1. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 OXYGEN THERAPY WORKSHOP SUSAN S. JACOBS RN, MS TAKING CARE OF YOURSELF: SHARED HEALTHCARE DECISION-MAKING NOVEMBER 12, 2015

2. Overview The Basics Assessment of the need for oxygen Portable oxygen systems now Reimbursement issues impacting the future Future Trends

3. 3 Anatomy of the Lungs

4. Getting the Oxygen into the Blood Oxygen is inhaled and then crosses the walls of the alveoli into passing blood vessels

5. Getting the Oxygen into the Blood 5 Inside the blood vessel, oxygen attaches to hemoglobin and is delivered to the body At the same time, carbon dioxide is released from the blood into the airsac and is exhaled

6. Causes of Hypoxemia in PF Destruction or scarring of alveolar-capillary membrane impairs the transfer of oxygen from the airsac into the bloodstream There is ‘mis-matching’ of areas of good ventilation with areas of good blood flow Patients may consume more oxygen than normal during regular breathing due to the stiffness of the lungs 1/3 of patients with normal exercise saturations may desaturate during sleep

7. Benefits of Oxygen 1965 marked the first scientific studies of LTOT – long term oxygen therapy- which was first given to patients with COPD/ emphysema Two studies in COPD patients confirmed improved survival on oxygen: Nocturnal Oxygen Therapy Trial Group (NOTT). Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial demonstrated improved survival for those hypoxemic COPD pts. who used oxygen 24 hrs vs only overnight. (Ann Intern Med. 1980;93:391-8). Medical Research Council Working Party. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. (Lancet. 1981;1:681-6).

8. Benefits of Oxygen If your oxygen levels are low (<88%), oxygen therapy may: Decrease shortness of breath (SOB) Decrease stress on the heart (lower heartrate, prevent pulmonary hypertension due to constriction of pulmonary blood vessels) Increase activity level Improve sleep quality Improve quality of life

9. What Happens If I Need Oxygen, But Don’t Use It? Increased heart rate Increased breathing rate Increased pressure in lung blood vessels (pulmonary hypertension) Increased work for the right side of the heart which pumps blood through lungs

10. Overview The Basics Assessment of the need for oxygen Available oxygen systems Reimbursement issues impacting the future Future Trends

11. If I am Short of Breath, Does it Mean I Need Oxygen? Not necessarily. Shortness of breath, especially with activity, is common in PF. Causes of SOB include: Greater ‘work’ to breathe due to the lung stiffness and smaller lung volumes (severity of PFTs) Muscle deconditioning Low oxygen levels

12. Testing for Hypoxemia SITUATIONTEST on ‘Room Air’ At restPulse oximetry at rest With activity Exercise oximetry, a 6 minute walk, or stairs if more exertion needed During sleepOvernight oximetry At altitude High Altitude Simulation Test (HAST)

13. Oxygen Levels and Altitude Sea Level8000 feet 760 mmHg560 mmHg Pa02 98 mmHgPa02 60-70 mmHg

14. What About Flying? Cabins are pressurized to 8000 ft which simulates altitude or breathing 15% oxygen Currently FAA allows portable oxygen concentrators (POCs) Need to arrange oxygen during flight IN ADVANCE Ask airlines medical section to fax your MD forms to complete 4 weeks before flight

15. “Fit to Fly” High Altitude Simulation Test (HAST) Interpretation (Breathing 15-17% oxygen for about 15-30 minutes; protocols vary) ResultRecommendation (Varies by Center and pt. risk factors) Pa02 > 55-65 mmHgOxygen not required Pa02 55-60 mmHgBorderline Pa02 < 55 mmHg or Sa02 < 85% In flight oxygen

16. How Do I Know If I Need Oxygen at Altitude? (Other Guidelines) Sea Level SaturationOxygen needed Over 95%None 92-95% and no risk factorsNone 92-95% with risk factorsDo hypoxic challenge (altitude simulation test) Less than 92%In flight oxygen Using oxygen at sea levelIncrease/double flow per MD recs

17. How Is Oxygen Prescribed: Insurance Requirements Medicare and Insurance Guidelines require (lots of) MD documentation “Certificate of Medical Necessity”: Oxygen saturation at rest and exercise on ‘room air’ Oxygen saturation at rest and exercise on oxygen Documentation in MD notes that oxygen is medically necessary AND portable oxygen is needed AND how long oxygen is needed AND at what flow rate AND what type of oxygen! Specific order needed for ‘pulse’ oxygen conserving device (OCD; on the regulator) Liter flow prescription needed for rest, exercise, sleep

18. How Is Oxygen Prescribed: Insurance Requirements TIP: Ask the company first if they have the type of system you want BEFORE you have them set up your oxygen. You can talk about this with your health care team. It is challenging to change after starting a 5 year contract with the company. Different companies may offer different portable options. If your liter flow needs change, a new CMN is needed

19. Overview The Basics Assessment of the need for oxygen Available oxygen systems Reimbursement issues impacting the future Future Trends

20. What Kind Of Oxygen Systems are Available? Concentrator: removes oxygen from air Stationary (not portable) plug into wall Portable Oxygen Concentrators (POCs) Compressed Gas: Green E tanks, or smaller ones (M6 or B, M4) Homefill or Transfill systems (compressed gas that you can refill yourself at home) D Tanks Liquid: (refillable at home – Liberator, Marathon, Helios) High Flow Systems: usually only in hospital; <15 L home Portable Ventilators:  work in progress

21. Compressed Gas: E Tank: compressed gas, semi-portable, lasts 3 hrs. on 3L/min continuous or 1.5 hrs on 5 L/min M6 (B) Tank: compressed gas, portable, lasts with OCD or OCR Transfill system with concentrator

22. Liquid Portable Refill from reservoir Portable delivers up to 6L/min. cont flow Evaporates if not used Homefill system Higher Costs of Liquid: -More frequent delivery -Longer time to service -More customer issues Liquid Oxygen

23. Portable Oxygen Concentrators One size does not fit all! (Range 3-20 lbs) Runs off battery; concentrates ambient air to 90-96% oxygen Can run off DC power–although more difficult at higher flow FAA approved; need 1 ½ battery life for length of flight No availability of continuous flow above 3; pulse up to 6 L/m Higher liter flow = shorter battery life

24. Portable Oxygen Concentrators Continuous Flow Delivers oxygen throughout the breathing cycle In general if you require 4-6 L/m, a pulse system might be adequate at 5-6 L/min pulse (need testing) Pulse Flow Minute volume delivery = volume of oxygen in each ‘pulse’ goes down as your respiratory rate goes up Fixed pulse delivery= same pulse volume delivered no matter what your rate of breathing

25. Portable Oxygen Concentrators Battery Life Continuous flow uses battery more quickly Higher pulse flow uses battery more quickly Higher breathing rate uses battery more quickly Time to charge battery varies between POCs Example: 3 L/m pulse lasts 2.5 hrs breathing at 15 BPM, or 1.5 hours breathing at 30 BPM Weight: make sure to include cart, AC/DC power supplies, extra battery Warranty if purchased: unit and battery coverage separate, shipping? Replacement?

26. High Flow Options Oxymizer Pendant Hi flow cannulas High flow concentrators ‘Y’ing together concentrators or tanks for 10-12 L/min. or higher

27. Problems for Oxygen Users Dry/bloody nose Use humidifier on concentrator if using over 4L/min Use nasal lubricants designed for oxygen users Skin irritation Soft tubing “Softech” Foam/fleece padding Non latex cannulas Everest silicone cannulas (Tonopah Medical) http://www.tonopahmed.com/products/everest.htm

28. Aesthetics Oxy-View glasses (oxyview.com)

29. Overview The Basics Assessment of the need for oxygen Available oxygen systems Reimbursement issues impacting the future Future Trends

30. Medicare Reimbursement Issues Impacting Future Portability US Medicare Competitive Bidding Program January 2011 Lowered Medicare reimbursement to oxygen providers by about 30%-40% Goal was to decrease fraud, cut costs, Must use ‘contract suppliers’ for Medicare Cost issues eliminated liquid oxygen for most providers Some patients were ‘grandfathered in’ and were able to maintain liquid oxygen if ordered by MD

31. Private Insurers’ Impact on Future Portability is Similar Certification requirements not as strict as Medicare Usually cover 60-80% of costs but their reimbursement is decreasing as well Co pay depends upon deductible status, availability of a secondary insurance If deductible not yet met = about $130-$180/mo for concentrator plus e tank or other portable compressed gas Still a cost issue for optimal portability

32. Future Issues for Reimbursement Costs driven by: Number of times technician needed for delivery Number of calls for customer issues Time for each service Pressure in compressed gas tanks (higher pressure = last longer but more expensive) 1500 psi vs 3000 psi

33. What you can do if you have questions about your service Contact your physician to clarify that the orders are correct and current for your oxygen needs Refuse any change in equipment that your supplier is requesting; put this in writing Contact Medicare as needed; they can refer you to a Competitive Acquisition Ombudsman (CAO)

34. Overview The Basics Assessment of the need for oxygen Available oxygen systems Reimbursement issues impacting the future Future Trends

35. Noninvasive Open ventilator (NIOV) system- combines oxygenation AND ventilation to decrease the muscle work of breathing- no longer available but hopefully technology will improve. 1 lb. weight (not including portable oxygen system)

36. Future Trends for Portability Prior to 2000, there were only 3 POCs available Now over 20 models from over 8 companies In 2012, POCs had a $242.5 million market which is predicted to rise to $1.9 billion by 2019 The competition for lighter technology, longer battery life, quieter motors, better aesthetics and mobility should drive innovation and lower prices http://www.oxygenconcentratorstore.com/blog/the-future-of-portable-oxygen-concentrators

37. The Future Priority = Lobbying for Oxygen Medicare Ombudsman for complaints and advice of your rights 1 800 633 4227 COPD info line 1 866 316 2673 Write congressman re: impact of oxygen reimbursement issues to you personally Contact MDs that are on Medicare Boards

38. Resources National Home Oxygen Patients Association www.homeoxygen.org Sea Puffers Cruises www.seapuffers.com Worldwide Oxygen Services 1 800 828 3627 www.nonin.com Nonin oximeter 1 800 882 8889 www.pulseox.info http://www.oxygenplusconcentrators.com/concentrators.html www.pulmonarypaper.org 800 950 3698 www.oxyview.com 877 699 8439 www.COPDfoundation.org Supplemental Oxygen Supplemental Oxygen Guide www.thelamfoundation.org Oxygen: Know Your Patient Rights www.COPDfoundation.org

39. Thank you! Questions?