The Science Journal of the American Association for Respiratory Care

1996 OPEN FORUM Abstracts

Pulmonary Rehabilitation In the Managed Care Environment

John. E. Hodgkin, MD Monday, November 4, 1996

There have been several definitions of Pulmonary Rehabilitation developed over the years. The American College of Chest Physicians came out with a definition back in 1974.^{1}. It says that "Pulmonary rehabilitation may be defined as an art of medical practice, wherein an individually tailored, multi-disciplinary program is formulated, which through accurate diagnosis, therapy, emotional support, and education, stabilizes or reverses both the physio- and psychopathology of pulmonary diseases and attempts to return the patient to the highest possible functional capacity allowed by his pulmonary handicap and overall life situation." An official position statement published by the American Thoracic Society in 1981,^{2} states that "Pulmonary rehabilitation really means providing good comprehensive respiratory care for patients with pulmonary disease." A group participating in a recent NIH Workshop on Pulmonary Rehabilitation came up with the following definition.^{3}. "Pulmonary rehabilitation is a multidimensional continuum of services directed to persons with pulmonary disease and their families, usually by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual's maximum level of independence and functioning in the community." Characteristics of current pulmonary rehabilitation programs based on a recent national survey are to be published in the November/December 1995 issue of the Journal of Cardiopulmonary Rehabilitation.

The justification for Pulmonary Rehabilitation and how it is delivered will change significantly under a Managed-Care environment. Employers and insurance companies are very aware of the 80/20 rule. This rule says that in a typical group, approximately 20% of the individuals account for 80% of the health care costs. Then percent of the individuals account for 70% of the cost, and one percent for 30% of the cost. If you can find out who is costing you the money, and can manage them in a way that reduces their need for ER visits and hospital visits, it's going to save a lot of money in a capitation environment. Disease Management is a comprehensive, integrated approach to care, based on the natural course of a disease, with treatment designed to prevent and/or minimize the impact of an illness. It is a concept based on the premise that providers using this approach can generate better health outcomes at lower costs. Physicians and hospitals have got to lower the cost of what they are doing or they won't be providers in the future.

One of the problems with the way we are providing care now is that the emphasis is on treatment rather than prevention. The reason is simple. Most insurance companies, including Medicare, pay for treatment, but not for prevention. There is often an uncoordinated delivery system which lacks for any continuity of care. Few are currently crossing geographic barriers e.g. from ICU, to acute care hospital units, to skilled nursing units, to homes to look at what is happening in these various settings. There are conflicting incentives between hospitals and physicians. Under DRG's, the longer the patient stays in the hospital, the more money the physician gets paid. The shorter the stay in the hospital, the more money the hospital makes. So, we're in conflict.

Under the principles of disease management you focus on prevention. In a capitation environment an integrated delivery system will be given a set amount of money, and can spend the money anyway it sees fit. Now, prevention principles become very important to keeping people out of the emergency room and the hospital. It is important that we understand a disease's natural course. We should diagnose and treat based on the disease, not reimbursement. Patients and families must be educated to raise compliance for better chronic disease outcomes. We must direct resources towards the best, most cost-effective approaches.

At a recent meeting on Disease Management, the following statement was made: "A disease management program for asthma might involve significant training for patients and families, such as the highly successful program at National Jewish Center for Immunology and Respiratory Medicine in Denver. There, high-risk patients spend a week learning about this disease. After learning about their disease, patients are almost 50% more likely to avoid hospitalization in the six months following treatment compared with those receiving routine medical management."^{4} What is being described in this statement is precisely what pulmonary rehabilitation programs do for individuals with asthma and COPD.

The clear incentive for Disease Management is cost savings in a capitated environment. Two things will be necessary in order to practice Disease Management: (1) a well integrated delivery system which has the capability to follow patients and influence care across treatment settings, and (2) a good system for gathering and assessing information so as to be able to identify problem areas.

In the past, pulmonary rehabilitation programs were justified on the basis that they improved the patient's ability to function, and generated revenue for the facility housing the program. In the future, such programs will be justified not only because they improve a patient's level of function, but because they save money for the hospital and physicians under capitation.


1. Petty TL. Pulmonary rehabilitation. Basics of RD. New York: American Thoracic Society, 1975. 2. American Thoracic Society. Position statement on pulmonary rehabilitation. Am Rev Respir Dis 1981; 124:663. 3. NIH Workshop on Pulmonary Rehabilitation Research. Am J Respir and Crit Care Med 1994; 149:507. 4. Zitter M. Disease Management: a new approach to health care. Medical Interface. Aug 1994.

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