
Kollef MH, Shapiro SD, Clinkscale D, et al. The effect of respiratory therapist-initiated treatment protocols on patient outcomes and resource utilization. Chest. 2000;117(2):467-475. [CrossRef] [PubMed]
 
Rice KL, Dewan N, Bloomfield HE, et al. Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial. Am J Respir Crit Care Med. 2010;182(7):890-896. [CrossRef] [PubMed]
 
Volsko TA. Cystic fibrosis and the respiratory therapist: a 50-year perspective. Respir Care. 2009;54(5):587-594. [CrossRef] [PubMed]
 
Shelledy DC, Legrand TS, Gardner DD, Peters JI. A randomized, controlled study to evaluate the role of an in-home asthma disease management program provided by respiratory therapists in improving outcomes and reducing the cost of care. J Asthma. 2009;46(2):194-201. [CrossRef] [PubMed]
 
Shelledy DC, McCormick SR, LeGrand TS, Cardenas J, Peters JI. The effect of a pediatric asthma management program provided by respiratory therapists on patient outcomes and cost. Heart Lung. 2005;34(6):423-428. [CrossRef] [PubMed]
 
Weimer MP. Home respiratory therapy for patients with chronic obstructive pulmonary disease. Respir Care. 1983;28(11):1484-1489. [PubMed]
 
Hoyert DL, Xu J. Deaths: preliminary data for 2011. National Vital Statistics Reports. 2012;61(6):1-52.
 
Foster TS, Miller JD, Marton JP, Caloyeras JP, Russell MW, Menzin J. Assessment of the economic burden of COPD in the US: a review and synthesis of the literature. COPD. 2006;3(4):211-218. [CrossRef] [PubMed]
 
Kacmarek RM, Durbin CG, Barnes TA, Kageler WV, Walton JR, O’Neil EH. Creating a vision for respiratory care in 2015 and beyond. Respir Care. 2009;54(3):375-389. [PubMed]
 
Barnes TA, Gale DD, Kacmarek RM, Kageler WV. Competencies needed by graduate respiratory therapists in 2015 and beyond. Respir Care. 2010;55(5):601-616. [PubMed]
 
Barnes TA, Kacmarek RM, Kageler WV, Morris MJ, Durbin CG Jr. Transitioning the respiratory therapy workforce for 2015 and beyond. Respir Care. 2011;56(5):681-690. [CrossRef] [PubMed]
 
Rabbi Hillel the Elder. Pirkei Avot (Ethics of the Fathers); 1:14 (from theMishnah).
 

Figures

Figure Jump LinkFigure 1. Autonomy for nurse practitioners, by state. (Reprinted with permission from the American Association of Nurse Practitioners.6)Grahic Jump Location

Tables

References

National Center for Health Statistics. Early release of selected estimates based on data from the 2011 National Health Interview Survey. Centers for Disease Control & Prevention website. http://www.cdc.gov/nchs/fastats/hinsure.htm. Accessed September 6, 2013.
 
Association of American Medical Colleges Center for Workforce Studies. The Complexities of Physician Supply and Demand: Projections Through 2025. Washington, DC: Association of American Medical Colleges; 2008.
 
Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762-2770. [CrossRef] [PubMed]
 
Kane L. Medscape pulmonary compensation report. 2011 Results. Medscape Business of Medicine. WebMD website. http://www.medscape.com/features/slideshow/compensation/2011/pulmonarymedicine. Accessed September 6, 2013.
 
Department of Health & Human Services. Medicare information for advanced practice registered nurses, anesthesiologist assistants, and physician assistants. Medicare Learning Network (ICN 901623), September 2011. Centers for Medicare & Medicaid Services website. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN901623.pdf. Accessed September 6, 2013.
 
State practice environment. American Association of Nurse Practitioners website. http://www.aanp.org/legislation-regulation/state-practice-environment. Accessed September 6, 2013.
 
Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ. 2011;29(5):230-250. [PubMed]
 
Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med. 2008;36(10):2888-2897. [CrossRef] [PubMed]
 
Stoller JK. 2000 Donald F. Egan Scientific Lecture. Are respiratory therapists effective? Assessing the evidence. Respir Care. 2001;46(1):56-66. [PubMed]
 
Spratt G, Petty TL. Partnering for optimal respiratory home care: physicians working with respiratory therapists to optimally meet respiratory home care needs. Respir Care. 2001;46(5):475-488. [PubMed]
 
Orens DK, Kester L, Konrad DJ, Stoller JK. Changing patterns of inpatient respiratory care services over a decade at the Cleveland Clinic: challenges posed and proposed responses. Respir Care. 2005;50(8):1033-1039. [PubMed]
 
Kollef MH, Shapiro SD, Silver P, et al. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med. 1997;25(4):567-574. [CrossRef] [PubMed]
 
Ely EW, Bennett PA, Bowton DL, Murphy SM, Florance AM, Haponik EF. Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med. 1999;159(2):439-446. [CrossRef] [PubMed]
 
Duan J, Tang X, Huang S, Jia J, Guo S. Protocol-directed versus physician-directed weaning from noninvasive ventilation: the impact in chronic obstructive pulmonary disease patients. J Trauma Acute Care Surg. 2012;72(5):1271-1275. [PubMed]
 
Kollef MH, Shapiro SD, Clinkscale D, et al. The effect of respiratory therapist-initiated treatment protocols on patient outcomes and resource utilization. Chest. 2000;117(2):467-475. [CrossRef] [PubMed]
 
Rice KL, Dewan N, Bloomfield HE, et al. Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial. Am J Respir Crit Care Med. 2010;182(7):890-896. [CrossRef] [PubMed]
 
Volsko TA. Cystic fibrosis and the respiratory therapist: a 50-year perspective. Respir Care. 2009;54(5):587-594. [CrossRef] [PubMed]
 
Shelledy DC, Legrand TS, Gardner DD, Peters JI. A randomized, controlled study to evaluate the role of an in-home asthma disease management program provided by respiratory therapists in improving outcomes and reducing the cost of care. J Asthma. 2009;46(2):194-201. [CrossRef] [PubMed]
 
Shelledy DC, McCormick SR, LeGrand TS, Cardenas J, Peters JI. The effect of a pediatric asthma management program provided by respiratory therapists on patient outcomes and cost. Heart Lung. 2005;34(6):423-428. [CrossRef] [PubMed]
 
Weimer MP. Home respiratory therapy for patients with chronic obstructive pulmonary disease. Respir Care. 1983;28(11):1484-1489. [PubMed]
 
Hoyert DL, Xu J. Deaths: preliminary data for 2011. National Vital Statistics Reports. 2012;61(6):1-52.
 
Foster TS, Miller JD, Marton JP, Caloyeras JP, Russell MW, Menzin J. Assessment of the economic burden of COPD in the US: a review and synthesis of the literature. COPD. 2006;3(4):211-218. [CrossRef] [PubMed]
 
Kacmarek RM, Durbin CG, Barnes TA, Kageler WV, Walton JR, O’Neil EH. Creating a vision for respiratory care in 2015 and beyond. Respir Care. 2009;54(3):375-389. [PubMed]
 
Barnes TA, Gale DD, Kacmarek RM, Kageler WV. Competencies needed by graduate respiratory therapists in 2015 and beyond. Respir Care. 2010;55(5):601-616. [PubMed]
 
Barnes TA, Kacmarek RM, Kageler WV, Morris MJ, Durbin CG Jr. Transitioning the respiratory therapy workforce for 2015 and beyond. Respir Care. 2011;56(5):681-690. [CrossRef] [PubMed]
 
Rabbi Hillel the Elder. Pirkei Avot (Ethics of the Fathers); 1:14 (from theMishnah).
 
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