Chair
Joseph Lewarski, BS, RRT
8909 East Avenue
Mentor, Ohio 44060
joerrt@aol.com

Major changes in reimbursement for unit dose medications for aerosol therapy are slated to become effective January 1, 2005. Compared to other reductions in reimbursement, these policy changes have not received much coverage in the trade and professional publications. But their impact will be as great as any previous reduction in home care reimbursement.

These changes are part of the Medicare Prescription Drug Improvement and Modernization Act, which was signed into law in 2003. This legislation called for a 17% reduction in reimbursement for unit dose medications in 2004, and for a complete change in how reimbursement is to be calculated for 2005.

Prior to the new law, over-the-counter and prescription medications were not covered services under Medicare. Unit dose medications, however, have been a covered service under the patient’s Medicare Part B benefit when the medications are necessary for the effective use of durable medical equipment. The rationale for covering unit dose medications but not metered–dose inhalers was that a spacer for a metered-dose inhaler is not considered durable medical equipment.

Each inhaled unit dose medication is coded using the Healthcare Common Procedure Coding System (HCPCS). Every medication has a different code and is reimbursed based upon the amount in milligrams of medication dispensed to the patient, up to a maximum amount. Medicare Part B pays 80% of the allowable costs. The remaining 20% is paid by a secondary insurance or by the patient.

The current reimbursement system for unit dose medications was defined in the Balanced Budget Act of 1997. The allowable for each medication is 95% of the unit dose medication’s average wholesale price (AWP). AWP is reported by the drug manufacturer to organizations that publish this data. An example is the Red Book published by Medical Economics, Inc. There is, however, no definition or procedure to determine how AWP is calculated. AWP does not include discounts from the manufacturer, and some suggest AWP does not accurately reflect the average price of the medication.

Beginning in 2005 unit dose medications will be reimbursed based upon average sales price (ASP) instead of AWP. ASP will be the average cost of the medication, including all discounts, rebates, and free product distributed. Medicare will reimburse for unit dose medications at ASP plus 6%. ASP will be recalculated every quarter, and there are stiff penalties in place for submission of any knowingly false pricing information.

This shift from AWP to ASP should be of great concern to the home care clinician, because if this change in reimbursement is implemented, there will be insufficient reimbursement for many providers to continue to provide unit dose medication services. In order to provide the services, the 6% above ASP would need to cover the inventory, dispensing, billing, and delivery costs of providing the service.

Earlier this year, the AARC urged all members to contact their U.S. House representatives and Senators to urge the reversal of this law to prevent these changes from taking effect. If you are not familiar with these changes or have not contacted your representatives, I urge you to please do so immediately by visiting the Capitol Connection page on the AARC web site. In the meantime, AAHomecare is gathering information through Muse and Associates on how these changes will affect home care providers. Once the data is collected, AAHomecare plans to make a presentation to the federal government on the detrimental impacts of the changes. The clinician needs to stay informed of these changes to understand how they will affect the delivery of respiratory care in the home and, most importantly, to respiratory patients.

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Just open a copy of the AARC Times or your local newspaper, or browse one of the job–hunting web sites, and you will see an unbelievable number of open RT positions posted. The shortage of qualified respiratory therapists is a problem plaguing hospitals, subacute facilities, and HME providers nationwide. These staffing shortages are disruptive. They also cause workload reallocation and gaps in the continuity of care. Not to mention the fact that staff turnover is expensive. For example, it costs approximately one-third of an existing employee’s salary to hire and train a replacement. If your market requires you to offer a sign-on bonus as a recruiting inducement, that cost is higher still.

All this is occurring at a time when the number of patients who require the care of qualified RTs is increasing. HME providers are under particular pressure because the aging baby boomer generation is funneling more and sicker patients into the home care setting at earlier ages than ever before. Finding and retaining enough qualified RTs to provide care for this growing cardiopulmonary patient population is a challenge.

The good news is that respiratory care educational programs have become more creative in their recruiting practices. They have marketed their programs to other allied health applicants, participated in medical occupation open houses, and enhanced their web sites. Recent reports of new programs, higher enrollments, and larger graduating classes are encouraging. If this trend continues, we should have more new RTs entering the field in a few years.

The bad news is that most HME providers recruit from the ranks of experienced RTs. HME RTs must be self-directed and capable of solving problems creatively. They must be able to draw upon their experience with a wide range of patient care situations and to apply that experience to the problems encountered in a home care setting. For example, you rarely have an emergency call from the ICU with something like, “my cat chewed through my power cord, again,” but it happens at home. Patients in the home care setting become comfortable with their therapists. HME RTs often report that they are treated like part of the patient’s family.

How can we keep these valuable employees on board? First we need to understand their various reasons for leaving. Some leave for a better job or more money. Others leave because the work is not what they expected or because of family problems. Still others resign because of “overwork,” “too little time to do the job,” or “too much stress.”

To help define these issues, I conducted an informal survey of a group of HME staff therapists, asking them what contributes to their job satisfaction. These RTs say they want to be treated with respect by their employer. They want to know that their efforts are appreciated. They want a chance to make a worthwhile contribution to the organization. They say they appreciate the opportunity to work a flexible schedule and to receive recognition for hard work. They also state that they want to be treated fairly. None of them put higher wages at the top of their list.

I then asked several successful HME managers to describe what they are doing to retain their strong RT employees. One manager told me she makes a point of recognizing staff members in front of their peers when they do a great job. As she puts it, “We just don’t say thank you often enough.” Another manager gives her staff opportunities to work on projects that are essential to the successful operation of her business. She says this has made her staff feel more like partners than like employees. A third manager says offering educational opportunities for his employees has contributed to his staff’s job satisfaction.

Recruiting new RTs is not always easy. Replacing seasoned employees is expensive. But we need to remember that it is not always about money. Often it is about job satisfaction. The managers I interviewed provide intangible perks like recognition and educational opportunities. The employees I surveyed want things that don’t cost any money, but do provide greater job satisfaction, which, in turn, creates loyalty and increases morale. High levels of morale and loyalty then lead to retention of talented, dedicated team members.

Strategies like making our RTs feel valued and appreciated are well worth the effort, because finding and retaining qualified RTs to provide care for a growing number of cardiopulmonary patients in the home setting is not going to get any easier.

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