Clinician Talk:

Making the Right Match

Oxygen generating portables are the new norm. The question is which device for which patient?

Many providers that shunned oxygen generating portable equipment (OGPE), such as transfilling cylinder systems and portable oxygen concentrators (POCs), are now accepting and even embracing these technologies. No longer is the question “on which patients should I useOGPE?” Now the question is “which OGPE should I use on this patient?”

Most of this change has been driven by the economic realities of the 36-month cap, national competitive bidding, the cost of responding to the ever increasing number of audits coming from CMS and contractors, as well as spiraling fuel prices. Reimbursement cuts have forced providers to recognize that acquisition costs for OGPE pales in comparison to the ongoing service costs associated with the traditional model of a stationary concentrator and delivered cylinders. In fact, the combined effects of “the cap” and the average cuts in oxygen reimbursement in the nine current competitive bidding areas results in a reimbursement that is 52 percent of what it was at the end of 2008.

Logically, with fewer dollars available and fuel and other operating costs rising, something has to give in order to service the same number of patients. Providers have to decide if they want to make cylinder deliveries or profits. The growing trend is to expand the use of OGPE equipment.

The benefits of this transition include significant reduction of ongoing service costs, enhancement of patient portability options, preservation of the ability to provide clinical support and the ability to still generate a profit. Not only will OGPE expand profits, but service area can be easily expanded as well. In fact, ProvidaCare’s Ryan Bennett recently identified that converting to OGPE technologies allowed them to expand their service area by 50 percent with no increase in service costs.

Clinical Considerations

OGPE technologies not only favor the provider economically, but they also offer the patient many clinical benefits as well — creating a win-win. Patients benefit through an enhanced ability to return to a lifestyle similar to that which they enjoyed prior to needing long-term oxygen. Also, the potential for falls in and around the home is reduced when extension tubing is eliminated from the floor. Moreover, morbidity, mortality and re-hospitalization may all be reduced through the promotion of regular ambulation and activity.

Lifestyle changes that occur in COPD happen slowly and insidiously, following the disease as it progresses. Part of the reason for these lifestyle changes is a decline in energy that accompanies low blood oxygen levels. When patients are discharged from the hospital on long-term oxygen they typically need additional time to fully recover from the acute exacerbation that had sent them to the hospital in the first place. For this reason it is important to remember that improvements in lifestyle will not immediately occur.

Rather, the restorative effect of oxygen will allow the patient to gradually return to the lifestyle that they enjoyed six months to a year prior to the exacerbation that culminated in their need for LTOT. Supplemental oxygen in any form will support these lifestyle improvements; however OGPE may be superior because of the ability to provide an unlimited supply of portable oxygen. An unlimited supply of portable oxygen eliminates the patient need to ration either their activities or their portable oxygen supplies, allowing for a more complete lifestyle return and an enhanced sense of independence, self-reliance and self-esteem.

Reducing the risk of patient harm resulting from falls is a hot topic for accrediting agencies and thus, by default, both acute care and homecare providers’ need to vigilantly address this issue. A particularly significant contributor to the risk of an oxygen patient falling is 50-foot clear plastic extension tubing. This tubing is ever present in the homes of patients that use a stationary concentrator as the primary ‘at-home’ oxygen source.

The significance of this risk can be viewed in relation to the effect that age has on vision and mobility. The age of the typical patient when they first start on long-term oxygen is 74 give or take eight years. At that age, the amount of light that the eye allows in is significantly reduced, dexterity is diminished and bones are more prone to fracture. While implementing the use of darker or colored tubing may have some affect in reducing risk, the risk is certainly still present. Promoting the use of OGPE around the home can help reduce the risk of falls. Small, patient refillable tanks and portable oxygen concentrators allow patients to perform activities of daily living while using a 4 foot to 7 foot cannula, eliminating the need to navigate around difficult-to-see coiled extension tubing and reducing the risk of falls.

As the source of an essentially unlimited supply of portable oxygen, OGPE products allow patients to be more active. COPD patients that are regularly active and routinely use oxygen have been shown to live longer and require less hospitalization.

Hospital administrators and discharge planners are especially interested in this last point. Section 3025 of the Patient Protection and Affordable Care Act mandates that beginning in 2015; hospitals will be financially penalized for excessive COPD 30-day readmission rates. Hospitals across the country will be compared based on 30-day readmission rates for a variety of diagnostic related groups (DRGs), and will be ranked into quartiles based on their rates of readmissions. For those hospitals in the quartile with the highest readmission rates CMS will reduce reimbursement for all Medicare covered patients and services by a predetermined amount — a situation that can cost each hospital millions of dollars.

On the other hand, hospitals that are able to substantially reduce their readmission rates, those that are rated in the quartile with the lowest readmission rates, will be rewarded by CMS sharing some of the savings derived from the reduced payments to the poorer performing hospitals. This carrot and stick approach has prompted a flurry of activity within hospitals as they seek out programs, care management models and partners to mitigate losses and potentially enhance revenue.

Providers would be wise to seize the opportunity to position themselves as more than mere vendors, but rather as partners that can provide real assistance in reducing readmissions of oxygen dependant COPD patients. Central to that effort are the aforementioned clinical benefits that OGPE provides to patients, both in improving patient outcomes and reducing readmissions.

Matching Technology to Patient Lifestyle

Matching ambulatory oxygen technology to a patient’s lifestyle necessitates consideration of both the capabilities and limitations of the technology along with the needs of the patient. Certainly each patient is different, but most share some general characteristics. These characteristics can help to identify the “typical” patient that can be treated with a standardized approach. The remaining “outlier” patients will require a different treatment approach and different technology.

What we know about the typical ambulatory patient is that they leave their home for two to six hours at a time five to six times a week. They are also 64 to 82 years old when they start on LTOT and they have the physical, visual and hearing impairments that come with age. They are also burdened with the cognitive consequences associated with COPD and prolonged hypoxia.

Transfill Technology

Currently there are three commercially available systems that fill high-pressure cylinders with oxygen derived from a concentrator. The portable components of these systems are mechanical and derived from technology that has been refined over decades.

These systems are durable, simple to operate and able to meet the ambulatory needs of the vast majority of patients. Given the performance and proven track record of transfill technology it should be given consideration for any ambulatory patient for which OGPE is being considered.

The advantages of transfill technology:

  • Meets needs of majority of ambulatory patients (95+ percent). Multiple cylinder sizes allow matching of cylinder to patient needs.
  • Proven with nearly a 10-year track record; greater than 200,000 units in use; and nearly 1 million patient applications in the United States.
  • Durable with very low failure rates in comparison to portable concentrators; and no electronics used in portable options.
  • Easy operation. Just like a standard cylinder & concentrator package, and accommodates all regulator & conserver options.
  • Broad clinical population: pediatric to higher flow patients.
  • Stationary concentrator base provides continuous flow oxygen at night .

The disadvantages of transfill technology:

  • Not FAA approved.
  • Must return to base unit to refill cylinders.
  • May require the patient to take additional cylinders for longer duration activities.

Portable Oxygen Concentrators

Portable oxygen concentrators (units that weigh less than 10 lbs) and transportable concentrators (units typically weighing 18 – 20 lbs) offer unique features that are ideal for meeting the needs of a select group of patients. POCs are ideal for the following conditions:

  • For patients that are traveling outside of their home area.
  • Patients that still work regularly and require portable oxygen for periods greater than six hours per day.
  • Patients that need portable oxygen for periods that are highly variable and unpredictable (such as outpatient dialysis, chemotherapy, etc).

The major drawback to this technology is its sophistication, which has been aptly described as “a laptop computer that makes oxygen” This is not a trivial concern. POCs are intended for use inside and outside of the home. They are exposed to motion, impacts, variations in temperature and humidity as well as inclement weather. Expecting POCs to support frequent routine use on a regular basis without experiencing higher rates of performance issues (relative to transfill technology) may be expecting too much. As previously stated, POCs are ideally suited to meet the needs of a select group of patients.

The advantages of POCs:

  • AA approval allows easy support of air travel.
  • Operates off of AC, DC and internal battery.
  • Relatively easy to operate.

The disadvantages of POCs

  • All commercially available units under 10 lbs do not offer continuous flow.
  • No consistency in pulse volumes between brands. Oxygen production& other specifications vary greatly; all POCs are not equal & some are very limited in application.
  • Anecdotal reports of frequent-regular failure
  • Expensive lithium ion batteries (which are currently not reimbursable by CMS).

Let the Patient Tell You

Now that you know the capabilities and limitations of the different OGPE technologies, the next step is to figure out which one to use on a new patient. No system is foolproof and accurate all of the time, however, a relatively simple solution is to ask the patient or their caregiver about their activities before they needed oxygen.

Try to get an understanding of the patient’s level of activity 6-months to a year ago– this should include an understanding of both activity frequency and duration. To get the patient to provide reliable answers ask non-leading, openended questions, such as “thinking about last summer, what kind of things did you do away from your home?” and “how many times in a week would you do things away from your home?”


Oxygen Generating Portable Equipment provides a trifecta of benefits. For patients, convenience, outcomes and safety are all enhanced, hospitals enjoy the potential to reduce unnecessary COPD readmissions, and providers are rewarded by reduced operating costs and improved positioning with their referral sources. Medicare guidelines specify that changing the oxygen equipment for a patient is prohibited unless one of four very specific circumstances exists.

  • The equipment is replaced with same/similar equipment (in the event the equipment breaks and needs to be replaced).
  • The patient’s physician orders different equipment (must be supported by the patient’s medical need).
  • The patient chooses to receive an upgraded item (newer technology) and signs an ABN (if the patient makes the switch after the 36th month you may not pass additional charges onto the patient).
  • Or, the DME MAC determines that a change in equipment is warranted.

Thus, it is imperative that the supplier recommend and implement the best oxygen system when the patient is first setup on LTOT. In order to make this a efficient process providers should implement a system that facilitates getting important information from the patient and the caregivers at the time of intake.

This article originally appeared in the February 2012 issue of HME Business.

HME Business Podcast