We’ve been in the practice of pulmonary medicine for the last 45 years. We’ve seen a large number of patients in respiratory failure. Hospitalization in an intensive or respiratory care unit may be required by some if the patient has obvious difficulty in moving air into and out of his lungs as manifested by a rise in his CO₂ level heralding CO₂ narcosis and impending coma. Then a quick intubation by placing an endotracheal tube into the trachea and attaching a mechanical ventilating machine to move the air for him can be lifesaving, slowly reducing the CO₂ retention and reducing the work of breathing so the patient can rest and sleep.

At the other end of the spectrum are COPD and ASTHMA patient that aren’t going downhill as fast and are in the early phases of respiratory failure. These can frequently be reversed by tweaking the pulmonary treatment on an outpatient basis. There are a host of options from adding antibiotics if there is evidence of associated bronchitis; increasing the bronchodilator regimen orally or by increasing the frequency of the nebulizers.

It is in this phase that management skills come into play when trying to keep the patient out of the ICU. Every pulmonary patient, whether asthmatic, COPD, chronic bronchitis, pneumonia, and others has a pulse oxygen level taken on each visit. If the oxygen saturation is dropping, this is an emergency developing. The oxygen companies have been able to deliver oxygen within two hours so we can safely allow the patient to go home and know that he will be on oxygen shortly.

This has worked very well for 45 years with huge savings in health care costs by avoiding the high rent district of the ICU which costs thousands of dollars per day.

Approximately July 1, 2014, Medicare in their cost containment mode, decided to get rid of many of the respiratory care companies who deliver the oxygen to our patients and deal with just the lower bidders. Last month we had a patient who was very short of breath. She could barely make it from her car to our office. Her oxygen saturation was 83% by the time she reached our office. It improved to 94% while resting. Medicare requires documentation of the severity of the respiratory failure. This is normally done by measuring the saturation and proceeding on a six minute walk to see how low the oxygen goes. This patient collapse within three minutes and her oxygen saturation fell to 81%. Normal arterial oxygen saturation is 95 to 99%. Normal venous oxygen saturation is 75%. The lungs bring it back up to 95%.

So we called the oxygen vender company to have oxygen delivered to this patient’s home. We assumed that she would be safely on oxygen within two hours. Unfortunately we didn’t check on this. The next day we received a phone call from the patient notifying us that the oxygen had not arrived. We called the oxygen company and were told they were processing the request. But it appeared that our request had not followed the Medicare guideline. The guidelines required the additional step of adding the oxygen and then rechecking the oxygen saturation while walking with the oxygen to make sure the oxygen was effective in correcting the hypoxemia. If resting breathing room air was effective in restoring a normal blood oxygen level, adding oxygen was not necessary at rest since she corrected at rest. She was not able to ambulate without oxygen and thus she would be bedfast without the addition of supplemental oxygen.

But the vendor manager stated that this was not valid enough. The stats had to be printed out directly from the pulse-oximeter.  Today’s visit was an urgent F/U inasmuch as the patient still has no oxygen after one month. Hence we made an urgent phone call to Apria with whom we have dealt for many years. Brianne answers the phone. She won’t give us her last name stating there is no one else with the same first name. She reviews the submission and states she wants office notes. We minded her that we have a consultative pulmonary practice, that we don’t have office notes as a family doctor may have, and all our notes are complete exams and consultations. We sent her the entire office visit for Oct 29 with the detailed oxygen saturation studies at rest and on walking along with the oxygen orders. Brianne acknowledged she had these notes, the detailed order, and the saturations that were required

Our oximeter has no printout – she stated that Medicare required a printout directly from the recording device. But the stats were recorded directly in our Electronic Medical Record – She stated that Medicare could not accept my EMR because it had my input instead of directly from the Oximeter and therefore may not be valid. We pointed out that we are a pulmonologist and had done this for 45 years and never had a problem with getting our lung failure patients who were in desperate respiratory straits get oxygen the same day. She stated they could do still get oxygen out the same day, but it had to be a valid request on valid printout forms. She stated that I was responsible for following Medicare guidelines. We asked Brianne to fax the page of Medicare Guidelines she was using so we could verify her statements in regards to a patient’s life at risk. She stated she would try but it would take a long time. But aren’t you following the Medicare guidelines to have this discussion? This is a critical disregard of a patient’s life in lung failure who can’t walk more than 20 yards before her oxygen gets so low she essentially loses consciousness if she can’t hold on to something or sit down while gasping at 30 breaths per minute. She can’t even get into her own car without collapsing and holding on to the building rails panting at 30 breaths per minute. This is a callous disregard for human life. . . We are now two months post evaluation and our patient in severe lung failure still has not received the lifesaving oxygen because of government medicine bureaucracy.

This has increased with Obamacare which delays lifesaving care, lowers the quality of care (QOC), and jeopardizes human life. This is what health care is like in UK, Canada, and much of the rest of the world. We should not have to go through the same failed experiment. The United States chartered a new world order in 1776. We shouldn’t have to deviating from own success story.

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Medical Myths originate when someone else pays the medical bills.

Myths disappear when Patients pay Appropriate Deductibles and Co-payments on Every Service.

If Patients had a financial leg in the decision, they would deal directly with Medicare to obtain oxygen.