0
Correspondence |

ResponseResponse FREE TO VIEW

Katherine Courtright, MD; Scott Manaker, MD, PhD, FCCP
Author and Funding Information

From the Pulmonary, Allergy, and Critical Care Division (Drs Courtright and Manaker) and the Department of Medicine (Dr Manaker), University of Pennsylvania.

CORRESPONDENCE TO: Katherine Courtright, MD, Pulmonary, Allergy, and Critical Care Division, Hospital of the University of Pennsylvania, Gates Bldg, 806 W, 3400 Spruce St, Philadelphia, PA 19104; e-mail: katherine.courtright@uphs.upenn.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts of interest: From 2010 to 2013, Dr Courtright’s spouse worked for Connolly, LLC, a Centers for Medicare & Medicaid Services Recovery Audit Contractor. Dr Manaker has received fees as a Grand Rounds speaker, lecturer, consultant, and expert witness on documentation, coding, billing, and reimbursement from hospitals, physicians, departments, practice groups, professional societies, insurers, and various attorneys. In March 2011, he received funding from Aetna Inc for consultation on diagnosis coding. Dr Manaker serves on the Hospital Outpatient Panel, a federal advisory commission to the Centers for Medicare & Medicaid Services. Dr Manaker also serves on the Board of Directors of CHEST Enterprises, Inc, a wholly owned, for-profit subsidiary of the American College of Chest Physicians.

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


Chest. 2014;146(2):e62-e63. doi:10.1378/chest.14-0691
Text Size: A A A
Published online
To the Editor:

We thank Mr Gaebler for his comments on our point/counterpoint debate.1-4 Perhaps said best by Representative Brady in the same issue, “disagreement on a piece of legislation is the rule, not the exception.”5 Differences aside, we are delighted with the interest sparked by this debate.

Critically, this debate focused on the hypothetical title question posed, not the specifics of bill HR 2619.6 Narrowing the focus to solely COPD still allowed spirited examination of many issues. Furthermore, as noted by Brady,5 the long journey from advocacy to law includes drafting many versions of legislation to meet the challenges of opposition and the demands from competing regulations before ultimate implementation. Indeed, HR 26196 is the most recent of iterative legislative initiatives by the American Association of Respiratory Care in partnership with the physician community.

We strove to frame the debate posed in the context of the real world in which we live, practice, and pay taxes. The debate posed independent practice, which does not preclude rendering services in the office, hospital, nursing facility, or home. For example, despite statutes mandating coverage, Medicare provides very narrowly defined G codes with limited reimbursement for pulmonary rehabilitation services in various settings.2 A similar such fate would undermine the noble intent of HR 2619. As we emphasized, some COPD self-management education (SME) services provided by respiratory therapists are currently reimbursed as “incident to” services.2 Depending on the final steps of regulation, enormous costs could ensue from the implementation of pulmonary disease SME provided by respiratory therapists without empirical, favorable, cost-benefit evidence.

Action preceding evidence can have enormous and potentially unjustified costs as demonstrated by the ongoing debate over critical care bed supply in the United States. The rapid increase in US critical care beds from 2000 to 2005 in response to perceived demand was followed by an exorbitant increase in intensive care expenditures7 without significant evidence of a concomitant increase in quality of care. Furthermore, newer data support the notion that critical care services could actually be reduced without harming patients,8 and controversy about critical care bed supply rages on.9

We agree with Dr Papadakos that further studies are warranted to refine an optimal approach to the delivery of COPD SME, but we believe that evidence of improved clinical and financial outcomes should precede law mandating expanded payment for such services. At a minimum, a study to confirm the safety of COPD SME is merited based on the most recent randomized controlled trial that was stopped early due to excess mortality in patients receiving this intervention.10

Again, we thank our colleagues for their thoughtful letters. From this lively debate, we hope that readers consider all the issues of reform as health care perpetually evolves through advocacy, legislation, and regulation.

References

Fuhrman TM, Aranson R. Point: should Medicare allow respiratory therapists to independently practice and bill for educational activities related to COPD? Yes. Chest. 2014;145(2):210-213. [CrossRef] [PubMed]
 
Courtright K, Manaker S. Counterpoint: should Medicare allow respiratory therapists to independently practice and bill for educational activities related to COPD? No. Chest. 2014;14(2):213-216. [CrossRef]
 
Fuhrman TM, Aranson R. Rebuttal from Drs Fuhrman and Aranson. Chest. 2014;145(2):216-217. [CrossRef] [PubMed]
 
Courtright K, Manaker S. Rebuttal from Drs Courtright and Manaker. Chest. 2014;145(2):217-218. [CrossRef] [PubMed]
 
Brady K. Whether a bill becomes a law. Chest. 2014;145(2):206-208. [CrossRef] [PubMed]
 
HR 2619: Medicare Respiratory Therapist Access Act of 2013. Govtrack website. http://www.govtrack.us/congress/bills/113/hr2619/text. Accessed March 24, 2014.
 
Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med. 2010;38(1):65-71. [CrossRef] [PubMed]
 
Wagner J, Gabler NB, Ratcliffe SJ, Brown SE, Strom BL, Halpern SD. Outcomes among patients discharged from busy intensive care units. Ann Intern Med. 2013;159(7):447-455. [CrossRef] [PubMed]
 
Gooch RA, Kahn JM. ICU bed supply, utilization, and health care spending: an example of demand elasticity. JAMA. 2014;311(6):567-568. [CrossRef] [PubMed]
 
Fan VS, Gaziano JM, Lew R, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med. 2012;156(10):673-683. [CrossRef] [PubMed]
 

Figures

Tables

References

Fuhrman TM, Aranson R. Point: should Medicare allow respiratory therapists to independently practice and bill for educational activities related to COPD? Yes. Chest. 2014;145(2):210-213. [CrossRef] [PubMed]
 
Courtright K, Manaker S. Counterpoint: should Medicare allow respiratory therapists to independently practice and bill for educational activities related to COPD? No. Chest. 2014;14(2):213-216. [CrossRef]
 
Fuhrman TM, Aranson R. Rebuttal from Drs Fuhrman and Aranson. Chest. 2014;145(2):216-217. [CrossRef] [PubMed]
 
Courtright K, Manaker S. Rebuttal from Drs Courtright and Manaker. Chest. 2014;145(2):217-218. [CrossRef] [PubMed]
 
Brady K. Whether a bill becomes a law. Chest. 2014;145(2):206-208. [CrossRef] [PubMed]
 
HR 2619: Medicare Respiratory Therapist Access Act of 2013. Govtrack website. http://www.govtrack.us/congress/bills/113/hr2619/text. Accessed March 24, 2014.
 
Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med. 2010;38(1):65-71. [CrossRef] [PubMed]
 
Wagner J, Gabler NB, Ratcliffe SJ, Brown SE, Strom BL, Halpern SD. Outcomes among patients discharged from busy intensive care units. Ann Intern Med. 2013;159(7):447-455. [CrossRef] [PubMed]
 
Gooch RA, Kahn JM. ICU bed supply, utilization, and health care spending: an example of demand elasticity. JAMA. 2014;311(6):567-568. [CrossRef] [PubMed]
 
Fan VS, Gaziano JM, Lew R, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med. 2012;156(10):673-683. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543