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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  • The cost cutting was responsible for me, and hundreds of other licensed Respiratory Therapists , losing our jobs. I was laid off in the middle of the day when I was with a patient, and told to return to the office immediately. There was no concern for the patient. I now have COPD and require home oxygen. I am fortunate in that, as a Registered Therapist for 35 years, I know what I have to do to be a functional . But the average COPD patient desperately needs the monthly home visits by a therapist to help them to be compliant with their oxygen and also nebulized treatments. Therapists also submit reports to the patient’s physician on the patient’s condition and any issues that need to be addressed by the physician. In other words , the patient is the one who is paying for this by inadequate and inferior medical care.
    I have read the previous submissions and agree with what has been stated. No need for me to repeat . Some companies resorted to having the receptionists fit C-PAP masks and also, monitor, advise, and instruct the patients in the use and care of their C-PAP machines.

  • Thank you for highlighting this major problem that plagues many people with various health conditions and is something that deserves prompt attention!

    I am a supplemental oxygen user and run support groups for COPD patients. Many of the patients can only get a noisy, bulky home stationary concentrator and nine tanks. They can also only get new tanks delivered every 90 days! If they want tanks between the 90 day deliveries, they have to drive or be driven to the Durable Medical Equipment (DME) company and try to swap their empty tanks for full ones IF there are any full ones available. This includes patients recently released from the hospital and a patient in s wheelchair.

    If patients need to get out more often than that or need additional oxygen, they are stuck. Because of competitive bidding driving reimbursement rates so low, there are only two DMEs supplying oxygen on our island and only one in many other parts of our state!

    Patients need and deserve the oxygen required to function and live! Please help get the reimbursement of oxygen revised so there are sufficient providers who will supply enough oxygen for patients to remain active and involved in life and work.
    Aloha,
    Valerie Chang
    Hawai’i COPD Coalition

  • I am so grateful that more providers are recognizing thinned to change our antiquated reimbursement system, and our traditional protocol for prescribing supplemental oxygen.
    Technology has outstripped both of the foregoing. Medicare statute requires prescriptions to use liter/minute instead of target oxygen saturation ranges.
    We know in the 21st center that technology permits a wide variety of supplemental oxygen systems both stationary and portable. Usually the least expensive are the least robust. “You get what you pay for”.
    However , there are patients who require higher volumes along with oxygen concentrations to relief their hypoxia. The current reimbursement system incentives providers to provide the least expensive whenever possible. They have a business to run. It is the prescribing physicians’ responsibility to assure their clinical goals are satisfied by the device used, but that takes time, and money given the wide range of devices and the need to titrate oxygen saturation for each patient when at rest and when active(if portable systems are to be used) This is not complicated.
    1, Change the requirement for supplemental oxygen to require a targeted oxygen saturation range to be maintained by patients (regardless of activity level)
    2. Change the Medicare reimbursement to levels that providers can operate their businesses regardless of the device needed for the each patient to maintain the range prescribed.Their are too many oxygen systems, especially portables that provide a wide range of oxygen/ gas output, some are not able to produce outputs in units of liters per minute which is medicare’s current statutory requirement. Prescribers are not usually aware of the differences.
    3, Get Congress to authorize Medicare pay for pulse oximeters, so patients can monitor and adjust dosages( this principle is not unlike the way diabetics monitor and adjust insulin using medicare reimbursed devices to monitor blood sugar). Oximeters cost a fraction of those used for blood sugar.
    3.Revise payment for pulmonary rehabilitation to get more hypoxic patients moving. Approximately 97% of the patients that can benefit from Pulmonary Rehabilitation, have access to a program. That’s a travesty !
    Our nation’s healthcare system is supposed to put patient needs first in cost effective way. We are failing on this issue. Please educate your lawmakers at state and national levels.
    Sam Giordano
    Chairman USCOPD Coalition

  • I’ve been a delivery driver for a DME company for 18 years. That doesn’t make me smarter than anyone else, only more experienced than some. Careful analyzing medications at a pharmacy with oxygen “equipment”. It’s a different animal. Mr. E could use a conserving regulator on a larger tank and make it through a shift depending on his l/m. Bulky, yes, but doable. Which is fifty percent of the job on setup. Qualifying needs weighed against what is available and also therapeutic. While shrinking reimbursements are not a small issue, neither is doctors promising patients equipment that may not be able to use to sustain o2 levels.

  • I would like to thank Drs. Block & Thakur for their article highlighting the problems involved in the current processes of delivering medical oxygen. The advent of Medicare/Insurance paying for oxygen as a supplement to a failing organ (the lungs) and the invention of the oxygen concentrator in the late 1970’s opened the door to improving care for COPD/CHF patients in a major way. This combined with Pulmonary Rehab and improved medications/treatment made the lives of millions of people to be vastly improved. As the doctors are pointing out the “Medical Team” has become rather hampered on at least one level of care – Adequate Oxygen Delivery. Medicare/Insurance have decided that Oxygen is a commodity on level with any number of over-the-counter health items and requires no special medical consideration (other than severely restricting payment/access to only individuals with chronic severe lung disease that is being followed closely by a physician and for which all of this is precisely documented by proper testing and physician notes). Payment levels for oxygen back in the 80’s and 90’s if considered in today’s dollars hovered somewhere around $500 per month (considering that this was the typical charge for one day of oxygen in the hospital – may have been on par) Things have radically changed the $80 or so payment for a months oxygen (combined with a 36 month cap with a 24 month period of required “free” oxygen delivery by the medial supply company) when considered in the 1980’s dollars would be about $19 a month. Obviously the “service” component of oxygen delivery has suffered and will continue to suffer for those that cannot afford to pay directly for that service. More and more patients are opting to directly purchase the smaller, lighter portable oxygen concentrators – BUT – this leaves a large gap for those that 1. Cannot afford this service and 2, Have oxygen demands that exceed the capacity of these devices. On a Final Sour Note – I suspect that things will only get worse until Medicare/Insurance sees that their current policies related to oxygen delivery are in fact “Penny Wise and Dollar Foolish”.

    Kevin Hill
    President
    CPS Medical

  • These payment issues are caused by:

    1. CMS capping oxygen reimbursement at 36 months and
    2. The long standing CMS policy of applying budget neutrality to home oxygen therapy.

    Both are laws and will require legislators to change the law.

    Demand your Congress person take action. Until then, CMS does not give one damn.

    Woody ONeal
    CFO – ONeal Medical
    ADMEA Board Member

  • I have a question about Mr E. Is he obese because of a genetic/physical abnormality , unavoidable drug side-effect, or because Mr E refuses to change his lifestyle?

    If it’s because of the latter, I have no sympathy for him. He should be placed at the bottom of the list for the equipment or be forced to pay out of pocket until he straightens up his lifestyle.

    • The issue is that at this point Mr. E is too sick to exercise his way to health. Maybe he didn’t take as good of care of himself as he probably should have when he was younger, which might have prevented the weight gain. But this is a very slippery slope. Some people (many) in our country can’t afford healthy food and to do routine exercise at a gym. Some have legitimate medical issues (orthopedic is common) preventing routine exercise and good habits. Some have genetic abnormalities that tend to make them “heavier” than would be optimal for long term health. In my clinical experience in patients with OHV, only a minority are that way because they intentionally didn’t exercise and intentionally didn’t even try for healthy habits. This is why we need to treat everyone. We can’t be making judgement calls on who does and does not “deserve” treatment.

  • I have a question about Mr E. Is he obese because of a genetic/physical abnormality , unavoidable drug side-effect, or because Mr E refuses to change his lifestyle?

    If it’s because of the latter, I have no sympathy for him.

  • As a respiratory therapist and the CEO of the association that represents the interests of respiratory therapists (American Association for Respiratrory Care) I can tell you that this is a travesty. CMS directives essentially limit the appropriate oxygen our patients require once discharged from the hospital. Liquid Oxygen provides a capabilty of higher flows which selected patients require. Due to CMS reimbursement it is impossible for companies to provide this without taking a loss. Our patients are suffering and we need to change this asap. Our patients need appropriate oxygen. Oxygen is a drug so it really should be reallocated as such and not considered a durable medical product

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