Basic and Advanced Pleural Procedures: Coding and Professional Fees Update for Pulmonologists.

There is an evolution of pleural procedures that involve broadened clinical indication and expanded scope that include advanced diagnostic, therapeutic, and palliative procedures. Finance and clinical professionals have been challenged to understand the indication and coding complexities that accompany these procedures. This article describes the utility of pleural procedures, the appropriate current procedural terminology coding, and necessary modifiers. Coding pearls that help close the knowledge gap between basic and advanced procedures aim to address coding confusion that is prevalent with pleural procedures and the risk of payment denials, potential underpayment, and documentation audits.

Financial Justification for Interventional Pulmonology Programs: Terminology and Programmatic Models.

Interventional pulmonology programs provide clinical benefit to patients and are financially sustainable. To appreciate and illustrate the economic value of interventional pulmonology programs to hospital systems, physicians must have an understanding of basic health-care finance. Total revenue, adjusted gross revenue, contribution margin, variable direct costs, and indirect costs are terms that are essential for understanding the finances of bronchoscopy. Command of such vocabulary and its application is crucial for interventional pulmonologists to successfully establish financially sustainable bronchoscopy programs. Two significant features of an economically sustainable bronchoscopy program are high procedural volume and low direct cost per case. Interventional pulmonology programs are valuable to the patients being served and hospitals as a whole. Consideration of the various factors needed to maintain financial sustainability is essential to improve the quality of care for patients because the cost of care remains a critical driver in defining value.

Basic Primer for Finances in Academic Adult and Pediatric Pulmonary Divisions.

The finances of academic medical centers (AMCs) are complex and rapidly evolving. This financial environment can have important effects on faculty expectations, compensation, and the work environment. This article describes the commonly used concepts and models related to financial decision-making in Pulmonology and Critical Care divisions across AMCs in the United States. Faculty clinical productivity is often measured by work relative value units, which are set nationally for a discrete piece of physician work and attempt to equilibrate aspects of care across specialties. The expected clinical productivity and salary for a given faculty member are often determined relative to one or more national benchmarks developed from data submitted by departments and schools across the country. The most commonly used benchmarks include those from the Association of American Medical Colleges and the Medical Group Management Association. Changes to the paradigm of fee for service reimbursement are beginning to change physician compensation and incentive structures. In addition, research and education are key academic missions for faculty. It is important to understand the limitations of extramural research funding and implications for the support of research infrastructure. Measurements of productivity within education have been less codified, but some centers are attempting to create educational relative value units similar to those used in clinical productivity. In summary, faculty should understand basic concepts of finances. This knowledge includes a common set of terms and concepts that can help all faculty understand basic financial considerations in their work and lead to success for their divisions.

Funding sources and effects of limited funding in pediatric pulmonology fellowship programs.

BACKGROUND: The pediatric pulmonology workforce is at risk. Access to pediatric pulmonologists to meet patient needs is limited and recruitment of new trainees to replace the aging, retiring physician population may be inadequate. Furthermore, sources of funding for graduate medical education are insecure. However, no prior studies have identified the funding sources of pediatric pulmonology fellowships or the effects of funding constraints. METHODS: We conducted a national survey of pediatric pulmonology training directors (PPTD) in the United States between 1 November, 2016 and 9 February, 2017 to examine the sources of funding for pediatric pulmonary fellows and the effect of funding limitations. RESULTS: We obtained data from 48 PPTD, representing 89% of pediatric pulmonology programs (N = 54). Limitations in funding restricted program size in 31% of programs. A significant number of programs had no funding to cover educational resources such as advanced degrees (38%), courses (23%), society membership (25%), and journals and books (15%). Twenty seven percent of PPTD perceived their program as financially insecure for academic year 2019 and beyond. CONCLUSIONS: Insufficient funding has limited the size of pediatric pulmonology programs and access to important educational resources. It is critical to ensure that there is adequate funding for pediatric pulmonology fellowship programs, as insecurity further endangers the pediatric pulmonology workforce and future provision of care for children with respiratory diseases.

Direct costs of overdiagnosed asthma: a longitudinal, population-based cohort study in British Columbia, Canada.

OBJECTIVES: A current diagnosis of asthma cannot be objectively confirmed in many patients with physician-diagnosed asthma. Estimates of resource use in overdiagnosed cases of asthma are necessary to measure the burden of overdiagnosis and to evaluate strategies to reduce this burden. We assessed differences in asthma-related healthcare resource use between patients with a confirmed asthma diagnosis and those with asthma ruled out. DESIGN: Population-based, prospective cohort study. SETTING: Participants were recruited through random-digit dialling of both landlines and mobile phones in the province of British Columbia, Canada. PARTICIPANTS: We included 345 individuals ≥12 years of age with a self-reported physician diagnosis of asthma. The diagnosis of asthma was reassessed at the end of 12 months of follow-up using a structured algorithm, which included a bronchodilator reversibility test, methacholine challenge test, and if necessary medication tapering and a second methacholine challenge test. PRIMARY AND SECONDARY OUTCOME MEASURES: Self-reported annual asthma-related direct healthcare costs (2017 Canadian dollars), outpatient physician visits and medication use from the perspective of the Canadian healthcare system. RESULTS: Asthma was ruled out in 86 (24.9%) participants. The average annual asthma-related direct healthcare costs for participants with confirmed asthma were $C497.9 (SD $C677.9) and for participants with asthma ruled out, $C307.7 (SD $C424.1). In the adjusted analyses, a confirmed diagnosis was associated with higher direct healthcare costs (relative ratio (RR)=1.60, 95% CI 1.14 to 2.22), increased rate of specialist visits (RR=2.41, 95% CI 1.05 to 5.40) and reliever medication use (RR=1.62, 95% CI 1.09 to 2.35), but not primary care physician visits (p=0.10) or controller medication use (p=0.11). CONCLUSIONS: A quarter of individuals with a physician diagnosis of asthma did not have asthma after objective re-evaluation. These participants still consumed a significant amount of asthma-related healthcare resources. The population-level economic burden of asthma overdiagnosis could be substantial.

Value-Based Proposition for a Dedicated Interventional Pulmonology Suite: An Adaptable Business Model.

Value-based care is evolving with a focus on improving efficiency, reducing cost, and enhancing the patient experience. Interventional pulmonology has the opportunity to lead an effective value-based care model. This model is supported by the relatively low cost of pulmonary procedures and has the potential to improve efficiencies in thoracic care. We discuss key strategies to evaluate and improve efficiency in interventional pulmonology practice and describe our experience in developing an interventional pulmonology suite. Such a model can be adapted to other specialty areas and may encourage a more coordinated approach to specialty care.

Cost-effectiveness of KRAS, EGFR and ALK testing for decision making in advanced nonsmall cell lung carcinoma: the French IFCT-PREDICT.amm study.

ALK rearrangement and EGFR/KRAS mutations constitute the primary biomarkers tested to provide targeted or nontargeted therapies in advanced nonsmall cell lung cancer (NSCLC) patients. Our objective was to assess the cost-effectiveness of biomarker testing for NSCLC.Between 2013 and 2014, 843 treatment-naive patients were prospectively recruited at 19 French hospitals into a longitudinal observational cohort study. Two testing strategies were compared, i.e. with "at least one biomarker status known" and "at least KRAS status known", in addition to "no biomarker testing" as the reference strategy. The Kaplan-Meier approach was employed to assess restricted mean survival time. Direct medical costs incurred by hospitals were estimated with regard to treatment, inpatient care and biomarker testing.Compared with "no biomarker testing", the "at least one biomarker status known" strategy yielded an incremental cost-effectiveness ratio of EUR13 230 per life-year saved, which decreased to EUR7444 per life-year saved with the "at least KRAS status known" testing strategy. In sensitivity analyses, biomarker testing strategies were less costly and more effective in 41% of iterations.In summary, molecular testing prior to treatment initiation proves to be cost-effective in advanced NSCLC management and may assist decision makers in defining conditions for further implementation of these innovations in general practice.

Investigating the cost implications of including all respiratory medicines in PCRS schemes.

AIM: This study estimates the additional cost to the State to pay for all respiratory medicines through the Primary Care Reimbursement Service (PCRS) schemes, reducing cost barriers to medication as a complement to existing chronic disease management programmes. Previous literature found higher medication adherence rates amongst medical card patients than those that had to pay or co-pay themselves. METHOD: A review of medication expenditure on the PCRS schemes from 2005 to 2015. Data on medicines sold into and out of pharmacies was used to estimate the proportion to PCRS schemes or private. Scenario analyses were conducted to estimate what the cost to the State would be to provide funding for all respiratory medicines. RESULTS: Trend analysis findings showed that respiratory medicines have been less than 10% of total PCRS medicine expenditure for the years reviewed. The largest portion of the respiratory medicine expenditure is allocated to 'drugs for obstructive pulmonary disorder' (OPD), ranging from 90% in 2005 to 69% in 2015. Eighty-seven per cent of drugs to treat OPD are dispensed publicly and 13% privately. A scenario analysis estimated that the extra cost to the State to be €20.2 m. CONCLUSIONS: Respiratory disease is included in the Irish Government's chronic disease management programme. This aims to deliver optimal care in the most appropriate setting so as to improve health outcomes and quality of life. Medication adherence is imperative to achieving these aims. Reducing cost barriers as a complement to other initiatives may improve medicine adherence thereby improving the effectiveness of disease management and patient outcomes.

Bronchoscopy in Nigerian Clinical Practice: A Survey of Medical Doctors' Perception, Use and Associated Challenges.

BACKGROUND: Bronchoscopy is a vital diagnostic and therapeutic procedure in pulmonological practice. The aim of this study was to determine the perception, use and challenges encountered by Nigerian medical doctors involved in this procedure. MATERIALS AND METHODS: A cross-sectional study was conducted among 250 medical doctors recruited from three major tertiary institutions in Nigeria between September 2013 and June 2014. A semi-structured questionnaire was self-administered to adult physicians, paediatricians, and surgeons as well as their trainees to obtain their perception, use and associated challenges in the use of bronchoscopy in clinical practice. RESULTS: The majority (91.6%) of the respondents perceived bronchoscopy as a beneficial procedure to respiratory medicine. However, 59.2% of them were not aware of the low mortality rate associated with this procedure. The commonest indications for bronchoscopic use were foreign body aspiration (88.8%) and management of lung tumors (75.6%). Only 21 (8.4%) of the respondents had received formal training in bronchoscopy. Very few procedures (1-5 cases per month) were performed. The respondents identified the lack of formal training in the art of bronchoscopy as the foremost challenge facing its practice in Nigeria. In addition, availability of bronchoscopes, level of awareness, knowledge of the procedure among medical doctors and the cost of the procedure were the challenges faced by the medical doctors. CONCLUSION: There is an urgent need to equip training centers with modern bronchoscopic facilities. In addition,well-structured bronchoscopic training programme is imperative to enhance the trainees' proficiency for the furtherance of bronchoscopic practice.

NSFC spurs significant basic research progress of respiratory medicine in China.

Over the years, research in respiratory medicine has progressed rapidly in China. This commentary narrates the role of the National Natural Science Foundation of China (NSFC) in supporting the basic research of respiratory medicine, summarizes the major progress of respiratory medicine in China, and addresses the main future research directions sponsored by the NSFC.

Tele-monitoring of ventilator-dependent patients: a European Respiratory Society Statement.

The estimated prevalence of ventilator-dependent individuals in Europe is 6.6 per 100 000 people. The increasing number and costs of these complex patients make present health organisations largely insufficient to face their needs. As a consequence, their burden lays mostly over families. The need to reduce healthcare costs and to increase safety has prompted the development of tele-monitoring for home ventilatory assistance.A European Respiratory Society Task Force produced a literature research based statement on commonly accepted clinical criteria for indications, follow-up, equipment, facilities, legal and economic issues of tele-monitoring of these patients.Many remote health monitoring systems are available, ensuring safety, feasibility, effectiveness, sustainability and flexibility to face different patients' needs. The legal problems associated with tele-monitoring are still controversial. National and European Union (EU) governments should develop guidelines and ethical, legal, regulatory, technical, administrative standards for remote medicine. The economic advantages, if any, of this new approach must be compared to a "gold standard" of home care that is very variable among different European countries and within each European country.Much more research is needed before considering tele-monitoring a real improvement in the management of these patients.

Rapid onsite evaluation: A comparison of cytopathologist and pulmonologist performance.

BACKGROUND: Rapid onsite evaluation (ROSE) has several potential benefits but also can prolong procedures if one must wait for a cytopathologist, and it can involve a considerable time commitment on the part of the cytopathologist. At the University of Arkansas for Medical Sciences, interventional pulmonologists have routinely reviewed cytology specimens. This study was performed to determine prospectively how accurately pulmonologists could perform ROSE and whether they could contribute to the efficiency of the process. METHODS: For sequential cases, the procedural pulmonologist documented a ROSE reading before the reading by the cytopathologist. Readings were compared between the two for agreement and for accuracy. The time commitment for the cytopathologist was also recorded. RESULTS: One hundred sixty-four sites were biopsied in 102 patients. With respect to onsite adequacy, there was a high level of concordance between pulmonology and cytopathology as evidenced by the κ score ( ± standard error) of 0.72 ± 0.15 and by disagreement in only 3 cases (2%). For the diagnostic category, there was once again a high level of concordance; there was agreement in 141 of the 164 cases (86%), and the weighted κ score was 0.89 ± 0.02. The cytopathologist's time in the endoscopy suite averaged 4.02 ± 6.9 minutes per procedure. CONCLUSIONS: Procedural pulmonologists can effectively learn enough cytology to be able to make ROSE a collaborative process and to greatly increase the efficiency of the cytopathologist.

Pre-clinical medical student experience in a pediatric pulmonary clinic.

OBJECTIVE: Our objective was to evaluate the educational value of introducing pre-clinical medical students to pediatric patients and their families in a subspecialty clinic setting. METHODS: First- and second-year medical students at the University of Michigan seeking clinical experience outside of the classroom attended an outpatient pediatric pulmonary clinic. Evaluation of the experience consisted of pre- and post-clinic student surveys and post-clinic parent surveys with statements employing a four-point Likert scale as well as open-ended questions. RESULTS: Twenty-eight first-year students, 6 second-year students, and 33 parents participated in the study. Post-clinic statement scores significantly increased for statements addressing empathic attitudes, confidence communicating with children and families, comfort in the clinical environment, and social awareness. Scores did not change for statements addressing motivation, a sense of team membership, or confidence with career goals. Students achieved their goals of gaining experience interacting with patients, learning about pulmonary diseases, and observing clinic workflow. Parents felt that they contributed to student education and were not inconvenienced. CONCLUSIONS: Students identified several educational benefits of exposure to a single pediatric pulmonary clinic. Patients and families were not inconvenienced by the participation of a student. Additional studies are warranted to further investigate the value of this model of pre-clinical medical student exposure to subspecialty pediatrics.

Comparative study on health care utilization and hospital outcomes of severe acute exacerbation of chronic obstructive pulmonary disease managed by pulmonologists vs internists.

BACKGROUND: Care for many chronic health conditions is delivered by both specialists and generalists. Differences in patients' quality of care and management between generalists and specialists have been well documented for asthma, whereas a few studies for COPD reported no differences. OBJECTIVE: The objective of this study is to compare consistency with Global initiative for chronic Obstructive Lung Disease guidelines, as well as rate, health care utilization, and hospital outcomes of severe acute exacerbation (AE) of COPD patients managed by pulmonologists and internists. MATERIALS AND METHODS: This is a 12-month prospective, comparative observational study among 208 COPD patients who were regularly managed by pulmonologists (Group A) and internists (Group B). Clinical data, health care utilization, and hospital outcomes of the two groups were statistically compared. RESULTS: Out of 208 enrolled patients, 137 (Group A) and 71 (Group B) were managed by pulmonologists and internists, respectively. Pharmacological treatment corresponding to disease severity stages between the two groups was not statistically different. Group A received care consistent with guidelines in terms of annual influenza vaccination (31.4% vs 9.9%, P<0.001) and pulmonary rehabilitation (24.1% vs 0%, P<0.001) greater than Group B. Group A had reduced rates (12.4% vs 23.9%, P=0.033) and numbers of severe AE (0.20±0.63 person-years vs 0.41±0.80 person-years, P=0.029). Among patients with severe AE requiring mechanical ventilation, Group A had reduced mechanical ventilator duration (1.5 [1-7] days vs 5 [3-29] days, P=0.005), hospital length of stay (3.5 [1-20] days vs 16 [6-29] days, P=0.012), and total hospital cost ($863 [247-2,496] vs $2,095 [763-6,792], P=0.049) as compared with Group B. CONCLUSION: This study demonstrated that pulmonologists followed national COPD guidelines more closely than internists. The rates and frequencies of severe AE were significantly lower in patients managed by pulmonologists, and length of hospital stay and cost were significantly lower among the patients with severe AE who required mechanical ventilation.

Use of computational fluid dynamics in respiratory medicine.

Computational Fluid Dynamics (CFD) is a computer-based tool for simulating fluid movement. The main advantages of CFD over other fluid mechanics studies include: substantial savings in time and cost, the analysis of systems or conditions that are very difficult to simulate experimentally (as is the case of the airways), and a practically unlimited level of detail. We used the Ansys-Fluent CFD program to develop a conducting airway model to simulate different inspiratory flow rates and the deposition of inhaled particles of varying diameters, obtaining results consistent with those reported in the literature using other procedures. We hope this approach will enable clinicians to further individualize the treatment of different respiratory diseases.

An official American Thoracic Society/American College of Chest Physicians policy statement: the Choosing Wisely top five list in adult pulmonary medicine.

The American Board of Internal Medicine Foundation's Choosing Wisely campaign aims to curb health-care costs and improve patient care by soliciting lists from medical societies of the top five tests or treatments in their specialty that are used too frequently and inappropriately. The American Thoracic Society (ATS) and American College of Chest Physicians created a joint task force, which produced a top five list for adult pulmonary medicine. Our top five recommendations, which were approved by the executive committees of the ATS and American College of Chest Physicians and published by Choosing Wisely in October 2013, are as follows: (1) Do not perform CT scan surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines; (2) do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (groups II or III pulmonary hypertension); (3) for patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia; (4) do not perform chest CT angiography to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay; (5) do not perform CT scan screening for lung cancer among patients at low risk for lung cancer. We hope pulmonologists will use these recommendations to stimulate frank discussions with patients about when these tests and treatments are indicated--and when they are not.

Transitional care management reimbursement to reduce COPD readmission.

Reducing preventable readmissions for COPD is an important national health policy goal. Thus far, Centers for Medicare & Medicaid Services (CMS) policies focused on incentivizing improvements in inpatient quality have had variable success. In its 2013 physician-payment rule, CMS announced new payments that reimburse ambulatory care providers for timely posthospital visits and transitional care management services. CMS hopes that posthospital transitional care and services will substitute for readmission, but the evidence supporting this hypothesis is mixed. In this article, we discuss ways for ambulatory pulmonologists to leverage transitional care management payments to enhance access for their patients with COPD while minimizing the risk of a paradoxic increase in readmission rates.