Efforts to Gain Pulmonary Rehabilitation Coverage Equity

JULY 2020

Efforts to Gain Pulmonary Rehabilitation Coverage Equity

“It takes more involvement of clinicians—people who are saying, ‘I can’t get what my patients need,’” asserts long-time advocate for pulmonary rehabilitation coverage, James Lamberti, MD, FCCP, who is heading the HPAC group responsible for advocacy efforts to change pulmonary rehabilitation health policy. Dr. Lamberti’s extensive career as a pulmonologist includes 21 years as Medical Director, Respiratory Care at Inova Fairfax Hospital in Falls Church, Virginia; President of NAMDRC; Medical Director of the Respiratory Care Program at Northern Virginia Community College; and Professor of Medicine at Virginia Commonwealth University School of Medicine, Inova Campus. Dr. Lamberti has seen the benefits patients gain from pulmonary rehabilitation programs—and the frustrations of the inadequacy of the current coverage. The combined voices of pulmonologists at hospitals across the country are needed to generate change in CMS reimbursement that will truly improve patients’ pulmonary health nationwide.

At a CHEST 2019 presentation, Dr. Lamberti identified three main failings of pulmonary rehabilitation health policy, highlighted from a 2016 study by Nishi and colleagues in the Journal of Cardiopulmonary Rehabilitation and Prevention: (1) lack of access; (2) inadequate reimbursement; and (3) inability to grow. Despite data from around the world confirming the benefits of pulmonary rehabilitation, only 3.7% of Medicare-eligible COPD patients receive it and only 43.5% of hospitals in the United States offer outpatient pulmonary rehabilitation.

Historically, CMS reimbursement has not been in line with hospital costs, nor have clinicians been proactive about providing justification to support efforts on behalf of hospital-based pulmonary rehabilitation programs. CMS created procedure codes in 2010 under the Outpatient Prospective Payment System (OPPS) and created an Ambulatory Payment Classification (APC) group that was based on insufficient data, which resulted in an inadequate initial median payment rate. Pulmonary rehabilitation is in need of attention as evidenced by the reimbursement rate in 2019 of $55.90 per session compared with $118.79 for cardiac rehabilitation.

The following was advised in a December 2018 policy briefing and recommendations statement addressing the burden of COPD in rural America to the National Advisory Committee on Rural Health and Human Services: “The Committee recommends that prior to the next revaluation of outpatient prospective payment rates, the Department of Health and Human Services consult with experts in pulmonary treatment to refine the definition of rehabilitation services and, in Medicare cost reports, confirm that there is adequate accurate data on this service to be used as a basis for the rate.” CHEST members who can share these data and point out the benefits of pulmonary rehabilitation programs are essential to moving this effort along.

While pulmonary rehabilitation is of great value to many recovering patients during the current COVID-19 pandemic, conducting programs and gathering data are challenging due to lack of quality reporting infrastructure as well as social distancing requirements. Telehealth coverage for pulmonary rehabilitation, another one of CHEST’s initiatives, can serve patients well under these circumstances.

Fixing the pulmonary rehabilitation inequities requires participation by clinicians who can and will champion access in their own institutions and submit charge data to CMS. Joining forces with likeminded physicians, through efforts CHEST will create to generate legislative and regulatory action, will result in better clinical situations for practitioners and ultimately for our patients.

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