Hos­pi­tals ramp up hy­per­baric ther­apy for di­a­bet­ics

Lodi News-Sentinel - - Local / Nation - By Phil Gale­witz

The Vil­lages Re­gional Hos­pi­tal did not sweat its de­ci­sion to add hy­per­baric oxy­gen ther­apy in 2013.

Hy­per­baric treat­ment, in­creas­ingly given to di­a­bet­ics — many of them el­derly with per­sis­tent wounds — in­volves breath­ing pure oxy­gen in­side a pres­sur­ized air cham­ber typ­i­cally for two hours each week­day, of­ten for more than a month. Twenty out­pa­tient ses­sions can bring a hos­pi­tal $9,000 in rev­enue.

Vil­lages serves a cen­tral Florida re­tire­ment com­mu­nity that sup­plied nearly half of the hy­per­baric pa­tients at an­other hos­pi­tal 30 min­utes away. Hos­pi­tal of­fi­cials knew their clien­tele pre­ferred their med­i­cal ap­point­ments only a golf-cart’s ride from home.

“Wound care was a ser­vice line we saw as low-hang­ing fruit,” said Todd Pow­ell, who over­sees hy­per­baric ther­apy at Vil­lages hos­pi­tal.

Many hos­pi­tals seem to agree. En­ticed by healthy Medi­care pay­ments — about $450 for a two-hour ses­sion — and for-profit man­age­ment com­pa­nies that do much of the work, nearly 1,300 U.S. hos­pi­tals have in­stalled hy­per­baric fa­cil­i­ties. That’s triple the num­ber that an in­dus­try group says of­fered the ser­vice in 2002, when Medi­care first de­cided to pay for the ther­apy for cer­tain di­a­betic wounds.

Medi­care — the largest payer of hy­per­baric ser­vices — has flagged ev­i­dence of overuse in at least some parts of the coun­try. Medi­care of­fi­cials de­clined to com­ment for this story, but they have re­tained cov­er­age for more than 15 years, even as stud­ies have ques­tioned the ther­apy’s ef­fec­tive­ness.

The Amer­i­can Di­a­betes As­so­ci­a­tion does not rec­om­mend the treat­ment. Af­ter an ADA com­mit­tee of ex­perts in di­a­betes care re­viewed the avail­able re­search last year, it con­cluded there was “not enough sup­port­ing data on the ef­fi­cacy of this treat­ment to rec­om­mend its use,” said Wil­liam Ce­falu, the as­so­ci­a­tion’s chief med­i­cal of­fi­cer.

Some ex­perts say hy­per­baric ther­apy’s in­creased use for di­a­betic wounds owes more to hos­pi­tals’ pur­suit of Medi­care rev­enue than to the treat­ment’s proven value.

“The sci­ence re­mains poor to sup­port its use, but it is be­ing widely used (in the United States), and one pos­si­ble ex­pla­na­tion to this may be re­lated to re­im­burse­ment,” ex­plained Dr. An­drew Boul­ton, an in­ter­na­tion­ally rec­og­nized ex­pert on hy­per­baric ther­apy, and a pro­fes­sor of medicine at Univer­sity of Manch­ester med­i­cal school in Great Bri­tain.

“Some folks are chas­ing the money. It’s seen as a money grab be­cause re­im­burse­ment has been fa­vor­able,” ac­knowl­edged John Peters, ex­ec­u­tive di­rec­tor of the Un­der­sea & Hy­per­baric Med­i­cal So­ci­ety, which ac­cred­its 200 hy­per­baric oxy­gen fa­cil­i­ties na­tion­ally and has in­spected 500 for ac­cred­i­ta­tion in the past 15 years.

Of­fered at a hand­ful of hos­pi­tals in the last decades of the 20th cen­tury, hy­per­baric cham­bers were a niche treat­ment for deep-sea divers suf­fer­ing with the bends — a painful and po­ten­tially fa­tal con­di­tion where gas bub­bles ac­cu­mu­late in the blood­stream dur­ing too-rapid as­cents from depth. In 2002 — af­ter in­dus­try lob­by­ing and some sug­ges­tive re­search — Medi­care ap­proved hy­per­baric ther­apy for cer­tain di­a­betic wounds that did not re­spond to con­ven­tional treat­ments.

That de­ci­sion drove a build­ing boom in out­pa­tient wound care cen­ters over the next halfdecade, fea­tur­ing hy­per­baric ther­apy. Medi­care cov­ers the treat­ment for more than a dozen con­di­tions in which skin fails to heal, such as fail­ing grafts and tis­sue dam­age from anti-cancer from ra­di­a­tion, but the USA’s ris­ing di­a­betic pop­u­la­tion sup­plies much of the de­mand.

It costs about $500,000 to in­stall a hy­per­baric unit with two cham­bers. With Medi­care’s lu­cra­tive re­im­burse­ment poli­cies, “hos­pi­tals can gen­er­ate cash al­most im­me­di­ately,” Peters said. Dur­ing hy­per­baric ses­sions, pa­tients merely lie on a bed in a glass-en­closed tube con­tain­ing high-pres­sure oxy­gen un­der a physi­cian’s su­per­vi­sion.

The busi­ness model is so com­pelling that man­age­ment com­pa­nies typ­i­cally pay for the equip­ment and staff. Hos­pi­tals pro­vide space for the cham­ber, make pa­tient re­fer­rals and han­dle billing. The com­pa­nies and the hos­pi­tals split rev­enue from in­sur­ers.

Be­cause of poor blood cir­cu­la­tion, di­a­bet­ics are sus­cep­ti­ble to de­vel­op­ing ul­cers in their lower legs and feet that heal poorly and can some­times lead to am­pu­ta­tions. Hy­per­baric oxy­gen ther­apy, in the­ory, works by stim­u­lat­ing the body’s cre­ation of new blood ves­sels and aid­ing the for­ma­tion of new skin around a wound. Side ef­fects are un­com­mon but in­clude ear and si­nus pres­sure, paral­y­sis and air em­bolisms.

In 2015, Medi­care im­posed stricter billing pro­ce­dures in three states where its ex­penses for hy­per­baric ser­vices were 21 per­cent above the na­tional av­er­age — pos­si­ble ev­i­dence of overuse or over­billing. Providers in Illi­nois, Michi­gan and New Jer­sey must get reg­u­la­tors’ preau­tho­riza­tion of ex­penses be­fore treat­ing Medi­care pa­tients for the most com­monly ap­proved con­di­tions in non-emer­gency cases. Else­where, Medi­care re­quires doc­u­men­ta­tion sup­port­ing hy­per­baric ther­apy’s need only af­ter ser­vices be­gin.

PHIL GALE­WITZ/KAISER HEALTH NEWS

A pa­tient is placed in a hy­per­baric oxy­gen cham­ber at the Vir­ginia Hos­pi­tal Cen­ter in Ar­ling­ton, Va.

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