Adventures in Adversity
Editor’s Note: Thomas Petty, M.D., really needs no introduction. He is often referred to as “the Father of the Oxygen Industry” and his name is frequently mentioned in speeches and interviews. Dr. Petty is still active in research and teaching today and most recently organized a team of Denver LTOT patients and clinicians on a “high-altitude” adventure to learn more about using oxygen therapy at high altitude. Here are just a few highlights from Dr. Petty’s distinguished career:
Thomas L. Petty, M.D., a pulmonologist, is a Professor of Medicine at the University of Colorado Health Sciences Center in Denver and Rush-Presbyterian-St. Luke’s Medical Center in Chicago. He was previously head of the Division of Pulmonary Sciences at the University and Director of the Fellowship Training Program from 1964 to 1989. Dr. Petty has published over 800 articles in journals. He was elected to Master Fellow of the American College of Chest Physicians (1995), the fifth such award given by the ACCP in its 61-year history. He was awarded Master Fellowship in the American Association of Respiratory Care in 1999.
The evolution of long-term oxygen therapy (LTOT) for COPD is a remarkable story, marked by periods of adversity from the beginning. In the early 1960s, oxygen for COPD patients was considered taboo because of fears with reducing respiratory drives. After this dogma was proven incorrect, the Denver group showed improved cardiac, hematopoietic, and overall exercise function and a dramatically improved quality of life in six patients well studied in a clinical research unit. Disbelievers thought that these improvements were only anecdotal and possibly a consequence of living at altitude. This adversity was partly overcome by studies done at sea level, showing similar results. Even so, the original manufacturer of liquid oxygen decided to stop their research on this product since we were the only center that was enthusiastic about the possibilities, based on our research and with use in 27 patients. By that time, we had persuaded the Dept. of Social Services of Colorado to pay for home oxygen, which we showed reduced hospitalizations. This was well before the advent of Medicare. Finally the company relented and moved LTOT into the limelight. I was featured in a TV press conference in New York in the spring of 1970. LTOT was finally launched! In 1970, when LTOT was available commercially, Medicare still did not provide reimbursement for this revolutionary care for selected patients with advanced COPD. It took an immense amount of lobbying and personal visits to Medicare, assisted by the Council of the American College of Chest Physicians, at a time when I was an officer.
Even with reimbursement the use of oxygen was not well accepted until the Nocturnal Oxygen Therapy Trial (NOTT) clearly showed an improvement in survival in ambulatory patients receiving oxygen most of the day, using a liquid portable system compared with the patients who received only nocturnal oxygen, some daytime oxygen from basically stationary sources, sometimes supplemented by high-pressure cylinders. While this study was underway, Medicare suddenly decided against reimbursement for liquid portable oxygen, because use of concentrators was increasing and less expensive. When the NOTT Study was published in 1980, it caused a complete turnaround and liquid portable oxygen reimbursement became popular once again.
Then came the “conspiracy” of modality neutral reimbursement, carefully engineered by the supply industry and endorsed by Medicare. Since suppliers could make greater profits with basically stationary systems, the use of the more effective liquid ambulatory oxygen went down dramatically. To deal with this new adversity, six Oxygen Consensus Conferences were begun in Denver in 1986 and continued at regular intervals; the sixth was held in August 2005. Each conference dealt with problems of prescribing and reimbursement for appropriate oxygen for patients who had an established need for this therapy. Gradually these conferences have led to a rethinking of reimbursement policies by CMS. Soon a stratified payment system and new reimbursement for ambulatory (wearable) systems will be enacted. Nonetheless, when I travel, I still see patients eating in restaurants and shopping in grocery stores, struggling with heavy E-cylinders. They tell me, “Medicare will not pay for liquid.” This lie really tees me off! In Denver, about 80% of oxygen users wear liquid oxygen!
Use of liquid oxygen and other lightweight portable systems are again on the rise.
Until this year, the Department of Transportation prohibited the use of personal oxygen on airliners. The advent of portable oxygen concentrators that patients can carry on board and an advance in enlightenment about oxygen safety changed these regulations. Now most, but not all, carriers allow personal oxygen concentrators on board with appropriate arrangements. Four new portable concentrators are now available, but reimbursement presents a problem, once again.
Another adversity that looms is the regulation that mandates transfer of ownership of oxygen equipment to patients after a period of time, presently a set at 36 months and possibly to be as low as 13 months. Should this come to be, adversity will again be overcome by new services to provide maintenance and repair and to help support patients in need. Ambulatory oxygen therapy and pulmonary rehabilitation have become the standard of care for patients able to get beyond the limits of their oxygen tubing, both inside and outside the home.
Pulmonary rehabilitation with ambulatory oxygen was the comparison by which lung volume reduction surgery (LVRS) was judged. LVRS did not improve survival. Ambulatory oxygen is a growing practice with both old and new technologies including attractive portable oxygen concentrators. Today, more patients receive LTOT than ever before and the oxygen supply industry is competitive. Whenever adversity rears its ugly head, it should be considered a challenge and an adventure.
This article originally appeared in the Respiratory Management Nov/Dec 2006 issue of HME Business.