Payment Reform as a Means of Achieving Justice

Abstract

Pulmonary rehabilitation (PR) is an evidence-based therapeutic option for patients with chronic respiratory diseases, particularly COPD. PR has been shown to reduce the number of hospital days for patients with COPD, acute COPD exacerbations, and hospital readmissions, which are clinical endpoints with a high impact on quality of life and health care costs. 1 Additionally, multiple studies have demonstrated that PR is equally or more cost-effective than tiotropium or long-acting bronchodilators, which are mainstays of current COPD treatment. 2 Access to PR and Implications on Justice Despite its many benefits, PR is severely underutilized, with only approximately 3% of Medicare beneficiaries with COPD receiving PR. 3 This is particularly true among vulnerable populations; white race, higher socioeconomic status, insurance plans with higher reimbursements rates, and proximity to urban areas are associated with increased PR use. 4 During the periexacerbation period of COPD in particular, the efficacy of PR on recovery, survival, and readmission is more dramatic, yet its inaccessibility is even more pronounced. 5

Cardiovascular and Pulmonary Research: The Year (2021) in Review

“…However, reimbursement for PR is less than half that of cardiac rehabilitation and dramatically less than other outpatient services, such as echocardiograms and pulmonary function tests. 4 Additionally, PR remains severely underutilized, with only an estimated 3% of Medicare beneficiaries utilizing this benefit. 4 It is likely even less utilized in the most vulnerable populations in the United States, making PR a health inequity.…”

“…4 A health inequity is defined as a difference in a health outcome or in the distribution of health resources between population cohorts caused by avoidable systemic structures rooted in racial, social, environmental, or economic injustice. 4…”

“…Soled et al 4 recently published an opinion essay in the Humanities Vantage section of CHEST describing payment reform as a means of achieving justice in the realm of PR. The authors first described 3 separate bioethical frameworks of justice, egalitarian, utilitarian, and distributive, followed by how our current systems fails to meet each ethical framework.…”

“…The authors first described 3 separate bioethical frameworks of justice, egalitarian, utilitarian, and distributive, followed by how our current systems fails to meet each ethical framework. 4 The egalitarian framework would have equal treatment of all people, with strict distribution of PR equally to all people regardless of attributes or characteristics. 4 This framework would likely require a first come, first serve or random selection policy to ensure equal distribution to the public.…”

Cardiovascular and Pulmonary Research: The Year (2022) in Review

“…During the research year in review education session at the APTA's CSM of 2022, one of the presented articles described PR as a health inequity. 27 A health inequity was defined as “a difference in a health outcome or in the distribution of health resources between population cohorts caused by avoidable systemic structures rooted in racial, social, environmental, or economic injustice.” 27 Home-based PR does not fully address all of the inequities that exist for PR, however it may improve access for patients who otherwise were without access to PR. With emerging data (from this SRMA primarily) describing the noninferiority of home-PR compared to center-PR, physical therapists and other health care workers may consider educating their patients about home-PR as a mode of PR delivery.…”