The first World Oxygen Day, celebrated October 2, 2023, was established by the Chronic Obstructive Pulmonary Disease (COPD) Foundation to spotlight the critical role that oxygen therapy holds in many people’s lives. To mark the occasion, the COPD Foundation and the Pulmonary Fibrosis Foundation cohosted the 2023 Oxygen Summit, an online event for health professionals and patient advocates highlighting key issues faced by providers and patients who use oxygen therapy. Those issues include access to liquid oxygen, reimbursement issues, and the need for more patient-focused care.
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Poor Reimbursement Limits Oxygen Options
Much of the difficulty with accessing oxygen therapy is due to provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, which required the Department of Health and Human Services to implement competitive bidding programs for certain kinds of durable medical equipment (DME), including supplemental oxygen supplies.
As noted by 2023 Oxygen Summit panel participant Chrysalis Ashton, RRT, BSRC, respiratory therapist and director of clinical operations for CareLinc Medical, a DME in Grand Rapids, Michigan: “With competitive bidding, reimbursement has continually fallen over the years, and that does limit the service levels and the equipment that we’re able to provide to our supplemental oxygen patients.”
Competitive bidding programs were initially rolled out in several metropolitan areas in the early 2010s and eventually became nationwide.1 The intention of the MMA’s provision for competitive bidding programs was cost reduction, a goal that was achieved. However, the competitive bidding process greatly disrupted the DME industry. Because of the competitive reimbursement criteria, DME companies could not remain solvent while continuing to provide certain products and services. As Ashton noted, this has significantly reduced patient access to supplemental oxygen, oxygen equipment, and patient education via DME respiratory therapists.2
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Liquid oxygen improves patient compliance and quality of life…However, liquid oxygen is roughly 4 times as expensive as oxygen concentrators.
More Portable Oxygen Options Needed
Accessing supplemental oxygen in a form that is easily used and affordable is also a challenge for patients, said Ashton.
Supplemental oxygen is available in a great variety of commercial formats, which differ considerably in their rate of oxygen output, size and weight, power options, and price. Compressed gas cylinders of oxygen are available, as are oxygen concentrators, which draw from room air to provide oxygen. Unlike compressed gas cylinders, oxygen concentrators don’t need to be refilled, but many need continual power access. Both are available in stationary or more mobile forms; some patients may need equipment to successfully carry some models. Some versions are also unsuitable for those with higher oxygen flow demands.3
Yet even with all these options, said Ashton, “There are just not great portable options for patients. The tanks are heavy, and they don’t last very long. So that can be a challenge. And then cost is also an issue as well, because reimbursement is so low.”
Oxygen as a cryogenic liquid (ie, liquid oxygen) takes up less space than oxygen in gas form, so it is lighter and easier to carry. Liquid oxygen can also provide continuous and high flow rates of oxygen. Liquid oxygen improves patient compliance and quality of life, including measures related to physical function, ambulation, and social interaction. However, liquid oxygen is roughly 4 times as expensive as oxygen concentrators.3
The pressures from competitive bidding have profoundly limited the availability of liquid oxygen to patients, as many DME companies are no longer offering it, even for patients who had previously benefited from it for years.4 John Linnell, an oxygen user and patient advocate who spoke at the 2023 Oxygen Summit, said that increased liquid oxygen availability is one of the most important priorities in improving the lives of patients who need supplemental oxygen, as it is so much more convenient for leading an active life.
Some patients face even greater challenges when it comes to finding appropriate supplemental oxygen therapy. Summit speaker Anand S. Iyer, MD, MSPH, an assistant professor at the University of Alabama at Birmingham in the Division of Pulmonary, Allergy, and Critical Care Medicine, also runs a pulmonary clinic for uninsured and underinsured patients. He noted that finding more portable options for such patients is even more difficult than for patients with better insurance coverage.
Multiple summit speakers also noted that access to pulmonologists may also be particularly limited for patients in rural or other underserved areas. This can also have downstream effects on oxygen therapy access.
What Clinicians Need to Know
Dr. Iyer urged his pulmonary and primary care colleagues to become educated about the specific details of prescribing different kinds of supplemental oxygen. “I want every clinician to think about the practical implementation of oxygen for patients and their families,” he said. “I urge them to think about the inadvertent side effects of the heavy, bulky tanks for a person who is trying to move these objects around as they get older. Sometimes we have to figure out more portable options for that person [who is a fall risk] and make sure the long tubing on their oxygen concentrator is not going to trip them.”
Dr. Iyer also highlighted results from a study recently published in the Annals of American Thoracic Society, which demonstrated that people with COPD using supplemental oxygen have almost twice the risk of social isolation and loneliness compared with the general population.5 Supplemental oxygen therapies “should be vital and lifesaving,” said Dr. Iyer. “But their tanks actually limit [patients’] ability to have mobility and independence, so professionals need to educate themselves about the options that exist.”
Pulmonologists and other health care providers also need to understand how to evaluate patients and periodically assess their precise oxygen needs. Summit speaker Karen Smoot, an oxygen therapy user and patient advocate, noted that patients often aren’t properly reevaluated as to whether their current oxygen needs are being met, which she sees a failure of communication and follow-up among the prescribing physician, the DME, and the patient. Respiratory therapists in the home might be ideally suited to perform initial and ongoing assessments of the exact oxygen needed, but many companies do not currently employ them for cost reasons.
As Ashton noted, “If we can catch patients when they are first put on oxygen, we can often help prevent additional hospital readmissions; we can add additional services and equipment sooner if needed. But unfortunately, because of reimbursement issues, we aren’t always seeing them early.”
Congressional Action, Innovation Needed
A coalition of professional and patient advocacy organizations, including the American Thoracic Society, the American Association of Respiratory Care, and the COPD Foundation, have banded together to urge congressional action on improving access to appropriate supplemental oxygen. Among the most important elements of the reform are the need for access to liquid oxygen, better reimbursement for respiratory therapists, adequate reimbursement more broadly, and more patient-centered care.6
As Smoot noted, “I believe that we need to look at reimbursement…because better follow up and access to respiratory therapists…isn’t going to change unless we have better reimbursement through Medicare for DME companies.”
“It’s a supplemental oxygen crisis,” said Dr Iyer, adding that “major reform is needed in this space that can help people with their well-being and independence and increase access to rural and underserved populations.”
Dr. Iyer also stressed the need for ongoing technological innovations in the field, in addition to current choices — a sentiment that was shared by other summit speakers. He noted that lighter and less cumbersome options could greatly improve the quality of life of patients who need supplemental oxygen for a variety of pulmonary diseases.
