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Sustainability Strategies for COPD

There are several strategies rural COPD programs are using to sustain programs that may be useful for rural healthcare systems and providers. The Rural Community Health Toolkit provides information about general Sustainability Strategies and Sustainability Strategies for Specific Issues.

Reimbursement for COPD Services

Several rural COPD programs rely on reimbursements from Medicare, Medicaid, and private insurers to finance COPD programs.

The Centers for Medicare and Medicaid Services (CMS) plays a prime role as a major payer of COPD-related services for patients enrolled in Medicare and Medicaid. For example, Medicare Part B covers several COPD-related services such as pulmonary rehabilitation, smoking cessation, and oxygen therapy or oxygen equipment and accessories.

Some states have begun to pass legislation that expands the definition of "healthcare providers." For example, in January 2019, Ohio passed Senate Bill 265 allowing for the designation of pharmacists as healthcare providers. Pharmacist services that may now be covered include drug therapy management and vaccine administration. This designation will allow pharmacists new billing options in order to expand access to care for many patients.

Other Payment and Reimbursement Considerations

One of the most common goals of COPD programs is to reduce hospital readmission rates. In 2015, Medicare added COPD as a condition for the Hospital Readmissions Reduction Program, a value-based purchasing program that measures hospital performance using excess readmissions within a 30-day period. Many programs indicated that being able to demonstrate that their COPD-related efforts had reduced hospital readmissions created buy-in from the administration and senior staff. Additionally, the Merit-based Incentive Payment System (MIPS) also includes COPD-related quality measures.

Of note, the National Advisory Committee on Rural Health and Human Services' Addressing the Burden of Chronic Obstructive Pulmonary Disease (COPD) in Rural America included three policy recommendations, two of which were related to payment rates and reimbursement:

  1. “The Committee recommends the Secretary and the Department of Health and Human Services undertake a national campaign to educate rural primary care providers and individuals with COPD symptoms about rural-urban disparities in COPD outcomes with an emphasis on the need to do more screening and referral for effective treatments to help manage the disease.
  2. 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.
  3. The Committee recommends the Secretary work with Congress to expand direct supervision of pulmonary rehabilitation to include physician assistants, nurse practitioners and other primary care providers under general supervision of a physician.”

Resources to Learn More

Identifying Patients with COPD at High Risk of Readmission
Document
Discusses hospital readmission rates within 30 days of discharge for COPD patients and determines risk of readmission by tracking a variety of demographic data, including age, comorbidity status, and payer type.
Author(s): Simmering, J., Polgreen, L., Comellas, A., Cavanaugh, J., & Polgreen, P.
Citation: Chronic Obstructive Pulmonary Diseases, 3(4), 729-738
Date: 5/2016

Understanding the Hospital Readmissions Reduction Program
Document
Provides an overview of readmission measures, performance period and eligibility, and payment methodology of the CMS Hospital Readmissions Reduction Program (RRP) regarding payment penalties to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions.
Organization(s): Lake Superior Quality Innovation Network
Date: 1/2019