It Is Time: Bachelor’s Degree Licensure Requirement for Respiratory Therapists

As The Centers for Medicare and Medicaid Services (CMS) expand their control and funnel their resources into new and expanding environments, respiratory care has the potential to be left behind.

This is a difficult pill to swallow for many respiratory therapists (RT), but the fact remains that CMS is driving innovation by way of keeping patients well and out of the hospital, while driving ill patients who are stable into skilled nursing facilities (SNFs). This is causing SNFs to care for much more acutely ill patients than ever before, leaving acute care hospitals mainly responsible for stabilization.

Unfortunately, CMS does not recognize Respiratory Care as a profession because RTs are not required to have a bachelor’s degree at a minimum to be licensed. And as a result, CMS does not require respiratory therapy to be provided solely by an RT.

Case-in-point: When the RUGS payment model was implemented within the skilled environment over 20 years ago, SNFs that previously paid for RTs to provide care for their residents stopped so they could remain competitive. Since all RT procedures were reimbursed the same whether provided by a nurse or an RT, administrators saw no financial advantage of having RTs on the bank role and chose to no longer employ them. This opened to the door for other professions to expand into an area where they should have clinically dominated.

If RT was a bachelor’s minimum profession, it would have more pull in its lobbying efforts to strengthen the roles of individual RTs with CMS-funded services. But this doesn’t even take into account the profession’s relative lack of engagement with the American Association of Respiratory Care (AARC) whose primary role is to lobby on its behalf.

It’s time RTs help secure the future of their profession by supporting the AARC and the bachelor’s minimum requirement to practice respiratory care.

The Value of Respiratory Therapists as Disease Managers


Stethoscope
Stethoscope (Photo credit: Wikipedia)

Below is additional proof that the future of respiratory therapy is in disease management:

A Respiratory Therapist Disease Management Program for Subjects Hospitalized With COPD

Patty C Silver, Marin H Kollef, Darnetta Clinkscale, Peggy Watts, Robin Kidder, Brittany Eads, DebbieBennett, Carolyn Lora, Michael Quartaro

SKILLED NURSING-BASED RESPIRATORY THERAPY SERVICES

Strategically Positioning Skilled Nursing Facilities for Success Under the Affordable Care Act

Beginning October 1, 2014, the Centers for Medicare and Medicaid Services (CMS) began to penalize acute care hospitals for readmitting patients diagnosed with Chronic Obstructive Pulmonary Disease (COPD) within 30 days of discharge. This was the result of the national Hospital Readmissions Reduction Program, established by the Affordable Care Act of 2010, which reduces payments to hospitals for excessive readmissions. The progressive percent reduction penalties for fiscal year (FY) 2013-2015 are provided below:

  • FY 2013 – 1% for all CMS reimbursements to a particular hospital with excess readmits
  • FY 2014 – 2% “
  • FY 2015 – 3% “

Any readmission is penalized if it occurs within 30 days, regardless of whether the patient was readmitted with a different diagnosis than the original, or if the patient readmits to a different hospital; however, the hospital reporting the initial diagnosis is still the one liable for the reimbursement penalty.

CMS penalty fees for FY 2013-2014 applied to the diagnoses of acute myocardial infarction, heart failure, and pneumonia. In 2013 alone, penalties totaled $2.2 million. In FY 2015, CMS added three more conditions to the readmission penalty list: arthroplasties of the total hip and total knee and COPD. These diagnoses will only compound the reductions in reimbursement hospitals will receive if they do not manage these conditions well moving forward.

COPD is one of the most difficult diseases to manage within this list of diagnoses. In 2012 over 1 million patients were admitted to acute care hospitals for an exacerbation of COPD;  in general, readmissions occur within 20% to 23% of cases. The direct costs of COPD in the US has been estimated at $32 billion in 2011; worldwide COPD is estimated to become the third leading cause of death by 2020.

Since COPD is a leading admitting diagnosis to acute care facilities, this new penalty has the potential to severely impact the financial health of already-struggling hospitals. It would be fair to conclude that hospitals will eventually only discharge their COPD and pneumonia patients to those post-acute care facilities that have excellent track records of respiratory disease management. Thus, long-term care and skilled nursing facilities should implement respiratory therapist-driven care paths to successfully manage patients suffering from COPD and pneumonia.

There are several clear advantages to using care paths according to the American College of Chest Physicians:

  1. Therapy can be adjusted more frequently in response to changes in the patient’s condition;
  2. Physicians are consulted for major clinical changes but not minor ones so nuisance calls can be avoided;
  3. Consistency of treatment is maintained and non-pulmonary physicians have the ability to use up-to-date methods of therapy by simply requesting that a protocol be instituted; and
  4. Respiratory therapists (RTs) are actively involved in achieving the goal of good patient outcomes instead of performing rigid tasks.

Respiratory-driven care paths are designed to maintain consistency with the medical staff’s respiratory care plans; ensure that therapy is timely, appropriate, and driven by the patient’s most recent condition; ensure cost-effective strategies  are implemented when appropriate; and most importantly, ensure that providers are notified of any clinical conditions that are outside the scope of the protocol.

Respiratory therapy care paths should be the responsibility of licensed clinicians who have achieved strict levels of advanced education, training, and experience in respiratory assessment and treatment modalities. RTs are licensed clinical professionals who possess these skills in abundance. RTs are obligated to complete either a two-year associate’s degree or a four-year baccalaureate degree in respiratory therapy assessment and technology. Upon graduation, RTs are qualified to undergo three national examinations, which upon passing leads to the Registered Respiratory Therapist (RRT) credential. The RRT credential demonstrates that the holding RT has the relevant critical thinking skills necessary to assess and make the correct decisions when treating patients with respiratory-related conditions.

By having RTs coordinate these care paths, long-term care and skilled nursing facilities will be best situated in maintaining lower readmission hospital rates versus national averages. The U.S average for 30 day re-hospitalization rates are 17.3% for pneumonia and 20.7% for COPD (medicare.gov/hospitalcompare/data/30daymeasure.html). Kingston Healthcare Company based in Toledo, Ohio has three skilled and long-term nursing facilities in Ohio and Indiana that employee RTs. In one such facility where they have RTs in-house 7 days/week, 12-16 hours/day, Kingston reported the following combined RTH rates for COPD & pneumonia in FY 2016:

  • 1st Quarter: 13.3%
  • 2nd Quarter:3.7%
  • 3rd Quarter: 7.69%
  • 4th Quarter: 12.5%

The approximate costs associated with employing RCPs in the skilled environment in the Midwest are as follows:

  • Human resource costs: $124,300 annually for 2 full-time respiratory therapists and $279,054 for 4.49 full-time therapists
  • Supply costs: $42,000 annually per facility
  • Capitol one-time, start-up cost: $26,000

Regardless of initial, start-up expenses, the benefits outweigh the associated costs over the long-run. It is in the best interest of patients who suffer from acute and chronic lung disease that they first seek facilities that employee RTs to assess and treat respiratory-related conditions, and that CMS adopt a reimbursement model that will allow skilled nursing facilities to incorporate RTs and complex respiratory assessment and therapy into their resident care models.

Preparing for the Future: Four Vital Strengths Respiratory Therapists Should Develop

The Future of Healthcare

It’s coming whether you like it or not, and it will be here sooner than you think. The “baby boomer” generation, born between 1946 and 1964, will arrive at the age of 65 between 2011 and 2029. The Center of Health Workforce Studies states: “Between 2000 and 2020, the U.S. population will add 19 million older adults. Overall, the numbers of older adults in this country will grow 138% in the next fifty years. By the year 2050, one of every five Americans will be age 65 or older.”1 This trend will have direct implications on the field of Respiratory Care due to the fact that respiratory therapists (RT) routinely see patients with chronic diseases that are disproportionately concentrated within the geriatric population. Combine these increased admission rates with growing RT vacancy rates and we have a serious crisis to solve.

1. The Strength of Adaptability

Due to factors such as declining reimbursement rates, rising costs of technology and increased competition between healthcare facilities driving up the cost of wages, healthcare as we now know it will have to change if it is to remain financially solvent. These changes will take their shape in the form of improved efficiencies in the way clinicians perform their duties and utilize technology. For example, we are currently witnessing the increased utilization of nurse practitioners to meet patient demands as physicians become more difficult to recruit. We are also seeing the skills of paramedics being utilized within emergency departments (ED) throughout the country as vacancy rates for registered nurses (RN) skyrocket.

Changes such as these will continue to occur as hospital administrators seek to invest in clinicians who can offer them the most “bang for their buck.” Respiratory therapists, therefore, will need to acquire and maintain strong, critical thinking skills in a variety of areas to remain in high demand and avoid having some of their key skills usurped by other professions. To adapt to these changes, RTs will need to be more diligent in asserting their skills and abilities that they are actually licensed to perform.

2. The Strength of Efficiency

The implementation of therapist-driven protocols will be vital in assuring that the best possible care is provided to cardiopulmonary patients in the coming years. Protocols will help establish credible paths in which non-pulmonary physicians and prescribing practitioners can confidently provide the best possible care for their pulmonary patients. The implementation of protocols, however, must be carried out with utmost attention. Respiratory managers should assure that physicians, RTs, and RNs are all appropriately solicited for what will work best at their particular hospital. It is also important that protocols are designed so as not to be reduced to mindless checkmarks, nor made so complex that they cannot be performed in a reasonable amount of time.

The efficient use of protocols in addition to the intelligent use of technology will also help stem the tide of overly difficult therapist workloads. According to my experience, there are nebulizers currently on the market that provide superior respirable doses2 and noticeably improved clinical outcomes3 to patients in only 3 to 5 minutes (e.g., VixOne; Westmed, Inc; Tuscon, Ariz.; and the Aeroeclipse; Monaghan Medical Corp; Plattsburgh, NY). Although they are more expensive, the time savings should allow RTs to focus more attention on the patients who truly need their services and thereby help decrease the overall average length of stay of pulmonary patients.

Since studies have proven that metered dose inhalers (MDI) are just as effective as hand-held nebulizers for the majority of patients who require aerosol therapy, it is also imperative to incorporate the transition from hand-held nebulizers to MDIs into the protocol mix.

3. The Strength of Marketability

As the years progress and technology expands, it will be very difficult for RTs to keep up to date with ever-expanding research and development within the sphere of respiratory therapy. It will, therefore, be important for the profession to implement processes for RTs to advance their knowledge and skills. Career ladders are strong tools that will provide a way for RTs to grow professionally and be rewarded for their efforts, while also providing an objective way for managers to attract and sustain high performers.

To be successful, however, career ladders must provide ways for RTs to advance professionally, and not just offer financial rewards to those who perform additional duties. Many competent RTs leave the profession because the field has not developed ways in which the most ambitious can advance in their careers. Thus, the profession will thrive best in an environment that has the ability to sustain its most tenured and talented experts as inexperienced new graduates enter the field.

The National Board for Respiratory Care has the ability to help rectify this problem by creating additional credentials that would assist RRTs in acquiring and maintaining the skills necessary to specialize in areas that will only continue to grow. Hypothetical credentials such as the RRT-CVS (Cardiovascular Specialist) could potentially lend credibility to allowing RRTs to administer cardiovascular agents during cardiac stress testing and assist in cardiac catheterizations, which are normally roles reserved strictly for RNs. Multitasking practices such as allowing RNs to refocus their expertise in procedures that only they are licensed to perform will result in improved efficiency without sacrificing quality.

4. The Strength of Education

As nurse practitioners and physician assistants are given more responsibility to assess and treat patients, it is imperative that RTs possess the appropriate levels of education necessary to develop and recommend the best care plans possible for their patients. The Committee on Accreditation for Respiratory Care can assist the profession in this arena by requiring accredited respiratory therapy educational programs to raise the RRT educational requirements to the baccalaureate level. Although this will add to the overall cost of healthcare on one end, on the other, it will save hospitals money long-term by allowing them to employ clinicians that can safely and efficiently multitask.

Although improving the educational requirements within the field of respiratory care is important, maintaining the associate-degree level certified respiratory therapist (CRT) credential will be vital to assuring there are appropriate numbers of therapists to provide fundamental respiratory care for all. There are many people who are considering a second career in healthcare. Understandably, many of these folks do not have the time and money to devote to four or more years of college. However, they do possess the skills necessary to effectively meet the mission of the respiratory care profession. CRTs who do not wish to advance to higher credentials should, therefore, be permitted to continue in assuring that vital technical duties are completed at their highest level.

Transitions described here will not occur until professional growth is actually possible. Moreover, this professional growth must offer the actual possibility to acquire higher levels of responsibility unavailable to those who do not possess the same level of training and education. As it currently stands, there is no difference in the educational requirements of a CRT and an RRT. Although there is a valid argument for adjusting the wage scale of an RRT slightly more than that of a CRT due to the objective demonstration of having the critical thinking skills necessary to pass the registry examinations, it is not fitting in most instances when both credentials routinely perform the same duties and require the same level of education.

These professional changes will only happen once pay scales match job descriptions, and job descriptions are differentiated according to education and credentials. But most of all, only managers possess the tools necessary to help make these changes, and they must take it seriously. Life for the respiratory therapy manager is going to be even more challenging within the coming years than it is already.