What could a fit mountaineer scaling the world’s tallest peak possibly have in common with an obese store clerk living at sea level? Both need equipment that can deliver extra oxygen but may have trouble getting it.

The New York Times recently published a harrowing story detailing how oxygen suppliers on Mount Everest have put climbers at risk by cutting costs to maximize profits. Some climbers have been harmed — the exact number is unknown — and some may have died due to a lack of oxygen.

A similar problem is occurring across the United States, due to cost-cutting in the medical equipment industry and oxygen being defined as “equipment” rather than as an essential medication.

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As physicians who care for people with lung disease, we witness daily the struggle to get oxygen therapy for patients who need it. These struggles manifest as long waits for equipment with innumerable back-and-forths between us, our staff, insurers, and the durable medical equipment companies that supply oxygen. Like the climbers on Everest, some of our patients have been harmed.

One had to delay cancer treatment because she did not have enough oxygen to travel to her appointments for radiation therapy. Several need so much oxygen that they must rely on family members to pick up their tanks from suppliers because they make deliveries only twice a month. One could not get enough oxygen to safely drive his wife to dialysis.

We wouldn’t tolerate a pharmacy failing to provide prescribed medication. We shouldn’t tolerate companies failing to deliver oxygen therapy, which is a lifeline for 1.5 million Americans.

Consider Mr. E, who has obesity hypoventilation syndrome. Excess weight on his chest makes it so difficult to breathe that his lungs simply cannot keep up with his body’s need for oxygen. By the time Mr. E made it to our clinic, his chronically low oxygen level had caused his body to make extra red blood cells, thickening his blood and putting him at high risk for having a stroke. This was a medical emergency, one that was worsening with every breath he couldn’t take.

Although Mr. E already had home oxygen in the form of a bulky machine that required constant power, he did not have portable oxygen that could get him through his workday restocking shelves in a grocery store. The small tanks he received lasted only an hour. Larger ones were cumbersome, and still wouldn’t last a whole shift. But he had to work, so he did — without supplemental oxygen.

What he needed was a portable oxygen concentrator: a small, lightweight machine that concentrates oxygen from the air. We ordered one for him. He waited 39 days to get it.

Stories like this are frustratingly common. In a 2016 survey of nearly 2,000 people who use supplemental oxygen, half reported problems ranging from broken equipment to inadequate portable oxygen. Such issues cause anxiety, social isolation, and increased use of health care.

Why such rampant problems?

Oxygen is paid for and provided in a different way than most medications. The government considers it to be “equipment,” putting it in the same category as wheelchairs, walkers, commodes, and the like. Lumping oxygen with essential but non-lifesaving equipment has had unforeseen consequences.

To reduce equipment expenditures, back in 2011 the Centers for Medicare and Medicaid Services implemented a competitive bidding program that forces durable medical equipment companies to compete for contracts. To land bids, companies have had to agree to ever-lower reimbursement for their services. Today, winning a bid can mean losing money, especially in rural settings where suppliers serve few patients over large areas. As a result, 41% of durable medical equipment companies closed between 2013 and 2017. Those that remain have cut costs by reducing selection, patient education, and delivery days, which has generally led to poor service.

This brings us back to Mr. E. The company we initially ordered his portable oxygen concentrator from had stopped carrying the devices, something we learned more than a week after placing the order. A different supplier turned us down because the portable concentrator it carried wasn’t able to deliver oxygen at the rate Mr. E needed. Our next order was rejected because the company would provide Mr. E with a portable oxygen concentrator only if it also provided his home oxygen. So we submitted a fourth order, this time for both a portable concentrator and home oxygen, even though Mr. E already had the latter from a different company. Three phone calls later, we were promised everything would be delivered within 24 hours.

It took five days.

This is unacceptable. It’s not OK for Mr. E and it’s not OK for the other Americans who need oxygen therapy.

We all need oxygen: whether we are fit, healthy, and trying to summit Everest or disadvantaged, ill, and trying to earn a living at sea level. It’s time to reconsider the wisdom of lumping lifesaving oxygen therapy with mobility devices and commodes. New payment models are needed to provide incentives for companies to institute high-quality service. Until reimbursement improves, it will be hard to expect much of oxygen suppliers. Current reimbursement makes good service a losing proposition.

Brian Block, M.D., and Neeta Thakur, M.D., are pulmonary and critical care physicians at Zuckerberg San Francisco General Hospital. Thakur is also a faculty member with the Center for Vulnerable Populations, which is based at the hospital, and a participant in the OpEd Project.

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  • Thank you for this wonderfully written article. I am sharing it with my Breathe Support Network of support groups. As a former caregiver of my mother who had IPF and now pulmonary fibrosis advocate, I see daily how important supplemental oxygen is for patients living with this fatal lung disease. I meet patients daily it seem that are not getting the supplemental oxygen they need. It is imperative that we keep fighting for this “medication”. Oxygen is just that… a medication. We need to get Congress to sit up and take notice that this needs to be reclassified. Patients can not go without this. They can’t “breathe less” (as some have been told by their DME provider). They can’t choose when and when not to use this vital lifeline. EVERY “body” needs oxygen and it needs a certain amount. We can’t just shut off that need.

  • Portable oxygen concentrators cost $1,850 upfront. Delivery to the home, education, supplies: cannulas, tubing etc. 24 hr service/on call, additional CMN’s for certification & again 1 year later for recertification. Accreditation, multiple audits & claw backs from Medicare taking back payments for i’s not being dotted.

    How does a company pay for employees, a building, etc. when the equipment doesn’t even pay for itself until 18 full months of renting/collecting 100% of fee schedule?

    E1390 rents for $73.90/month
    E1392 rents for $37.01/month
    Total: $110.91/month

    Physicians & Pharmacists: I challenge you to invest $1,850 upfront for every patient you bring on your service. How long will you be in business? This does not including your building, delivery vehicles, fuel, insurance, employees, billing, etc.

    Oxygen rents for 36 months then payments end. As a supplier you’re required to continue servicing the patient for free (24hr service/on call) & provide free supplies for another 24 months. 60 months of service for 36 months of payments.

    3993 total allowable, 80% paid by insurance, 20% collected from the patient. For 5 years of service & supplies with equipment that costs $1850 (Portable O2 Concentrator)

    I don’t know how any company can offer Oxygen services & stay in business?

    EXAMPLE:
    10 new patients/month on service would cost 18,500 in equipment upfront for 1,109 in reimbursement month 1. How do you pay for a building, technician, biller, billing system, insurance, fuel, phones (24hr coverage)? After 1 full year at 100% collection rates you would have only collected 13,308.

    Suppliers take the blame. Patients needing oxygen suffer even more.

  • This is only going to get worse. No one wants to provide oxygen because they lose money. The one thing that will help COPD and Pulmonary Fibrosis patients is exercise, which requires higher flows. Without enough oxygen, they continue to exercise and go about their daily activities, and compromise their cardiac system with too-low saturations. The general public also seriously needs to be educated about the things they CAN do, and how concentrators work and why they can’t just buy a tiny concentrator that will run at 10 L/min!! (Yes, I get this question all the time).

  • The Era of Cost Cutting has dominated health policy since the 1980s. This began as the Reagan reaction to runaway health care costs. Note that cost controls have been a failure – and the program changes have added their own administrative and management costs which continue out of control. These costs force practices and hospitals to cut the personnel that delivery the care because this is and should be the biggest budget item in a health care entity. In other words health care, which is about people serving people, have fewer and more abused people that attempt to meet all the requirements of caring and all the other requirements piled on. Not surprisingly those smaller have fared poorly and are closing or compromised by design.

    The managed care movement took over leadership of the Era of Cost Cutting in the 1990s and that is why we have the Three Ms – metrics, measurements, and micromanagements of cost and outcomes. To Err is Human led the way with micromanagement of quality – doubling down with micromanagement of costs.

    Read Kip Sullivan and others at the Health Care Blog to see how the managed care groupthink took over and shaped ACA and continues to shape the designs thrust upon us by CMS.

    Note that the assumption of overutilization as the enemy. The cost cutters see themselves as white knights battling the costly health care monster. It is not hard to see that this works out poorly where most Americans suffer because of insufficient workforce and underutilization. The designers don’t see the consequences. They are focused on the dollars – not the people. In other words, the designs have little clue regarding the damage that they are doing.

    Even worse, health access mission foundations and associations such as Commonwealth and AAFP now promote micromanagement, costly primary care medical home, and discriminatory payment designs involving pay for performance and value based. These designs penalize the providers who care for populations with the least resources and inherently the least outcomes. But the designers have managed to add outright discrimination to neglect. The Three Cs of consultants, corporations, and CEOs benefit and the rest of us do not.

    The Era of Cost Cutting is so dominant that every new innovation must pass the test of cost cutting. Go to the CMS Innovation Center and do your own review. This means that innovation is about cost cutting and has little to do with improving care. If you understand innovation you can understand that you should give an innovative intervention every chance to demonstrate benefit. Then you can discard it if it did not work. You can understand that cost cutting and innovation do not support one another.

    Investment and innovation go together. In the area of health access improvement (Michigan BCBS working with primary care, homebound elderly and telehealth, hospice patients) you can see improvements in cost, quality, and access. These are about putting people together with people who care and care for them. Investments are required for innovation with each patient – the heart of primary care. Instead, the dollars are being stolen from primary care practices and they have less and less ability to innovate – while innovative health policy designers celebrate their victories.

    Improvements in health access have resulted in improvements in costs and outcomes. But cost cutting specific to health access compromise can only harm.

    Costs continue to increase – demonstrating little impact of micromanagement of cost other than to feed the Three Cs – corporations, consultants, and CEOs. The Three Cs and their Three Ms (think managed care metrics measurements micromanagements) dominate health care and fuel cost cutting focus to greater and greater degrees.

    It is important to understand how cost cutting results in the big squeeze placed on those who deliver the care. Registered nurses have been squeezed the longest and the most by cost cutting designs. These designs were aimed at hospitals. In reactions the hospitals focused on their new bottom line designs. To increase revenue they needed to admit more per year so they needed to discharge patients faster. To make more they needed to decrease the numbers of personnel. Nurses became fewer and were forced to do more work faster.

    DRGs were put in place in 1983 with bundling and prospective payment – and over 700 small hospitals paid the least under cost cutting designs – have closed with about 1 per month continuing. The designs pay them the least, the designs penalize them the most, the designers have no clue about delivering care in these hospitals. Indeed, the DRG program had 1 year of testing in New Jersey with little short or long term feedback as to the consequences to patients, to delivery team members, or to large regions of the United States not like New Jersey.

    Patches have kept many open – but the patches must be passed and can result in being held hostage by legislators. So instead of focusing on a sufficient financial design – the advocates focus on patchwork. This works out great for legislators, but poorly for most Americans.

    The DRG design has also been connected to morbidity and mortality. Nurse staffing ratios set lower also have poor outcome associations. The focus on profit squeezes the workforce even more. But CMS wants more bundling of services – which is really about more cost cutting.

    Cost cutting is killing off Basic Health Access. Most agree that primary care needs an increase in payments – but when this must come out of their pocket – they oppose it. The budget designs of Congress and entities such as CMS make it difficult to invest in an area such as primary care because cuts must come from others. The others are far more powerful and more organized. Basic, cognitive, office services suffer – especially where most Americans already have half enough generalists and general specialists.

    So primary care withers away steadily from revenue too low to keep up with usual practice cost of delivery increases. And the hammer of innovation regulation makes it worse with HITECH, MACRA, Primary Care Medical Home, and Value Based. Each of these has added tens of thousands in costs per physician. Each of these impact the time for patient interactions, for team member interactions, and for team member family interactions.

    Cost cutting plus massive regulatory cost increases are killing primary care. The impact is worst where most Americans most need care and is least where Big Health care dominates – where patients have higher income and better health plans and can modify the cost increases.

    New physicians such as myself entering practice in 1983 faced the full gauntlet – paid least for office primary care services, paid least in Oklahoma, paid least for Area 99 rural, and a 15% cut because I was a new physician. This was a borrow from the flight controller strike and resulting two tier design. We did manage to fight this off in court – but there was no restoration of the funds cut. The cost cutters never restore – they only take away.

    Frankly there has been little change in primary care financing for decades. About 2621 counties are lowest in MD DO NP PA generalists and general specialists because CMS dominates the design and plans dominated by CMS pay too little or don’t work at all for primary care (high deductible, plans that don’t pay). CMS is the main reason for shortages. CMS controls 120 million lives and over 1 trillion dollars a year. Their expansion health plans are totally inadequate to support the practices and hospitals where most Americans most need care. There is nothing that other branches of HHS such as HRSA can do that will overcome the CMS design. HRSA has millions in each of various grants to promote training or support local health care centers – but these are small change compared to what CMS does with its design. Sadly, many are distracted by this patchwork at HRSA and focus on keeping the funds for training or for centers – while CMS continues to pound away at primary care and Basic Health Access by its dominating designs.

    The original Medicare and Medicaid designs increased dollars to health care dramatically. This was good – and bad. It was good for these 2621 counties that had very little. It has been bad because those most organized and making the most – made substantially more. Each design change they help to structure or modify to work best for them. The original design has steadily been modified in their favor. They get the most lines of revenue and the top reimbursement in each line.
    Cost cutting has been the reaction. This has been Bad and Ugly.
    The Good
    The billions more injected into 2621 counties still shortest in health professionals were invested in workforce. It turns out that investments in care of the elderly and the poor works out to help serve others in these counties – the ones with half enough basic workforce.
    It was also the ideal time for the restoration of family medicine. The American people demanded a return to a personal physician. The new specialty of family medicine restored in 1970 blasted to 3000 annual graduates in a decade. This was only possible because the financial design injected more billions in the places where family physicians practice. Not surprisingly the declining financial design, especially where workforce is lowest, has resulted in declines in family practice result for MD DO NP and PA. Each year the proportions found in family practice continue to plummet as do primary care levels where needed.

    The damage to workforce has not been all. There is great damage to the practice of medicine within practices. Policy designers at the insurance company and state levels have tried to trim costs via spreadsheet approaches. They take what is spent in each area and try to figure out how to spend less – on goods, equipment, drugs, services, hospitalizations, and more.

    Preapprovals and special billing regulations force offices to hire more billing personnel. This limits the support for the delivery team members.

    Spreadsheet designed cost cutting involving drugs and drug access has wounded and killed more than can be counted. Some drugs can be cut from some patients – but in other patients the barriers in the way of these drugs can kill. Spreadsheet designers do not know people, drugs, or diseases.

    Sometimes these cuts ended up shifting patients to other options that cost even more as when cost cutters cut Medicaid from 7 to 3 prescriptions a month and mentally ill patients cost many times more than estimated savings – not counting costs outside of health care (law, legal, damages). It takes more than just a spreadsheet to design health policy.

    Once again note that many of the changes force medical personnel to do more – acting to disable physician offices and distract them from patient focus.

    There are protections vs doctors or researchers that experiment who can damage hundreds or perhaps thousands. There are no such protections against unethical experimentation in health policy. To really eliminate or exterminate, it takes policy. The Era of Cost Cutting has damaged tens of millions in health, economics, and other outcomes. And few even question the consequences. When doctors protest, we are branded as luddites or poor quality when our focus is on what is happening to patients, our practices, and the practice of medicine. We hurt when we see the system abusing our patients and when they cannot get what they need.

    Decades of work were involved in human subject research to protect vulnerable populations, to establish informed consent, to assure beneficent intent, and more. Health policy cost cutters have no such limitations. The science is poor and the experimentation is rampant. These have been worse due to the politization of health policy. Researchers are seeking to prove the value of policies – which is not the same as a scientific approach.
    Even worse, policies are implemented on assumptions and with limited or no demonstrations or trials. Fire, ready, aim is not good for people or practice.

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