Society News

The CHEST Foundation is proud to announce the winners of the first round of the 2017 NetWorks Challenge! Our first place winner, Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork, and our second place finisher, Women’s Health NetWork, both receive session time at CHEST 2017 on a topic of their choice and two travel grants to help their NetWork members attend CHEST 2017.

The CHEST Foundation is proud to announce the winners of the first round of the 2017 NetWorks Challenge! Our first place winner, Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork, and our second place finisher, Women’s Health NetWork, both receive session time at CHEST 2017 on a topic of their choice and two travel grants to help their NetWork members attend CHEST 2017.

The CHEST Foundation is proud to announce the winners of the first round of the 2017 NetWorks Challenge! Our first place winner, Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork, and our second place finisher, Women’s Health NetWork, both receive session time at CHEST 2017 on a topic of their choice and two travel grants to help their NetWork members attend CHEST 2017.

Gender Disparities in Occupational Health

Over the past few decades, the presence of women in the workforce has changed significantly. According to the US Bureau of Labor Statistics Current Population Survey, in 2015, 46.8% of the workforce included women compared with 28.6% in 1948. Along with this change, there has been an increased focus on gender disparities in occupational health.

Krystal Cleven, MD

Fellow-in-Training Member

Does Beta-agonist Therapy With Albuterol Cause Lactic Acidosis?

Cohen and associates (Clin Sci Mol Med. 1977;53:405) suggested that lactic acidosis can occur in at least two different physiologic clinical presentations. Type A occurs when oxygen delivery to the tissues is compromised. Dodda and Spiro (Respir Care. 2012;57[12]:2115) indicated that type A lactic acidosis was due to hypoxemia, as seen in inadequate tissue oxygenation during an exacerbation of asthma. In severe asthma, pulsus paradoxus and air trapping (causing intrinsic positive end-expiratory pressure, or PEEP) served to decrease tissue oxygenation by decreasing cardiac output and venous return, leading to type A lactic acidosis. Bates and associates (Pediatrics. 2014;133[4]:e1087) considered the role of intrapulmonary arteriovenous anastomoses (IPAVs) when a status asthmaticus patient improved after cessation of beta-agonist therapy. Type B lactic acidosis occurs when lactate production was increased or lactate removal was decreased even when oxygen was delivered to tissue. Amaducci (http://www.emresident.org/gasping-air-albuterol-induced-lactic-acidosis/) explained how high dosages of albuterol, beyond 1 mg/kg, created an increased adrenergic state that, with reduced tissue perfusion, increased glycolysis and pyruvate production, resulting in measurable hyperlactatemia. The authors (Br J Med Pract. 2011;4[2]:a420) noted that lactic acidosis also occurs in acute severe asthma due to inadequate oxygen delivery to the respiratory muscles to meet an elevated oxygen demand or due to fatiguing respiratory muscles. Ganaie and Hughes reported a case of lactic acidosis caused by treatment with salbutamol. Salbutamol is the most commonly used short-acting beta-agonist. Stimulation of beta-adrenergic receptors leads to a variety of metabolic effects, including increase in glycogenolysis, gluconeogenesis, and lipolysis, thus contributing to lactic acidosis. All authors agreed that the mechanism of albuterol-caused lactic acidosis was poorly understood.

Douglas E. Masini, EdD, FCCP

Steering Committee Member

Withdrawal of OSA Screening Regulation for Commercial Motor Vehicle Operators

Compared with the general US population, the prevalence of sleep apnea (SA) is higher among commercial motor vehicle (CMV) drivers (Berger et al. J Occup Environ Med. 2012;54[8]:1017). Additionally, the risk of motor vehicle accidents is higher among individuals with SA compared with those without SA (Tregear et al. J Clin Sleep Med. 2009;5[6]:573), and treatment of SA is associated with a reduction in this risk (Mahssa et al. Sleep. 2015;38[3]341).

Vaishnavi Kundel, MD

NetWork Member

Corrections to previous NetWork articles

July 2017

Clinical Research

Mohsin Ijaz’s name was misspelled.

August 2017

Transplant

The name under Shruti Gadre’s photograph is wrong. It says Dr. Ahya instead of Dr. Gadre.

The authorship of the article at the end of the article is incorrect. It says Vivek Ahya, instead of Shruti Gadre and Marie Budev.

Gender Disparities in Occupational Health

Over the past few decades, the presence of women in the workforce has changed significantly. According to the US Bureau of Labor Statistics Current Population Survey, in 2015, 46.8% of the workforce included women compared with 28.6% in 1948. Along with this change, there has been an increased focus on gender disparities in occupational health.

Krystal Cleven, MD

Fellow-in-Training Member

Does Beta-agonist Therapy With Albuterol Cause Lactic Acidosis?

Cohen and associates (Clin Sci Mol Med. 1977;53:405) suggested that lactic acidosis can occur in at least two different physiologic clinical presentations. Type A occurs when oxygen delivery to the tissues is compromised. Dodda and Spiro (Respir Care. 2012;57[12]:2115) indicated that type A lactic acidosis was due to hypoxemia, as seen in inadequate tissue oxygenation during an exacerbation of asthma. In severe asthma, pulsus paradoxus and air trapping (causing intrinsic positive end-expiratory pressure, or PEEP) served to decrease tissue oxygenation by decreasing cardiac output and venous return, leading to type A lactic acidosis. Bates and associates (Pediatrics. 2014;133[4]:e1087) considered the role of intrapulmonary arteriovenous anastomoses (IPAVs) when a status asthmaticus patient improved after cessation of beta-agonist therapy. Type B lactic acidosis occurs when lactate production was increased or lactate removal was decreased even when oxygen was delivered to tissue. Amaducci (http://www.emresident.org/gasping-air-albuterol-induced-lactic-acidosis/) explained how high dosages of albuterol, beyond 1 mg/kg, created an increased adrenergic state that, with reduced tissue perfusion, increased glycolysis and pyruvate production, resulting in measurable hyperlactatemia. The authors (Br J Med Pract. 2011;4[2]:a420) noted that lactic acidosis also occurs in acute severe asthma due to inadequate oxygen delivery to the respiratory muscles to meet an elevated oxygen demand or due to fatiguing respiratory muscles. Ganaie and Hughes reported a case of lactic acidosis caused by treatment with salbutamol. Salbutamol is the most commonly used short-acting beta-agonist. Stimulation of beta-adrenergic receptors leads to a variety of metabolic effects, including increase in glycogenolysis, gluconeogenesis, and lipolysis, thus contributing to lactic acidosis. All authors agreed that the mechanism of albuterol-caused lactic acidosis was poorly understood.

Douglas E. Masini, EdD, FCCP

Steering Committee Member

Withdrawal of OSA Screening Regulation for Commercial Motor Vehicle Operators

Compared with the general US population, the prevalence of sleep apnea (SA) is higher among commercial motor vehicle (CMV) drivers (Berger et al. J Occup Environ Med. 2012;54[8]:1017). Additionally, the risk of motor vehicle accidents is higher among individuals with SA compared with those without SA (Tregear et al. J Clin Sleep Med. 2009;5[6]:573), and treatment of SA is associated with a reduction in this risk (Mahssa et al. Sleep. 2015;38[3]341).

Vaishnavi Kundel, MD

NetWork Member

Corrections to previous NetWork articles

July 2017

Clinical Research

Mohsin Ijaz’s name was misspelled.

August 2017

Transplant

The name under Shruti Gadre’s photograph is wrong. It says Dr. Ahya instead of Dr. Gadre.

The authorship of the article at the end of the article is incorrect. It says Vivek Ahya, instead of Shruti Gadre and Marie Budev.

Gender Disparities in Occupational Health

Over the past few decades, the presence of women in the workforce has changed significantly. According to the US Bureau of Labor Statistics Current Population Survey, in 2015, 46.8% of the workforce included women compared with 28.6% in 1948. Along with this change, there has been an increased focus on gender disparities in occupational health.

Krystal Cleven, MD

Fellow-in-Training Member

Does Beta-agonist Therapy With Albuterol Cause Lactic Acidosis?

Cohen and associates (Clin Sci Mol Med. 1977;53:405) suggested that lactic acidosis can occur in at least two different physiologic clinical presentations. Type A occurs when oxygen delivery to the tissues is compromised. Dodda and Spiro (Respir Care. 2012;57[12]:2115) indicated that type A lactic acidosis was due to hypoxemia, as seen in inadequate tissue oxygenation during an exacerbation of asthma. In severe asthma, pulsus paradoxus and air trapping (causing intrinsic positive end-expiratory pressure, or PEEP) served to decrease tissue oxygenation by decreasing cardiac output and venous return, leading to type A lactic acidosis. Bates and associates (Pediatrics. 2014;133[4]:e1087) considered the role of intrapulmonary arteriovenous anastomoses (IPAVs) when a status asthmaticus patient improved after cessation of beta-agonist therapy. Type B lactic acidosis occurs when lactate production was increased or lactate removal was decreased even when oxygen was delivered to tissue. Amaducci (http://www.emresident.org/gasping-air-albuterol-induced-lactic-acidosis/) explained how high dosages of albuterol, beyond 1 mg/kg, created an increased adrenergic state that, with reduced tissue perfusion, increased glycolysis and pyruvate production, resulting in measurable hyperlactatemia. The authors (Br J Med Pract. 2011;4[2]:a420) noted that lactic acidosis also occurs in acute severe asthma due to inadequate oxygen delivery to the respiratory muscles to meet an elevated oxygen demand or due to fatiguing respiratory muscles. Ganaie and Hughes reported a case of lactic acidosis caused by treatment with salbutamol. Salbutamol is the most commonly used short-acting beta-agonist. Stimulation of beta-adrenergic receptors leads to a variety of metabolic effects, including increase in glycogenolysis, gluconeogenesis, and lipolysis, thus contributing to lactic acidosis. All authors agreed that the mechanism of albuterol-caused lactic acidosis was poorly understood.

Douglas E. Masini, EdD, FCCP

Steering Committee Member

Withdrawal of OSA Screening Regulation for Commercial Motor Vehicle Operators

Compared with the general US population, the prevalence of sleep apnea (SA) is higher among commercial motor vehicle (CMV) drivers (Berger et al. J Occup Environ Med. 2012;54[8]:1017). Additionally, the risk of motor vehicle accidents is higher among individuals with SA compared with those without SA (Tregear et al. J Clin Sleep Med. 2009;5[6]:573), and treatment of SA is associated with a reduction in this risk (Mahssa et al. Sleep. 2015;38[3]341).

Vaishnavi Kundel, MD

NetWork Member

Corrections to previous NetWork articles

July 2017

Clinical Research

Mohsin Ijaz’s name was misspelled.

August 2017

Transplant

The name under Shruti Gadre’s photograph is wrong. It says Dr. Ahya instead of Dr. Gadre.

The authorship of the article at the end of the article is incorrect. It says Vivek Ahya, instead of Shruti Gadre and Marie Budev.

Giants in Chest Medicine

Jack Hirsh, MD, FCCP.

By Dr. S. Z. Goldhaber.

Original Research

IVIg for Treatment of Severe Refractory Heparin-Induced Thrombocytopenia.

By Dr. A. Padmanabhan et al.

The Impact of Statin Drug Use on All-Cause Mortality in Patients With COPD:

A Population-Based Cohort Study.

By Dr. A. J. Raymakers et al.
 

Pathologic Findings and Prognosis in a Large Prospective Cohort of Chronic Hypersensitivity Pneumonitis.

By Dr. P. Wang et al.
 

Evidence-based Medicine

Etiologies of Chronic Cough in Pediatric Cohorts: CHEST Guideline and Expert Panel Report.

By Dr. A. B. Chang et al, on behalf of the CHEST Expert Cough Panel.

Giants in Chest Medicine

Jack Hirsh, MD, FCCP.

By Dr. S. Z. Goldhaber.

Original Research

IVIg for Treatment of Severe Refractory Heparin-Induced Thrombocytopenia.

By Dr. A. Padmanabhan et al.

The Impact of Statin Drug Use on All-Cause Mortality in Patients With COPD:

A Population-Based Cohort Study.

By Dr. A. J. Raymakers et al.
 

Pathologic Findings and Prognosis in a Large Prospective Cohort of Chronic Hypersensitivity Pneumonitis.

By Dr. P. Wang et al.
 

Evidence-based Medicine

Etiologies of Chronic Cough in Pediatric Cohorts: CHEST Guideline and Expert Panel Report.

By Dr. A. B. Chang et al, on behalf of the CHEST Expert Cough Panel.

Giants in Chest Medicine

Jack Hirsh, MD, FCCP.

By Dr. S. Z. Goldhaber.

Original Research

IVIg for Treatment of Severe Refractory Heparin-Induced Thrombocytopenia.

By Dr. A. Padmanabhan et al.

The Impact of Statin Drug Use on All-Cause Mortality in Patients With COPD:

A Population-Based Cohort Study.

By Dr. A. J. Raymakers et al.
 

Pathologic Findings and Prognosis in a Large Prospective Cohort of Chronic Hypersensitivity Pneumonitis.

By Dr. P. Wang et al.
 

Evidence-based Medicine

Etiologies of Chronic Cough in Pediatric Cohorts: CHEST Guideline and Expert Panel Report.

By Dr. A. B. Chang et al, on behalf of the CHEST Expert Cough Panel.

John O’Leary is a father of four, business owner, speaker, writer, and former hospital chaplain—a fortunate guy. But he attributes the best of everything he has to an unfortunate event that happened back in 1987.

At the age of 9, O’Leary was involved in a house fire that left burns on 100% of his body, 87% of which were third degree. Doctors gave O’Leary less than a 1% chance to live, odds that were overwhelming—but not entirely impossible to beat.

Despite what the health-care professionals told his mother, when O’Leary asked her if he was going to die, she responded by asking her son if he wanted to die or if he wanted to live: a question that O’Leary says must have taken lot more courage for a mother to ask than it did for a 9-year-old to answer.

Although he was taken aback, the answer seemed obvious to O’Leary. Of course he wanted to live. And live he did, but only after 5 months in the hospital and the amputation of all of his fingers.

After he returned to school 18 months later with his classmates welcoming him back with a parade, O’Leary didn’t see the necessity in sharing his story. “I always knew my story, I just never truly embraced it.”

O’Leary’s father told him that he wanted to thank the community members who truly helped their family through the tough times and that he planned to do so by writing a book. With the help of O’Leary’s mother, 100 copies of Overwhelming Odds were originally printed and given to members of the community. Today, over 70,000 copies of their book have been sold.

John O’Leary is a father of four, business owner, speaker, writer, and former hospital chaplain—a fortunate guy. But he attributes the best of everything he has to an unfortunate event that happened back in 1987.

At the age of 9, O’Leary was involved in a house fire that left burns on 100% of his body, 87% of which were third degree. Doctors gave O’Leary less than a 1% chance to live, odds that were overwhelming—but not entirely impossible to beat.

Despite what the health-care professionals told his mother, when O’Leary asked her if he was going to die, she responded by asking her son if he wanted to die or if he wanted to live: a question that O’Leary says must have taken lot more courage for a mother to ask than it did for a 9-year-old to answer.

Although he was taken aback, the answer seemed obvious to O’Leary. Of course he wanted to live. And live he did, but only after 5 months in the hospital and the amputation of all of his fingers.

After he returned to school 18 months later with his classmates welcoming him back with a parade, O’Leary didn’t see the necessity in sharing his story. “I always knew my story, I just never truly embraced it.”

O’Leary’s father told him that he wanted to thank the community members who truly helped their family through the tough times and that he planned to do so by writing a book. With the help of O’Leary’s mother, 100 copies of Overwhelming Odds were originally printed and given to members of the community. Today, over 70,000 copies of their book have been sold.

John O’Leary is a father of four, business owner, speaker, writer, and former hospital chaplain—a fortunate guy. But he attributes the best of everything he has to an unfortunate event that happened back in 1987.

At the age of 9, O’Leary was involved in a house fire that left burns on 100% of his body, 87% of which were third degree. Doctors gave O’Leary less than a 1% chance to live, odds that were overwhelming—but not entirely impossible to beat.

Despite what the health-care professionals told his mother, when O’Leary asked her if he was going to die, she responded by asking her son if he wanted to die or if he wanted to live: a question that O’Leary says must have taken lot more courage for a mother to ask than it did for a 9-year-old to answer.

Although he was taken aback, the answer seemed obvious to O’Leary. Of course he wanted to live. And live he did, but only after 5 months in the hospital and the amputation of all of his fingers.

After he returned to school 18 months later with his classmates welcoming him back with a parade, O’Leary didn’t see the necessity in sharing his story. “I always knew my story, I just never truly embraced it.”

O’Leary’s father told him that he wanted to thank the community members who truly helped their family through the tough times and that he planned to do so by writing a book. With the help of O’Leary’s mother, 100 copies of Overwhelming Odds were originally printed and given to members of the community. Today, over 70,000 copies of their book have been sold.

The old adage of not wanting to see how laws or sausage is made holds true today, perhaps more so than ever. But certain clinical realities within pulmonary medicine virtually ensure that legislation is actually part of any reasonable solution.

NAMDRC has initiated an outreach to all the key medical, allied health, and patient societies that focus on pulmonary medicine to determine if consensus can be reached on a focused laundry list of issues that, for varying reasons, lean toward Congress for legislative solutions.

Here is a list of some of the issues under discussion:

• Home mechanical ventilation. Under current law, “ventilators” are covered items under the durable medical equipment benefit. In the 1990s, in order to circumvent statutory requirements that ventilators be paid under a “frequent and substantial servicing” payment methodology, HCFA (now CMS) created a new category – respiratory assist devices and declared that these devices, despite classification by FDA as ventilators, are not ventilators in reality, and the payment methodology, therefore, does not apply.

Over the past several years, the pulmonary medicine community tried its best to convince CMS that its rules were problematic, archaic, and costing the Medicare program tens of millions of dollars in unnecessary expenditures. A formal submission to CMS, a request for a National Coverage Determination reconsideration, was denied with a phrase now echoed throughout health care, “it’s complicated.” The only effective solution is a legislative one.

• High flow oxygen therapy for ILD patients. Oxygen remains the largest single component of the durable medical equipment benefit and, largely due to competitive bidding, has seen payment drop dramatically since the implementation of competitive bidding.

One can easily argue that competitive pricing is self-inflicted by the DME industry as the rates are set through a complicated formula based on bids from suppliers. But the impact has been particularly hard on liquid systems, the delivery system choice of not only many Medicare beneficiaries but also is the modality of choice for patients with clear need for high flow oxygen. While delivery in the home for high flow needs can be met by some stationary concentrators, the virtual disappearance of liquid systems, attributable to pricing triggered by competitive bidding, results in many ILD patients unable to leave their homes. The only effective solution is a legislative one.

• Section 603. This provision of the Balanced Budget Act of 2015 was designed to inhibit hospital purchases of certain physician practices that were based on aberrations within the Medicare payment system that rewarded hospitals significantly more than the same service provided in a physician office. For example, a physician office-based sleep lab may be able to bill Medicare for a particular service, but if the hospital purchases that physician practice and bills for the same service, it might receive upwards of twice as much payment.

While all involved seem to agree that this provision was not intended to target pulmonary rehabilitation services, it is being hit particularly hard by CMS rules implementing the statute. Any new pulmonary rehab program that is not within 250 yards of the main hospital campus must bill at the physician fee schedule rate, a rate about half of the hospital outpatient rate. Furthermore, existing programs that choose to expand must do so within the confines of their specific current location, unable to move a floor away. Doing so would trigger the reduced payment methodology.
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CMS agrees this is clearly an example of unintended consequences, but CMS also acknowledges it does not have the authority to remedy the situation. The agency itself signaled the only way to exempt pulmonary rehabilitation services is to seek Congressional action.

And now to the “sausage” part of the equation. Congressional action on virtually anything except renaming a post office becomes a political, as well as substantive, challenge. Here are just some of the considerations that must be addressed by any legislative strategy.
 

1. Any “fix” must be clinically sound and supported across a broad cross section of physician and patient groups. And the fix must give some level of flexibility to CMS to implement it in a reasonable way but tie their hands to force changes in policy.

2. Any “fix” must have a strong political strategy that can muster support within key Congressional committees (House Ways & Means Committee and Energy & Commerce Committee, along with the Senate Finance Committee, let alone 218 votes in the House and 51 votes in the Senate.

Given these issues, almost regardless of the political environment, it is time to begin working on substantive solutions so that when the political climate improves, pulmonary medicine is ready to move forward with a coordinated cohesive strategy.

The old adage of not wanting to see how laws or sausage is made holds true today, perhaps more so than ever. But certain clinical realities within pulmonary medicine virtually ensure that legislation is actually part of any reasonable solution.

NAMDRC has initiated an outreach to all the key medical, allied health, and patient societies that focus on pulmonary medicine to determine if consensus can be reached on a focused laundry list of issues that, for varying reasons, lean toward Congress for legislative solutions.

Here is a list of some of the issues under discussion:

• Home mechanical ventilation. Under current law, “ventilators” are covered items under the durable medical equipment benefit. In the 1990s, in order to circumvent statutory requirements that ventilators be paid under a “frequent and substantial servicing” payment methodology, HCFA (now CMS) created a new category – respiratory assist devices and declared that these devices, despite classification by FDA as ventilators, are not ventilators in reality, and the payment methodology, therefore, does not apply.

Over the past several years, the pulmonary medicine community tried its best to convince CMS that its rules were problematic, archaic, and costing the Medicare program tens of millions of dollars in unnecessary expenditures. A formal submission to CMS, a request for a National Coverage Determination reconsideration, was denied with a phrase now echoed throughout health care, “it’s complicated.” The only effective solution is a legislative one.

• High flow oxygen therapy for ILD patients. Oxygen remains the largest single component of the durable medical equipment benefit and, largely due to competitive bidding, has seen payment drop dramatically since the implementation of competitive bidding.

One can easily argue that competitive pricing is self-inflicted by the DME industry as the rates are set through a complicated formula based on bids from suppliers. But the impact has been particularly hard on liquid systems, the delivery system choice of not only many Medicare beneficiaries but also is the modality of choice for patients with clear need for high flow oxygen. While delivery in the home for high flow needs can be met by some stationary concentrators, the virtual disappearance of liquid systems, attributable to pricing triggered by competitive bidding, results in many ILD patients unable to leave their homes. The only effective solution is a legislative one.

• Section 603. This provision of the Balanced Budget Act of 2015 was designed to inhibit hospital purchases of certain physician practices that were based on aberrations within the Medicare payment system that rewarded hospitals significantly more than the same service provided in a physician office. For example, a physician office-based sleep lab may be able to bill Medicare for a particular service, but if the hospital purchases that physician practice and bills for the same service, it might receive upwards of twice as much payment.

While all involved seem to agree that this provision was not intended to target pulmonary rehabilitation services, it is being hit particularly hard by CMS rules implementing the statute. Any new pulmonary rehab program that is not within 250 yards of the main hospital campus must bill at the physician fee schedule rate, a rate about half of the hospital outpatient rate. Furthermore, existing programs that choose to expand must do so within the confines of their specific current location, unable to move a floor away. Doing so would trigger the reduced payment methodology.
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CMS agrees this is clearly an example of unintended consequences, but CMS also acknowledges it does not have the authority to remedy the situation. The agency itself signaled the only way to exempt pulmonary rehabilitation services is to seek Congressional action.

And now to the “sausage” part of the equation. Congressional action on virtually anything except renaming a post office becomes a political, as well as substantive, challenge. Here are just some of the considerations that must be addressed by any legislative strategy.
 

1. Any “fix” must be clinically sound and supported across a broad cross section of physician and patient groups. And the fix must give some level of flexibility to CMS to implement it in a reasonable way but tie their hands to force changes in policy.

2. Any “fix” must have a strong political strategy that can muster support within key Congressional committees (House Ways & Means Committee and Energy & Commerce Committee, along with the Senate Finance Committee, let alone 218 votes in the House and 51 votes in the Senate.

Given these issues, almost regardless of the political environment, it is time to begin working on substantive solutions so that when the political climate improves, pulmonary medicine is ready to move forward with a coordinated cohesive strategy.

The old adage of not wanting to see how laws or sausage is made holds true today, perhaps more so than ever. But certain clinical realities within pulmonary medicine virtually ensure that legislation is actually part of any reasonable solution.

NAMDRC has initiated an outreach to all the key medical, allied health, and patient societies that focus on pulmonary medicine to determine if consensus can be reached on a focused laundry list of issues that, for varying reasons, lean toward Congress for legislative solutions.

Here is a list of some of the issues under discussion:

• Home mechanical ventilation. Under current law, “ventilators” are covered items under the durable medical equipment benefit. In the 1990s, in order to circumvent statutory requirements that ventilators be paid under a “frequent and substantial servicing” payment methodology, HCFA (now CMS) created a new category – respiratory assist devices and declared that these devices, despite classification by FDA as ventilators, are not ventilators in reality, and the payment methodology, therefore, does not apply.

Over the past several years, the pulmonary medicine community tried its best to convince CMS that its rules were problematic, archaic, and costing the Medicare program tens of millions of dollars in unnecessary expenditures. A formal submission to CMS, a request for a National Coverage Determination reconsideration, was denied with a phrase now echoed throughout health care, “it’s complicated.” The only effective solution is a legislative one.

• High flow oxygen therapy for ILD patients. Oxygen remains the largest single component of the durable medical equipment benefit and, largely due to competitive bidding, has seen payment drop dramatically since the implementation of competitive bidding.

One can easily argue that competitive pricing is self-inflicted by the DME industry as the rates are set through a complicated formula based on bids from suppliers. But the impact has been particularly hard on liquid systems, the delivery system choice of not only many Medicare beneficiaries but also is the modality of choice for patients with clear need for high flow oxygen. While delivery in the home for high flow needs can be met by some stationary concentrators, the virtual disappearance of liquid systems, attributable to pricing triggered by competitive bidding, results in many ILD patients unable to leave their homes. The only effective solution is a legislative one.

• Section 603. This provision of the Balanced Budget Act of 2015 was designed to inhibit hospital purchases of certain physician practices that were based on aberrations within the Medicare payment system that rewarded hospitals significantly more than the same service provided in a physician office. For example, a physician office-based sleep lab may be able to bill Medicare for a particular service, but if the hospital purchases that physician practice and bills for the same service, it might receive upwards of twice as much payment.

While all involved seem to agree that this provision was not intended to target pulmonary rehabilitation services, it is being hit particularly hard by CMS rules implementing the statute. Any new pulmonary rehab program that is not within 250 yards of the main hospital campus must bill at the physician fee schedule rate, a rate about half of the hospital outpatient rate. Furthermore, existing programs that choose to expand must do so within the confines of their specific current location, unable to move a floor away. Doing so would trigger the reduced payment methodology.
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CMS agrees this is clearly an example of unintended consequences, but CMS also acknowledges it does not have the authority to remedy the situation. The agency itself signaled the only way to exempt pulmonary rehabilitation services is to seek Congressional action.

And now to the “sausage” part of the equation. Congressional action on virtually anything except renaming a post office becomes a political, as well as substantive, challenge. Here are just some of the considerations that must be addressed by any legislative strategy.
 

1. Any “fix” must be clinically sound and supported across a broad cross section of physician and patient groups. And the fix must give some level of flexibility to CMS to implement it in a reasonable way but tie their hands to force changes in policy.

2. Any “fix” must have a strong political strategy that can muster support within key Congressional committees (House Ways & Means Committee and Energy & Commerce Committee, along with the Senate Finance Committee, let alone 218 votes in the House and 51 votes in the Senate.

Given these issues, almost regardless of the political environment, it is time to begin working on substantive solutions so that when the political climate improves, pulmonary medicine is ready to move forward with a coordinated cohesive strategy.

SVS is seeking proposals for invited sessions from internal committees and members alike for the 2018 Vascular Annual Meeting, June 20-23 (exhibits: June 21 to 22; plenaries: June 21 to 23) in Boston, Mass.

Invited sessions consist of postgraduate courses, breakfast sessions, concurrent sessions and workshops/small-group sessions. Submitters will be asked to address educational needs, provide objectives, indicate proposed formats and identify target audiences.

The deadline is 3 p.m. Central Daylight Time, Friday, Sept. 15. Submitters will be notified the week of Sept. 25 if their proposals have been selected for further development. Contact [email protected] or call 312-334-2327 with questions.

SVS is seeking proposals for invited sessions from internal committees and members alike for the 2018 Vascular Annual Meeting, June 20-23 (exhibits: June 21 to 22; plenaries: June 21 to 23) in Boston, Mass.

Invited sessions consist of postgraduate courses, breakfast sessions, concurrent sessions and workshops/small-group sessions. Submitters will be asked to address educational needs, provide objectives, indicate proposed formats and identify target audiences.

The deadline is 3 p.m. Central Daylight Time, Friday, Sept. 15. Submitters will be notified the week of Sept. 25 if their proposals have been selected for further development. Contact [email protected] or call 312-334-2327 with questions.

SVS is seeking proposals for invited sessions from internal committees and members alike for the 2018 Vascular Annual Meeting, June 20-23 (exhibits: June 21 to 22; plenaries: June 21 to 23) in Boston, Mass.

Invited sessions consist of postgraduate courses, breakfast sessions, concurrent sessions and workshops/small-group sessions. Submitters will be asked to address educational needs, provide objectives, indicate proposed formats and identify target audiences.

The deadline is 3 p.m. Central Daylight Time, Friday, Sept. 15. Submitters will be notified the week of Sept. 25 if their proposals have been selected for further development. Contact [email protected] or call 312-334-2327 with questions.

September is Peripheral Artery Disease Awareness Month. To help SVS members educate patients and to spread awareness about vascular surgeons, we have prepared several things you can share.

1. An infographic for patients and their families. We urge you to print it and post around the office or your institution.

2. A quick resource web page for patients, offering patients a PAD video playlist and links to articles and information on PAD.

3. The latest PAD research information for physicians, along with clinical practice guideline links. If you have contacts among primary care physicians or other referrers, please feel free to send them this link.

4. Two press releases on PAD, to share with your communications people, public relations departments and/or patients

•             Don't Fall for These 6 Internet Myths About Statins

•             Often misdiagnosed, PAD can be mild or deadly

September is Peripheral Artery Disease Awareness Month. To help SVS members educate patients and to spread awareness about vascular surgeons, we have prepared several things you can share.

1. An infographic for patients and their families. We urge you to print it and post around the office or your institution.

2. A quick resource web page for patients, offering patients a PAD video playlist and links to articles and information on PAD.

3. The latest PAD research information for physicians, along with clinical practice guideline links. If you have contacts among primary care physicians or other referrers, please feel free to send them this link.

4. Two press releases on PAD, to share with your communications people, public relations departments and/or patients

•             Don't Fall for These 6 Internet Myths About Statins

•             Often misdiagnosed, PAD can be mild or deadly

September is Peripheral Artery Disease Awareness Month. To help SVS members educate patients and to spread awareness about vascular surgeons, we have prepared several things you can share.

1. An infographic for patients and their families. We urge you to print it and post around the office or your institution.

2. A quick resource web page for patients, offering patients a PAD video playlist and links to articles and information on PAD.

3. The latest PAD research information for physicians, along with clinical practice guideline links. If you have contacts among primary care physicians or other referrers, please feel free to send them this link.

4. Two press releases on PAD, to share with your communications people, public relations departments and/or patients

•             Don't Fall for These 6 Internet Myths About Statins

•             Often misdiagnosed, PAD can be mild or deadly

Learn all about coding and reimbursement, from the essentials to modifiers to future initiatives at the SVS Coding and Reimbursement Workshop, Oct. 13-14, in Chicago.

Hours are 1 to 5 p.m. Friday, Oct. 13, and 7:30 a.m. to 4:15 p.m. Saturday, Oct. 14. An optional E&M workshop (separate fee applies) will be held from 9 a.m. to noon Friday, Oct. 13.

Friday topics are: coding and reimbursement essentials, global surgical packages, getting paid the first time when applying surgical modifiers and the Medicare rule on non-physician practitioner billing.

Saturday topics include an overview of Current Procedural Terminology, coding for open surgical reconstruction; catheterization, angiography, angioplasty and stenting: cerebrovascular, brachiocephalic, visceral and renal; lower-extremity endovascular arterial intervention; open and endovascular treatments for venous insufficiency and IVC filters; aneurysm repair coding, fenestrated endovascular repair of the visceral and infrarenal aorta coding, hemodialysis access and wound care coding; vascular lab coding and information on MACRA, MIPS and APMs.

Also on the agenda is future SVS CPT coding initiatives.

Cost is: $880 for an SVS member or staff, $955 for a non-member and $250 for residents and trainees.

Cost for the optional workshop if $100 for an SVS member or staff, $215 for a non-member and $50 for residents and trainees.

Instructors are Teri Romano, RN, MBA, CPC, CMDP; Sean P. Roddy, MD; Robert M. Zwolak, MD, PhD; and Sunita D. Srivastava, MD.

Learn more and register here.

Learn all about coding and reimbursement, from the essentials to modifiers to future initiatives at the SVS Coding and Reimbursement Workshop, Oct. 13-14, in Chicago.

Hours are 1 to 5 p.m. Friday, Oct. 13, and 7:30 a.m. to 4:15 p.m. Saturday, Oct. 14. An optional E&M workshop (separate fee applies) will be held from 9 a.m. to noon Friday, Oct. 13.

Friday topics are: coding and reimbursement essentials, global surgical packages, getting paid the first time when applying surgical modifiers and the Medicare rule on non-physician practitioner billing.

Saturday topics include an overview of Current Procedural Terminology, coding for open surgical reconstruction; catheterization, angiography, angioplasty and stenting: cerebrovascular, brachiocephalic, visceral and renal; lower-extremity endovascular arterial intervention; open and endovascular treatments for venous insufficiency and IVC filters; aneurysm repair coding, fenestrated endovascular repair of the visceral and infrarenal aorta coding, hemodialysis access and wound care coding; vascular lab coding and information on MACRA, MIPS and APMs.

Also on the agenda is future SVS CPT coding initiatives.

Cost is: $880 for an SVS member or staff, $955 for a non-member and $250 for residents and trainees.

Cost for the optional workshop if $100 for an SVS member or staff, $215 for a non-member and $50 for residents and trainees.

Instructors are Teri Romano, RN, MBA, CPC, CMDP; Sean P. Roddy, MD; Robert M. Zwolak, MD, PhD; and Sunita D. Srivastava, MD.

Learn more and register here.

Learn all about coding and reimbursement, from the essentials to modifiers to future initiatives at the SVS Coding and Reimbursement Workshop, Oct. 13-14, in Chicago.

Hours are 1 to 5 p.m. Friday, Oct. 13, and 7:30 a.m. to 4:15 p.m. Saturday, Oct. 14. An optional E&M workshop (separate fee applies) will be held from 9 a.m. to noon Friday, Oct. 13.

Friday topics are: coding and reimbursement essentials, global surgical packages, getting paid the first time when applying surgical modifiers and the Medicare rule on non-physician practitioner billing.

Saturday topics include an overview of Current Procedural Terminology, coding for open surgical reconstruction; catheterization, angiography, angioplasty and stenting: cerebrovascular, brachiocephalic, visceral and renal; lower-extremity endovascular arterial intervention; open and endovascular treatments for venous insufficiency and IVC filters; aneurysm repair coding, fenestrated endovascular repair of the visceral and infrarenal aorta coding, hemodialysis access and wound care coding; vascular lab coding and information on MACRA, MIPS and APMs.

Also on the agenda is future SVS CPT coding initiatives.

Cost is: $880 for an SVS member or staff, $955 for a non-member and $250 for residents and trainees.

Cost for the optional workshop if $100 for an SVS member or staff, $215 for a non-member and $50 for residents and trainees.

Instructors are Teri Romano, RN, MBA, CPC, CMDP; Sean P. Roddy, MD; Robert M. Zwolak, MD, PhD; and Sunita D. Srivastava, MD.

Learn more and register here.

The mobile companion app (Apple products only) for VESAP4 is expected to be released by mid-September. The app permits users to access the program offline anywhere and sync up with the desktop app when later connected to the Internet.

It will be available on the iTunes store and is free to VESAP4 purchasers. Learn more about the fourth edition of the Vascular Education and Self-Assessment Program (VESAP4) here.

The mobile companion app (Apple products only) for VESAP4 is expected to be released by mid-September. The app permits users to access the program offline anywhere and sync up with the desktop app when later connected to the Internet.

It will be available on the iTunes store and is free to VESAP4 purchasers. Learn more about the fourth edition of the Vascular Education and Self-Assessment Program (VESAP4) here.

The mobile companion app (Apple products only) for VESAP4 is expected to be released by mid-September. The app permits users to access the program offline anywhere and sync up with the desktop app when later connected to the Internet.

It will be available on the iTunes store and is free to VESAP4 purchasers. Learn more about the fourth edition of the Vascular Education and Self-Assessment Program (VESAP4) here.

SVS is seeking proposals for invited sessions from internal committees and members alike for the 2018 Vascular Annual Meeting, June 20-23 (exhibits: June 21 to 22; plenaries: June 21 to 23) in Boston, Mass.

Invited sessions consist of postgraduate courses, breakfast sessions, concurrent sessions and workshops/small-group sessions. Submitters will be asked to address educational needs, provide objectives, indicate proposed formats and identify target audiences.

The deadline is 3 p.m. Central Daylight Time, Friday, Sept. 15. Submitters will be notified the week of Sept. 25 if their proposals have been selected for further development. Contact [email protected] or call 312-334-2327 with questions.

SVS is seeking proposals for invited sessions from internal committees and members alike for the 2018 Vascular Annual Meeting, June 20-23 (exhibits: June 21 to 22; plenaries: June 21 to 23) in Boston, Mass.

Invited sessions consist of postgraduate courses, breakfast sessions, concurrent sessions and workshops/small-group sessions. Submitters will be asked to address educational needs, provide objectives, indicate proposed formats and identify target audiences.

The deadline is 3 p.m. Central Daylight Time, Friday, Sept. 15. Submitters will be notified the week of Sept. 25 if their proposals have been selected for further development. Contact [email protected] or call 312-334-2327 with questions.

SVS is seeking proposals for invited sessions from internal committees and members alike for the 2018 Vascular Annual Meeting, June 20-23 (exhibits: June 21 to 22; plenaries: June 21 to 23) in Boston, Mass.

Invited sessions consist of postgraduate courses, breakfast sessions, concurrent sessions and workshops/small-group sessions. Submitters will be asked to address educational needs, provide objectives, indicate proposed formats and identify target audiences.

The deadline is 3 p.m. Central Daylight Time, Friday, Sept. 15. Submitters will be notified the week of Sept. 25 if their proposals have been selected for further development. Contact [email protected] or call 312-334-2327 with questions.