QUESTION 11. What do you think the Respiratory Therapist of the .docx

QUESTION 1
1. What do you think the Respiratory Therapist of the Future
should look like (education level, duties) and why do you think
this would be beneficial for the health care community as a
whole?
QUESTION 2
1. During class we investigated what it is like to work as an RT
in other countries. We discussed the UK health model and the
US health model. Briefly describe the difference between the
two (i.e. who performs the duties of an RT in the UK model vs
US model).
QUESTION 3
1. What steps do you have to take to work as a Respiratory
Therapist in Ohio once you graduate here on May 7th?
QUESTION 4
1. In class we investigated what the licensing process is in other
states. Which state has no licensing requirement? For those
states that do require a license, name 4 documents that need to
be submitted to gain licensure.
QUESTION 5
1. What is one leadership trait that you think is most important
and why?

QUESTION 6
1. Why do you think it's important to develop a system for
establishing RT workloads?
QUESTION 7
1. Explain the difference between a HMO, a PPO, and a POS
health insurance plan.
QUESTION 8
1. When it's time to choose a health insurance policy, what
features or costs of the various options will you prioritize and
why?
Reimbursement
Health Insurance in the US
Health insurance:
You pay a company a monthly fee
When you get sick, the hospital/physician/etc sends a bill to
your insurance company and they pay for the services provided
If there is any portion of the bill left you pay for the remainder
out of pocket or the physician/hospital waives the remainder
Typically, regular services (i.e. physician visit) have a “co-pay”
which is a set fee ($10, $20, etc) that you pay for each visit

Health Insurance in the US
MOST US citizens fall into one of the following categories:
Employer plan
Your employer pays a portion of your monthly fee for you, to
ensure they have healthy employees who can work
Typically these plans offer good coverage and you only pay $50
to $100 per month, which is taken right out of your pay check
COBRA: if you leave your job/are fired, your employer is
legally obligated to offer you the ability to keep your health
insurance at full price (you pay your share AND your employers
share, typically upwards of $500 per month)
Private plan
VERY EXPENSIVE for the patient
Either you don’t have an employer or your employer does not
offer insurance, you have to find your own plan which can run
upwards of $500 per month
Government plan
Medicare: covers people 65 and older
Medicaid: covers people with disabilities and in certain low-
income groups
History of Health Insurance in the US
So how did we end up with our current health insurance system?
1800s: Most workers were tradesmen, working in extremely
dangerous industrial environments (i.e. steel mills)
By 1907, death and dismemberment were causing a 10% loss in
the workforce
The industry recognized that people were risking their lives and

livelihood without any safety net– employers and unions began
offering “accident insurance” that offered disability, death, and
burial benefits
Modern group insurance can be traced to about 1910
History of Health Insurance in the US
About the 1920s, doctors and hospitals started charging more
than the average American could realistically pay (this gap
widen as the depression grew worse)
During WWII (1940s), the government actually froze wages
Employers could not offer higher wages to attract and keep
employees, so instead they tried to offer the most enticing
‘benefit package’
During their rise from 1940s to 1990s, healthcare packages
continued to cover more and more expense shifting the cost of
healthcare out of the patient’s pocket
1965: the government created Medicare and Medicaid to help
those who were not likely to be working and therefore didn’t
have access to insurance (elderly and disabled)
By 1995, approximately ½ of healthcare costs were covered by
private insurance and ½ were covered by the government
through Medicare/Medicaid services
Types of Insurance Plans
HMO
Health Maintenance Organization
All medical services must be provided by doctors and hospitals
who have a contract with the HMO
Any care provided outside the HMO is not covered
PPO

Preferred Provider Organization
Medical services are provided at a discounted rate by doctors
and hospitals with a contract
Other care provided is at higher cost but still covered
POS
Point of Service
Blend of the other 2 plans
The Social Security Act of 1965
Prior to 1965, insurance was primarily tied to the employer (no
job = no insurance)
The Social Security Act created Medicare and Medicaid
Medicare for the elderly (65 years +)
Medicaid for the poor and disabled
Currently, these 2 programs are the largest payors for healthcare
in the US
Medicare Parts A, B, C, D
A: covers hospital services
B: physician services
C: aka Medicare Advantage, a network plan where the federal
government essentially pays for private health coverage (only
about 26% of enrollees are under this plan)
D: covers outpatient prescription drugs exclusively through
private prescription drug plans (added in 2006)
CMS (Centers for Medicare and Medicaid) oversees the
administration of these programs
Understanding Billing and Coding
In order for physicians and hospitals to send a bill, the
insurance company needs to know what they are paying for

To expedite this, codes have been implemented so each
treatment and disease fits nicely into a category
Basics
DRG = Diagnosis Related Group
Developed by Medicare, lumps patients in groups based on
diagnosis, procedure, and demographic data
These groups have similar length of stay and consumption of
hospital resources
Helps estimate the cost of each hospital admission
ICD-9 and ICD-10 = International Classification of Diseases
Universal numerical code assigned to diagnosis
Ensures that insurance company knows what diagnosis the
patient had for that particular treatment
CPT or CPT-4 = Current Procedural Terminology
Universal numerical code assigned to procedures
Each procedure will have an attached ICD code
Diagnosis can change the amount of money covered or even
exempt coverage
Reimbursement Models for Hospital Stays
DRGs:
Payment is per admission based on established estimates
Length of stay and individual charges do not matter, the
hospital will ONLY receive the lump sum associated with that
DRG
Overages are eaten by the hospital
Used by Medicare and some private insurance plans
Per-stay Model:
Payment is per admission based on established estimates
Typically assigned to categories such as: obstetrical, neonatal,
medical, and surgical

Length of stay and individual charges do not matter, the
hospital will receive the lump sum associated with that category
Per Diem Model:
Payment is per day based on established estimates
Very similar to above, only the sum is based on 1 day
Length of stay will effect sum, charges do not
Percent of Charges:
Payment is calculated based on a percentage of total charges
Insurance agrees to pay up to a certain percentage of the billed
charges
Both length of stay and charges effect sum
Reimbursement for Outpatient Services
APC/HCPCS Codes
Uses APC (Ambulatory Patient Classification) and HCPCS
(Healthcare Common Procedure Coding System) codes to
determine payment rate for similar clinical characteristics and
costs
Specific values are placed on procedures linked with similar
diagnostic codes, and CMS will only pay that value (similar to
the DRG model of inpatient care)
Many private insurance companies follow this model and prices
set by CMS
RVUs (Relative Value Units):
Used by many private insurance companies and sometimes CMS
Sets a value in “units” tied to specific CPT codes (specific
procedures)
The number of RVUs assigned to the procedure is determined
by:
The physician’s time and level of skill required (52%)
Practice expense or overhead cost: made up of costs of
maintaining a practice, including rent, equipment, supplies and
non-physician staff costs (44%)

Malpractice expense or professional liability (4%)
The number of RVUs assigned then determines how much they
can charge (higher the RVUs, higher the cost of the procedure)
Laws and Regulations
Stark Law:
Prohibits physicians from referring Medicare/Medicaid patients
to an outside entity in which the physician or their immediate
family has a financial relationship (i.e.: physician also owns an
oxygen company, they can’t refer their COPD patients to that
company to get all their oxygen)
Anti-Kickback Statute:
Physicians cannot receive gifts or cash in exchange for patient
referrals
False Claims Act:
Cannot file a ‘claim’ that is fabricated (i.e.: physician charges
CMS for a procedure that a patient never received)
EMTALA (Emergency Treatment and Labor Act):
Hospitals MUST examine and stabilize patients experiencing an
emergency without consideration of insurance or ability to pay
Creating a Vision for Respiratory Care:
Future of Health Care—2015 and Beyond, Part II
AARC Initiative 2015

Summary of future trends in health care enterprise of the US
Primary emphasis will be on changes which will
Improve quality
Decrease cost
Increased emphasis on care of individuals with chronic
conditions (e.g. COPD) since frequency of these patients will
increase as baby boomers age.
There will be an increased focus on wellness and prevention,
since this is more cost-effective than high-tech, episodic, acute
care
An increasing proportion of health care will be delivered in
lower-cost, non-acute care facilities
Increases in technology will continue to make the cost of
episodic, acute care more and more effective, but also more and
more expensive
Information technology will continue to play a greater and
greater role in the delivery of Health care services
Electronic medical records
Telemedicine
Telecare
Increased convenient access to information (e.g. evidence based
medicine)
Patients and families will be able to learn more about their
conditions and participate more actively in their own care
The use of protocols will continue to expand
Respiratory care technology will continue to expand

Closed-loop mechanical ventilation
More sophisticated monitoring of patients
More sophisticated diagnostic instruments
Drugs will become more numerous and sophisticated
More delivered by aerosol including drugs for organs other than
the lungs
Designer drugs
Gene therapy
Simpler and more efficient extra corporeal gas exchange devices
More and more respiratory care will be delivered outside the
hospital arena
LTAC’s
Physician offices
Home
Fee for service clinics and urgent care centers
The respiratory therapist will become more and more involved
in research and education
A Vision for the RT of the Future
The second 2015 and Beyond Conference identified the
competencies that will be required of a graduating Respiratory
Therapist in the future. Seven competency areas were
identified:
Diagnostics
Disease management
Evidence-based medicine and respiratory care protocols

Patient assessment
Leadership
Emergency and critical care
Therapeutics
Within each competency area specific competencies were
further identified. A total 73 individual competencies were
identified
How identified competencies match the future trends in
respiratory aspects of health care
Two factors are driving the changes listed above
Demand for cost reduction
Demand for quality improvement
Cost reduction
Strategies for reducing healthcare costs are being implemented
throughout the industry
These include
Increasing productivity
Greater emphasis on wellness
One mechanism for making more efficient use of staff is the
development of multidisciplinary care teams where a function is
carried out by a team rather than someone from just one
specialty (e.g. nursing)
One area where this is occurring is in the area of case
management and disease management.
RT’s are slowly moving into this area once dominated

completely by RN’s
RT’s are beginning to assume leadership roles when cases have
a primarily respiratory focus
Development of multidisciplinary Rapid Response Teams in the
hospital which always include RT’s as members helps to
identify patients at risk for ICU admission and treat before that
occurs. Respiratory distress is the number one reason for rapid
response calls.
Demand for quality improvement
Reduction of medical errors
Certain occurrences have been classified as “sentinel events”
which are not reimbursable by the federal government. Private
insurance has adopted the same standards
VAP
Skin breakdown
Readmission following discharge within a certain time frame for
certain conditions such as COPD exacerbation, CHF,
pneumonia. These are among the most common conditions
resulting in readmission
Preventing these occurrences has already resulted in cooperative
care teams in the ICU in the case of VAP and skin breakdown
This will require development of new models of care,
emphasizing follow-up of patients, identifying problems before
they require rehospitalization, and modification of therapy once
the patient is out in the community (home or skilled nursing
center)
The skill set of the RT is uniquely suited to deal with patients
with these conditions.
The development of leadership skills will be necessary for RT’s

to move into leadership roles in the area of health care.
Use of protocols
Research has shown that protocols both lower costs and improve
patient care
Decrease medical errors
Identify the most appropriate treatment since they are usually
based on published evidence
Decrease frequency of unneeded treatment
Result in earlier cessation of treatment
Delivery of respiratory therapy by protocol has been defined by
the AARC as “Initiation or modification of a patient care plan
following a predetermined, structured set of physician orders,
instructions or interventions in which the therapist is allowed to
initiate, discontinue, refine, transition, or restart therapy as the
patient’s medical condition dictates.”
First respiratory protocols were developed in the 1980’s. Today
most protocols are for therapy outside of the critical care arena.
The future will see the development of more and more protocols
for use in the ICU (e.g. therapist driven ventilatory management
protocols).
Therapists should not use protocols but should play a role in
their development. This will require a whole new skill set.

The therapist in the critical care environment
Mechanical ventilation is the major competency area in the ICU.
The graduate RT must be prepared to enter the ICU as an expert
in mechanical ventilation.
Know the appropriate application of various modes of MV (e.g.
VC, PC, SIMV-PSV, HFOF, APRV, NIV, etc) and how they are
best applied to severe respiratory disease states (e.g. ARDS,
trauma, COPD, sepsis, pneumonia, etc)
Know the pathophysiology of disease states and how that
impacts on MV
Know various forms of monitoring and how they impact MV
(e.g. ventilator wave forms, lab values, hemodynamic
parameters)
Know the application of adjuvant modalities such as ECMO,
ventricular assist devices
Have a knowledge of pharmacology of drugs used in the ICU
for treatment of respiratory patients and their impact on all
organ systems

The most important tool for the graduate respiratory therapist is
Critical Thinking Skills
Seven domains of critical thinking specific to respiratory care
have been elucidated through research:
Prioritizing
Anticipating
Troubleshooting
Communicating
Negotiating
Decision making
Reflecting
Critical thinking skills will allow for the graduate respiratory
therapist to assimilate new knowledge and skills once he/she
reaches the work place and contribute in the most meaningful
way at the earliest opportunity.
The Evolution of the Future Respiratory Therapist
The knowledge base and skill set of the respiratory therapist
will continue to enlarge as health care becomes more and more
complex.
Today all educational programs prepare the graduate therapist
for the RRT credentialing examination. This credential has
been recognized by the AARC, the NBRC, and CoARC as the
appropriate credential for all respiratory therapists to achieve.
Licensure of respiratory therapists exists in 49 of the 50 states.
At the present time all states recognize the CRT credential as

the minimum required for licensure.
In Ohio beginning on Jan 1, 2015 all new applicants will have
to have the RRT credential in order to receive a license.
The development of the 2015 and Beyond document has raised
the bar for the graduate respiratory therapist. In doing so it has
also raised the bar for the practicing RRT.
The 2015 and Beyond document envisions the evolution of the
future respiratory therapist in three major steps:
The Graduate Respiratory Therapist
No credential in hand
Possessing the competencies outlined in the 2015 and Beyond
document
Fully prepared to earn the RRT credential
The Practicing Registered Respiratory Therapist
Possessing the skills outlined in the 2015 and Beyond document
Adding to them through additional education and experience in
the work place
The Registered Respiratory Therapist Specialist
As the required knowledge base and the scope of practice of the
profession of Respiratory Care increase, more and more RRT’s
will become RRT Specialists.
More and more specialty credentials are being developed, and
this trend is likely to continue. For example Ohio State is
presently doing a needs assessment study to determine whether
a master’s level Advanced Practice Respiratory Therapist who
would have a level of education and responsibility similar to
that of a physician assistant or advanced practice nurse is a
viable option at this time.
See table below for a partial list of specialist credentials which
are either a part of respiratory care or closely related.

The Evolution of the Future Respiratory Therapist
Educating the RT of the FUTURE
Primary Focus of Part III of the “2015 and Beyond” initiative.
Results of the third conference were published in Respiratory
Care, May 2011, 56(5) 681-690.
Major recommendation and time lines for major policy changes
and effective dates for implementation are as follows:
Healthcare Leadership and Management
1

1
The ability to assess and enlist the help and support of others to
accomplish a common task or goal, which will meet the needs
and expectations of the surrounding environment
A great leader is able to get people to believe what they believe
– a shared belief or purpose is a very effective way to inspire a
team toward a common goal.
Pygmalion Effect: The greater the expectation place on an
employee/person, the better they perform
2
Leadership
2
Vision – able to see the future and has a clear and exciting idea
where the organization is going and what it is trying to
accomplish
Courage – willing to take risks to achieve the vision, trust
intuition
Integrity – truthfulness is the foundation for trust, and is
absolutely necessary

3
Great leaders possess traits and qualities that transcends all
types of businesses and organizations
3
Humility – a good leader will always give credit where credit is
due, and have the self confidence to admit a mistake
Desire for service – to be a great leader, your need to help
others must be a guiding principal
Strong interpersonal skills – leaders who posses, usually are
more successful in their personal and professional lives
4
Leadership traits, cont.
4
The Patient Protection and Affordable Care Act (ACA),
Meaningful Use, Electronic Health Record (EHR)
Reimbursement for healthcare services continues to be cut as
the number of “never events” that are not covered by CMS
increases
Patient satisfaction scores now affect reimbursement by CMS

Leaders must find smarter, more efficient ways to provide
exceptional care for their patients
5
Challenges facing leaders in healthcare
5
Institutional and agency administrators who say they care about
patients, but must reflect overriding budget considerations in
every action, confuse and demoralize healthcare workers.
Most individuals in healthcare chose the occupation not because
of income potential, but because they have a sense of caring and
social justice.
6
Leaders are faced with new and ever increasing demands
6
Many healthcare workers, including respiratory therapists, are
frustrated in their current role in hospitals.
At times, they feel overworked and unable to provide their own
standards of quality care
7
Healthcare Environment

7
Discouraged, frustrated and stressed out healthcare
workers.
8
This has resulted in:
8
As a leader, it is your responsibility to minimize the frustrations
felt by your staff, encourage them to do their best each day, and
support them in doing so by being their greatest
advocate.
9
Leadership’s responsibility

9
Clinical Practice Guidelines
As an example, Promedica has the following CPGs currently
available for physician’s use/order:
Bronchodilator, Bronchopulmonary hygiene, Hyperinflation,
Vent management & weaning, O2.
By using their critical thinking skills, the guidelines allows the
RT’s to use an assessment grid to determine the best care for
the patient
Research has shown, this will reduce unnecessary therapy,
ABG’s and the number of vent days
10
Maximizing an RT’s time
10
Respect, belonging, worth, intentional listening
Shared governance – delegation and inclusiveness
Input on policies that affect their jobs
Resources and training necessary to do their jobs well
Clear, frequent and honest communication about issues that
affect their jobs
Recognition and reward for doing a great job
11

Employee Satisfaction is essential to a successful organization
11
Increased productivity and teamwork
Improved moral
Decreased employee turnover
Ultimately, improved patient care and patient satisfaction!
12
Happy employees mean:
12
Electronics – smart phones, Facebook, Twitter
Multi-Generations at the work place
Different views of the workplace
and workforce (Traditionalists, Baby Boomers, Gen X and
Millenials)
Increased demand for a work-life balance
Employee engagement

13
As a manager, employee challenges can include:
13
Healthcare is very policy driven – policies are developed to
ensure consistency with processes and patient safety
Closing the generation gaps-varying degrees of knowledge
surrounding today’s technology
Creative employee scheduling (weekend only, 12 hour shifts)
Offer projects for employees to participate in, Professional
Enhancement Programs (PEP)
14
Resolving challenges
14
Computerized Order Entry (CPOE), EHR, Medication Barcode
Scanning

CPOE: Physician push back – takes longer, but compliance &
acceptance is improving
Employees must be able to adapt to ever-changing computer
systems
Learning a new process (like barcode scanning) can cause
delays in treatment initially
Merger with a big system – the good and the bad
Collaboration, camaraderie, support
Financial and resource support
Increased time demands and new or different regulations
15
Other Challenges…
15
Disciplinary action
Failure to follow policy
Arterial puncture
A-Line site managment
Attendance & punctuality
Dependability
Workplace violence
Personal threats
Gun threats
Social media
Facebook posting
Copy name badge for Admin Rx
16
Bad Behavior

16
Leaders seek to improve the performance of those just under the
high performers
Leaders would rather “separate” low performers (Low
performers are very time consuming)
Underperformers have minimal interest in improvement
At times, underperformers lack confidence and it is leaderships
responsibility to get to the root of the problem
17
Underperformers
17
The Patient Protection and Affordable Care Act

What is the PPACA
No one knows: https://youtu.be/N6m7pWEMPlA
Patient Protection and Affordable Care Act
Referred to as ACA or Obamacare
Signed into law in 2010 and upheld (essentially enacted) in
2012
Essentially put into law reform with these goals:
Expand coverage,
Hold insurance companies accountable,
Lower health care costs,
Guarantee more choice, and
Enhance the quality of care for all Americans.

What was the problem the ACA is trying to solve?
The government is paying too much in healthcare dollars
We’re already in debt, the government cannot afford this
There are too many uninsured citizens
When uninsured people seek care, the bill goes unpaid and the
hospitals cannot afford the free care
Healthcare in general is too expensive
No matter who is paying for it (government, out of pocket, or
private insurance), our system cannot sustain itself at this rate

The ACA wasn’t the first proposed healthcare reform: Brief
History
1915: AALL Bill
Proposed: limited coverage to the working class and all others
that earned less than $1200 a year, including dependents. The
services of physicians, nurses, and hospitals were included, as
was sick pay, maternity benefits, and a death benefit of fifty
dollars to pay for funeral expenses. Costs were to be shared
between workers, employers, and the state.
Ultimately failed, in part due to widespread fear of communism,
and healthcare reform was not brought up again until the 1930s
History of Healthcare Reform
1935: President FDR passes Social Security Act
Healthcare reform was originally proposed with this Act,
however, it was ultimately removed in fear that it would
jeopardize the entire Act. Focus was placed on passing Social
Security benefits as this was a higher priority with so many
Americans out of work during the Depression
1939: FDR tries a second time with the Wagner Bill, National

Health Act of 1939
Gave general support for a national health program to be funded
by federal grants to states and administered by states
Ultimately failed with a resurgence of conservatives taking
office around the same time and widespread opposition to
national healthcare
1945-1953: Truman Administration
Truman recommended to Congress a proposal for universal
health insurance coverage, administered and paid for by a
National Health Insurance Board
Widespread opposition to “socialized medicine” caused it’s
failure
Passed “The Hospital Survey and Construction Act of 1946”
provided federal grants and loans to build, expand and
modernize hospitals. The consequences of the resulting rapid
and unregulated growth in healthcare facilities would require
future legislation, during the Ford administration, to bring it
under control

1953 – 1961: Eisenhower Administration
In 1956 the "Military Medicare" program was enacted,
providing payment for healthcare services for military
dependents
1961 – 1963: Kennedy Administration
Kennedy supported a more modest form of universal health
care, essentially laying the blocks of what would become
Medicare (limiting coverage to those 65 years and older)

1963 – 1969: Johnson Administration
the Social Security Amendments of 1965 provided healthcare
coverage to those 65 years of age and older, and to the poor,
blind and disabled. It covered healthcare services provided by
hospitals, physicians, nursing facilities and home care
providers. It would not be long before proposals for health
coverage for those not covered under Medicare/Medicaid would
surface.
1969-1974: Nixon Administration
proposed the National Health Insurance Standard Act. The
proposal called for government-prescribed minimal levels of
insurance coverage, mandated to be provided through employers
and financed by payment of premiums by employers and
employees. This plan would maintain competition between

private insurers and expand coverage. The NHISA would also
provide government subsidies for premiums for certain
employees. While the NHISA did not pass, Nixon was
successful in gaining passage of the Health Maintenance
Organization Act of 1973, which laid some of the ground work
for managed care.
1974-1977: Ford Administration
Runaway healthcare costs due to inflation and unchecked
growth in the healthcare world, followed by an increase in
government spending through Medicare/Medicaid programs.
The National Health Planning and Resources Development Act
of 1974 was an effort to reign in escalating healthcare costs.
The goals of the HPRDA were to reduce and avoid unnecessary
duplication of healthcare facilities and services; it sought to do
so by essentially mandating certificate of need programs in the
states. Eventually repealed.

1977-1981: Carter Administration
Carter campaigned for president calling for national healthcare
insurance with universal coverage, and as president he went to
work to prepare a legislative proposal for the same. The details
of President Carter's plan never received much of a
congressional or public audience, as a deep recession and other
economic issues took priority.

1981-1989: Reagan Administration
Reagan started a movement to shift the cost of healthcare away
from the government. Several new laws were enacted aimed
primarily at reducing the growth in federal spending on health
care, and improving efficiencies. This was to be accomplished
by changing Medicare reimbursement methodologies — in most
cases reducing reimbursement to hospitals and physicians —
and stepping up anti-fraud measures.
1989-1993: George H.W. Bush Administration
President Bush's agenda for healthcare legislation consisted of
additional measures to reduce the growth of federal health care
spending and reduce fraud and abuse in the Medicare and
Medicaid programs. Notable among the Bush healthcare
legislative reforms was a prohibition on physician "self-
referrals" for clinical laboratory services

1993-2001: Clinton Administration
proposed to provide affordable health insurance for all through
a concept called “managed competition.”
Under the Clinton proposal, health insurance coverage would be
provided through private insurers competing for customers in a
highly regulated market, overseen and coordinated by regional
health alliances to be established in each state. All health plans
would be required to provide a minimum level of benefits.
Employers would be required to provide insurance coverage for
their employees and pay 80 percent of the premium. The
proposal ultimately failed due to widespread opposition.

2001-2009: George W. Bush Administration
Healthcare was low priority, however, they did manage to pass
one of the largest expansions to Medicare in the history of the
program. The Medicare Drug Improvement and Modernization
Act of 2003 made numerous changes to the Medicare program,
the most important of which is the prescription drug coverage
benefit, created as Medicare Part D.
2009-2017: Obama Administration
Healthcare reform was one of Obama’s first priorities in office,
proposing legislature at just 6 months in to his first term. The
ACA went through widespread debate and controversy, but was
ultimately signed into law in March 2010. In 2012 the ACA was
taken to the supreme court to determine whether it was within
the constitution, it was upheld that year.

Controversy
Among debate the question was raised whether Congress had a
right to enact the law under the Constitution. The supreme court
ruled:
The individual mandate is a permissible exercise of Congress'
taxing power and thus constitutional.
The Medicaid expansion "cram down" provision (essentially
requiring all states to expand Medicaid coverage to all
otherwise eligible individuals with incomes up to 133 percent of
the federal poverty level) is an impermissible exercise of
Congressional power and thus unconstitutional.
In its irreducible essence, the PPAACA provides for:
A mandate for "large" employers to provide health insurance
coverage for its employees;
A mandate for virtually all citizens to have health insurance
coverage through an employer sponsored plan, a government
plan or an individual plan;
Creation of federal and/or state healthcare exchanges to
facilitate obtaining healthcare insurance;
Federal financial subsidies for health care insurance for
individuals meeting low income standards;
A mandate that all health plans provide a certain minimal level
of essential benefits; and
Prohibitions against denials of coverage based on pre-existing

conditions and against lifetime benefit limits.
Details of the ACA
The ACA is in some respects a conglomeration of some of the
pieces of past proposals for major healthcare reform. All of the
following have been proposed in some form before the passing
of the ACA:
The provision of health insurance coverage through private
insurers instead of directly through the government,
Employer mandated health insurance,
The creation of state, regional or national clearinghouses for
insurance,
Federal subsidies for low income individuals,
“Guaranteed eligibility”, you cannot be refused coverage due to
a pre-existing condition

Details of the ACA: Expanded Coverage
By 2022, the Congressional Budget Office estimates the
Affordable Care Act will have extended coverage to 33 million
Americans who would otherwise be uninsured
Increased eligibility for Medicaid
Families making less than 133 percent of the poverty line
($29,000 for a family of four) will now be covered through
Medicaid. Families between 133 percent and 400 percent of the
poverty line will get tax credits on a sliding scale to help pay
for private insurance
Increased coverage from employer mandate/incentive
Businesses that have 50 or more full time employees will be
fined if they do not offer insurance
Small businesses that have fewer than 10 employees, average
wages beneath $25,000, and that provide insurance for their
workers will get a 50 percent tax credit on their contribution
Increased coverage by requiring the public to hold insurance
Require all US Citizens and Legal Residents to hold qualifying
insurance or face fine of $695 per year or up to 2.5% of
household income (whichever is greater)

Details of the ACA: Hold Insurance Companies Accountable
Insurance companies are not allowed to discriminated based on
preexisting conditions
They cannot refuse coverage due to a known condition
Provide dependent coverage for children up to age 26 for all
individual and group policies
Series of other small rules to essentially standardize insurance
coverage from plan to plan with a goal of improving access to
care for the consumer
Details of the ACA: Lower Healthcare Costs
Simplify health insurance administration by standardizing
process
Series of cost containment changes to Medicare and Medicaid

programs
Authorize the FDA to approve generic versions of biologic
drugs and grant biologics manufacturers 12 years of exclusive
use before generics can be developed
Reduce waste, fraud, and abuse in public programs by:
allowing provider screening, enhanced oversight periods for
new providers and suppliers, including a 90-day period of
enhanced oversight for initial claims of DME suppliers, and
enrollment moratoria in areas identified as being at elevated
risk of fraud in all public programs,
Require Medicare and Medicaid program providers and
suppliers to establish compliance programs
Develop a database to capture and share data across federal and
state programs, increase penalties for submitting false claims,
strengthen standards for community mental health centers and
increase funding for anti-fraud activities.
Details of the ACA: Guarantee More Choice
Create state-based American Health Benefit Exchanges and
Small Business Health Options Program (SHOP) Exchanges,
administered by a governmental agency or non-profit
organization, through which individuals and small businesses

with up to 100 employees can purchase qualified coverage.
Establish an internet website to help residents identify health
coverage options (effective July 1, 2010) and develop a
standard format for presenting information on coverage options
Details of the ACA: Enhance Quality of Care
Support comparative effectiveness research by establishing a
non-profit Patient-Centered Outcomes Research Institute to
identify research priorities and conduct research that compares
the clinical effectiveness of medical treatments
Award five-year demonstration grants to states to develop,
implement, and evaluate alternatives to current tort litigations
in medical malpractice
Develop a national quality improvement strategy that includes
priorities to improve the delivery of health care services, patient
health outcomes, and population health. Create processes for the
development of quality measures involving input from multiple
stakeholders and for selecting quality measures to be used in
reporting to and payment under federal health programs

Future Directions
As stated previously, Presidential Administrations have a HUGE
IMPACT on healthcare, and we just elected a president who is
strongly against the ACA
Congress has chosen to move forward with repealing this act
and everything that resulted from it

The future is uncertain, we’ll explore some of the repercussions
we may see as a result of this decision
Repealing the ACA
The senate and the house have both chosen to start the repeal
process as of Jan 13, but we have a ways to go
Logically, we should not be repealing this act without a
replacement drafted FIRST, but it appears that we aren’t going
to do that
Relevant committees will convene over the next few weeks to
begin the process of drafting a repeal bill. The resolution has a
provision that directs these committees to come up with a draft
of the repeal bill by January 27

What’s Next?
Option 1: Replacement Superhighway
The fastest and least disruptive path for Republicans to follow
would be to repeal the ACA and advance a replacement bill at
the same time
This would provide both insurers and patients a clear picture of
what's going to happen fairly quickly, which would prevent
disruptions to the market
No details have been released of a potential replacement plan
The levels of government could prevent the replacement bill
from being passed, leaving us with no replacement

Option 2: The Long and Winding Road
Partial repeal of the law under what is called budget
reconciliation — delaying until a later date so that Republicans
can craft a full replacement bill
In theory, this allows GOP lawmakers to advance the political
goal of repeal while giving enough time to develop a
comprehensive plan for replacement
Cons: Depending on the parts of the law that are repealed
through the reconciliation process, you could see destabilization
in the individual insurance market
An unstable market could mean an increase in cost for everyone
in the face of uncertainty

Option 3: Leave As-Is
Simply pass a few bills that make minor but needed adjustments
to the law without a full-on repeal
Changes would be most minimal for most consumers
Democrats would likely be agreeable because they have been
calling for reform for a long time
Republicans likely wouldn’t take this route because they have
been calling for complete repeal from the beginning and won’t
back down
Option 4: Repeal without Replacement
After running against the bill for so long, the GOP could just
repeal it and label it a disaster, making small changes along the
way but not introducing a full-scale replacement

Seems the least likely option, ripple effect would be devastating
Political blowback
Millions lose coverage and unable to access insurance due to
pre-existing conditions and cost
Worst Case Scenario
Closing Thoughts…
Behind Healthcare Reform: https://youtu.be/0gcARSUEF0s
Durable healthcare -- redesigning a system to work for
everyone: https://youtu.be/mY2LIQbiGbo

Transitioning the respiratory therapy workforce for 2015 and
beyond
AARC Initiative 2015
What changes will be necessary to fulfill identified roles and
responsibilities
In order to equip the RT of the future, we’ll need to make
changes in:
Education
Accreditation
Credentialing process
To determine how to best make those changes and what they
might entail, surveys were sent to RT program directors, RT
department directors, deans, and RT educators
These questions included:
Competencies
Education level
Credentials needed

responsibilities
Options and opinions were evaluated by a panel of 35
stakeholders during the 3rd and final conference
After thorough discussion the following recommendations were
approved by majority vote
(remember, these are recommendations, not regulations)
responsibilities
Education
By 2020, ALL RT programs should be authorized to grant
baccalaureate or graduate degrees
Programs currently residing in institutions that are not able to
grant higher than associates either should be phased out or build
a partnership with a university to award bachelor or higher
Most states have laws allowing community colleges to grant
higher degrees, however, there is a great deal of red tape to get
through to achieve this
Education Recommendation Rationale
Education requirements of the RT graduate have not changed in
40 years, but the role of the RT has greatly expanded
Techniques, medications, and devices have become increasingly
complex

The RT of today is expected to:
Assess and quantify the patient’s cardiopulmonary status
Provide appropriate respiratory care by applying protocols
Evaluate the medical and cost effectiveness of the care
delivered
Contribute to the discussion of goals and discussion of therapy
on rounds
Provide evidence supporting various approaches to respiratory
care used in the ICU
Discuss and recommend care for patients presenting with
diseases that affect the respiratory system
The RT must achieve higher levels of education and training to
respond to these increasing future demands
The profession’s current failure to demand an adequate entry-
level education negatively affects the perception of our
profession– namely suggesting associate level education means
a more technical and less professional career
Education Recommendation obstacles
As of 2011 there were:
356 (87%) community college RT programs awarding associate
degrees
55 (13%) programs awarding baccalaureate degrees (most at 4
year universities)
Transitioning these associate programs is a very large obstacle–
AARC has some recommendations and resources in place to
assist these programs, but the reality is many of these programs
are going to face the following:
Inability to cooperate with a nearby university to establish a
degree completion program
Inability to award bachelor degree from current institution
based on state and college regulations
Military programs are unlikely to be able to make the transition

based on military structure and degree requirements for it’s
officers vs. enlisted corps
Costs may be incredibly high, and process may take several
years or longer
In addition to these issues, the necessity of transition to
bachelor’s degree is widely disputed
There is a clear difference between ‘recommendation’ and
‘requirement’– while the pro-bachelors group is pushing for this
to become a requirement, it is still simply a recommendation
(meaning there is no established punishment for ignoring the
recommendation)
The pro-associate group is arguing there has been no proof that
increased education leads to increased competency (exam pass
rates are very similar)
Credentials
2 recommendations:
NBRC should retire the CRT exam after 2014 (accomplished)
Separate CRT and RRT exams should be combined after 2014
(accomplished)
Credential recommendation rationale
It is widely acknowledged that there is no difference in job
duties between those holding a CRT vs RRT credential
With this current practice model there is little incentive to
achieve RRT level
According to surveys, it is widely agreed among education
program directors and department directors that RRT is the
preferred credential for new hires
Having 2 credentials without a major differentiation in duty

confuses the public, patients, and even other healthcare
colleagues who are not aware of the difference
The CRT credential was actually developed for 12 month
training programs that no longer exist
The majority of conference participants believe that the
respiratory therapy profession needs 1 level of credential
(RRT), one education goal, and one expectation for competency
of graduates entering the workforce
Licensure
Establish a commission to assist state regulatory boards in
requiring RRT designation in order to achieve licensure
All states should begin to require RRT in order to be granted
licensure
Ohio has already established this requirement
Transition of the RT Workforce
3 recommendations outlined
The AARC sections should develop standards to assess
competency of RTs in the workforce relative to their
assignments
Sections include critical care, neonatal and pediatric care,
education, etc
These standards should address the variety of work sites that
employ Rts
Standards should address RT knowledge, skills, and attributes
relative to the tasks being evaluated

Continuing Education
The AARC encourages clinical department educators and state
affliates’ continuing-education venues to use CLINICAL
SIMULATION as a major tactic for increasing competency
Consortia and Cooperative Models
AARC and CoARC are encouraging associate degree programs
to align themselves with baccalaureate degree granting
institutions for the award of baccalaureate degree
i.e. Community College provides respiratory program, but
students also complete additional courses through local
University to ultimately achieve bachelor’s degree
Some community colleges have the ability to grant
baccalaureate degrees, however, there is a great deal of work
involved for the program to be allowed to change their status
from associate to bachelor program
The AARC has budgetary resources available to help associate
programs in their transition
Promotion of a Career Ladder
AARC Board of Directors encourages members of the existing
workforce to obtain advanced competencies and education

Creating a Vision for Respiratory Care:
Future of Health Care—2015 And Beyond, Part I
AARc Initiative 2015
I. history
Profession is approximately 70 years old
Earliest therapists were not even therapists
Called “oxygen orderlies” or “oxygen technicians”
Most hospitals in mid-20th century did not have wall O2
Patients got O2 either via mask, nasal cannula or Oxygen Tent
O2 came from H-cylinders which had to be changed out every
few hours
Initially all received only on the job training (OJT)
Early training programs
Hospital-based and appeared in the late 1940’s and 1950’s
Graduates called themselves “Inhalation Therapists” to separate
themselves from the OJT’s
American Association of Inhalation Therapists formed in
Chicago in 1954
Credentials (RRT) were first awarded in 1961 (oral exams by 2
physicians, then later by a physician and therapist). Later
(1983) other credentials were added (CITT and CRTT) which
could be passed by written examination. In 1978 the Clinical
Simulation Exam replaced the oral examination for the RRT
Standards for the first educational programs established in 1962
All candidates for a credential had to be a graduate of an
accredited education program after 1975—no more OJT’s taking
the tests.

History continued…
The American Association of Inhalation Therapists became the
American Association for Respiratory Therapy (AART) in 1972
AART became the AARC in 1986
Florida was the first state to gain licensure in 1984; Ohio
licensure in 1988; 49/50 states now require RT’s to be licensed
All states recognize the CRT as the minimum credential
required for licensure
The NBRC will only allow graduates of accredited Associate
and Baccalaureate degree programs to sit for the written exam
Approximately 455 respiratory care programs are accredited in
the US—a few more in Canada
The Inhalation Therapist as a clinician began because many
early inhalation therapists were interested in cardiopulmonary
disease processes and their treatment and because of the support
of a group of anesthesiologists—there has always been a strong
bond between anesthesia and Respiratory Care
The Inhalation Therapist as a clinician also was stimulated by
the appearance of new therapeutic modalities that depended on
mechanical devices in the late 1940’s and 1950’s.
Patients on O2 required assessment and weaning
Earliest bronchodilators delivered by nebulization appeared in
the late 1950’s.
Since nebulizers were driven by compressed gas, oxygen
orderlies/inhalation therapists performed the task
Assessment skills required here to administer bronchodilators,

especially since the early bronchodilators had many side effects.
The IPPB treatment was developed
First appeared in 1949
Most common device was the Bird Mark V, VI, and VII
Nursing wanted nothing to do with the machines—too
complicated
Since they required compressed gas, logical for oxygen
orderlies/inhalation therapists to perform
Assessment skills required to give IPPB treatments
Earliest mechanical ventilators appeared in the 1950’s
Nursing wanted nothing to do with them—too complicated.
They required too much constant attention for physicians to run
them full time
They required even more compressed O2 than cannulas or tents,
so oxygen orderlies were required even more to keep them
running. Was a natural progression for oxygen orderlies to take
over running the vents (we are more mechanically inclined than
RN’s???). Later hospitals added in the wall O2
Even greater assessment skills required to run vents
PB 7200 introduced in 1983 (first with microprocessors)
Earliest blood gas machines appeared in about 1949.
Also required compressed gases for calibration
They were incredibly challenging to keep up and running so
either RT’s or lab personnel ran them (depending upon the
hospital)
Physicians caring for patients on mechanical ventilation quickly
realized that they needed ABG’s for effective ventilator
management. Since the respiratory therapist was already right
there, it was more likely that RT would maintain blood gas
analyzers

The field of Respiratory Care has been a leader in the adoption
of evidence-based practice.
This began with the “Sugarloaf Conference” in 1974 which
examined the scientific basis for a number of respiratory
therapy practices
The use of IPPB to deliver bronchodilator treatments on nearly
all respiratory patients was demonstrated to have no more
medical value that the use of a small volume nebulizer to
deliver the bronchodilator
O2 therapy and bronchodilator therapy were shown to be
effective, however.
The emphasis on evidence-based practice has led to things like
the
AARC’s Clinical Practice Guidelines. Clinical practice
guidelines are common throughout various areas of medicine
today, but Respiratory Care was the first allied health field to
make extensive use of them.
Respiratory Care Journal Conferences—Extensive expert review
of various burning questions in Respiratory Care with expert
commentary. Published in Respiratory Care Journal
The Respiratory Care profession which began and was confined
entirely to hospitals in the early days has now moved out into a
number of other venues including:
Long-term care facilities

Nursing homes
Long-term Acute Care Hospitals (LTAC’s)
Military
Front-line combat critical care (respiratory therapists have been
killed in action)
Support and care of military dependents and veterans
Physicians’ offices
Evaluation of outpatients (e.g. PF testing)
Patient education
Home care
Case management and discharge planning—still very few doing
this
Disaster response teams; all DMAT (Disaster Medical
Assistance Team) teams now include respiratory therapists
Medical devices sales
15. The educational process for Respiratory Care has become
more and more demanding over the years.
The primary factor driving the increase in education level has
been the increasing complexity of medical care, especially
devices over the years.
The first BS programs were introduced in the 1980’s.
A small number of Master’s programs in Respiratory Care have
become available within the last 10 years.
Specialized credentials have been developed
CPFT
RPFT
NPS
SDS
ACCS
The NBRC has developed a matrix of skills and knowledge

areas which are tested on each of the credentialing exams.
The AARC plays a major role in education of clinicians, the
public, and students
II. The 2015 and Beyond conferences
Three conferences organized by the AARC in 2008, 2009, 2010
to envision the RT of the future. Goals of the three conferences
were to:
Identify long-term future trends in health care that will impact
the RT profession
Identify the competencies that will be required of RT’s in order
to the profession to continue to be a player in the health care
arena
Identify the educational processes which must be developed in
order to allow RT’s to master those competencies
II. Conference 1– the healthcare system
As population ages more patients will be diagnosed with
chronic and acute respiratory illnesses
Increased accuracy in diagnosis due to better technology
Treatment will be aimed more and more at outpatient
management and avoidance of hospital admissions to decrease
costs
Increasing numbers of comorbid conditions will be identified
that will require simultaneous management with the respiratory
illness, requiring more interdisciplinary care
Health promotion and prevention rather than acute treatment
will become the goal of care

Cost of medical care will continue to increase in spite of
increased efficiency of care
Individual consumers will pay an increasing percentage of
health care costs
Consumers, industries, and governments will find it
increasingly difficult to keep up with increased costs
The personal electronic health record will be increasingly used,
even in the home
Information technology will take an increasingly important role
in the health care arena
Health care informatics will become a specialty area of allied
health care
There will be a shift out of acute care hospitals as much as
possible
Hospitals will continue to provide expensive, episodic care,
including cutting-edge respiratory life support. Level of patient
acuity and complexity will continue to increase in hospitals
Wherever possible acute care will move to sub-acute facilities
and even patients’ homes
Sub-acute and chronic care will increase in volume and
complexity
New care delivery models will be developed
Retail health clinics (e.g. urgent care centers) and mass-
marketed care centers (e.g. some chain pharmacies have opened
walk-in clinics in conjunction with their pharmacy operations)
will be developed
Telemedicine and telecare will be used increasingly
Healthcare delivery system which are today unheard of (e.g.
hospital-at-home and medical-home) will appear. Some will
succeed and some will fail
Main driver of this movement will be decreased costs and cost

competition will continue to intensify, at times to the detriment
of patient care
Medical care will undergo increasing scrutiny for quality and
cost effectiveness
Reimbursement will be linked to outcomes and there will be
pay-for-performance type incentives for medical care
practitioners
Systems to decrease rate of medical errors will become more
important
More emphasis on the team approach with improved
communication among team members in order to better
coordinate care
Government will become increasingly involved in monitoring
and setting of quality standards
II. Conference 1– the Healthcare Workforce
The healthcare workforce is aging, and this trend will continue
Older healthcare workers will leave the workforce in increasing
numbers
As the US population ages, increased numbers of healthcare
workers will be needed, even when increased efficiencies of the
system are taken into account
The result of all of this will be shortages of all healthcare
workers, those who work at the bedside and those who have
supporting roles (e.g. lab techs, medical records). These
shortages are being projected by the US Bureau of Labor
Statistics
Shortages that were predicted to occur during the 2005-2010
period have not materialized, however. In 2000 the national
rate of unfilled positions in RC departments was 5.9%. In 2005,
the rate was 8.6%. Today it is probably about 2%.
Shortages of teaching faculty and programs will limit the

number of new graduates, and the educational system will be
unable to meet the demand
New educational models will be required to reduce the cost of
education and allow for fewer educators to more efficiently
prepare more graduates
Healthcare organizations may begin to develop educational
programs to help meet the shortage
II. Conference 1 – The RC Profession
Respiratory care will continue to increase in complexity
Clinical decisions will become increasingly reliant upon data—
evidence based medicine
Published studies
Internal organizational outcomes data
The use of protocols will become the most common way to
deliver respiratory care, including complex tasks such as
ventilator management
Research shows that protocolized care is more efficient and
cost-effective
Protocols allow lower level clinical decisions to be shifted from
physicians to RT’s
Interdisciplinary care teams (including even patients and patient
families) will become more predominant, and RT’s will need to
learn to work effectively in this environment
The US population will become more diverse ethnically and
culturally. RT’s will need to develop cultural competencies
RT’s will be required to function in an environment with
increased levels of computerization and information technology
As evidence based medicine becomes more important, RT’s will
need to be able to function in research

II. Conference 1– Factors Driving Change
Cost
We have the most expensive health care system in the world,
but our outcomes are not the best in the world
Healthcare costs are rising faster than the rate of inflation
Most health insurance comes from private corporations—they
are cutting back on coverage to reduce costs
Number of retirees is increasing. Medicare Part A is projected
to have only about 10 years of funding left at current
expenditure rates and projected population changes
Demographics
Population is aging
Baby boomers are just reaching retirement age and will not be
gone from the system for another 20-30 years.
As a result the burden of chronic disease is expected to rise
rapidly during this period
The US population is projected to grow by about 20-25% during
the period 2000 to 2025. Means increased healthcare capacity
will be needed.
II. Conference 1– Factors Driving Change
Shift in disease patterns
US population is living 35 years longer than it did 100 years
ago
Means progressive increase in chronic disease
Our health care system is designed to focus on acute disease
management, not to manage or prevent chronic
Technology
New treatment and diagnostic modalities will be created

Even more important, however, is changes in information
technology. Information will flow from medical experts to
patients and families; this will result in patients and families
becoming more involved in their own care
Technology will also aid in development of new health care
delivery models
Telemedicine and telecare will become more widely used.
Consumers
Health care will become a commodity driven by price,
marketing, convenience, customer satisfaction
Healthcare delivery organizations will compete for patients in
the same way that department stores and auto dealership do.
Ohio laws and licensure
What you need to do to maintain your ability to practice
respiratory care
I’ve graduated, now what?
Take NBRC test to obtain your CREDENTIAL
This is your nationally recognized ability to practice
MANDATORY for all RTs practicing in the US
MUST BE RENEWED EVERY YEAR
In order to renew you must pay a fee ($25/yr) to the NBRC (if
you skip this fee, you will pay it as a lump sum at the end of 5
years)

Every FIVE years you have to prove you’ve achieved 30 credit
hours of continuing ed (CEUs)
If you fail to renew or are denied renewal at 5 years, you must
RETAKE THE EXAMS and will be denied the ability to
practice until you’ve successfully passed again
DON’T LET IT LAPSE!!!
NBRC.ORG
Obtain state LICENSE
This is your state recognized ability to practice in THAT
STATE ONLY
States may have different requirements (i.e. background check,
specific documentation of school and work history, etc)
All states will have a FEE (around $100) and require renewal
typically every TWO years
Some states also require a set number of CEUs in order to renew
If you are denied renewal or let your license lapse you will not
be allowed to practice until you have an active state license!
Respiratorycare.ohio.gov
Maintain continuing education in order to RENEW state license
and national credential
CEU credits can come from a number of places:
Online courses (usually video/PowerPoint + quiz)
Conferences (national or local)
Webinars
Credits must be approved through a recognized RC body (can’t

use physician credits for RT licensure)
KEEP TRACK OF YOUR CREDITS
You will need to prove that you successfully completed CEUs
AARC membership makes tracking very easy
KEEP COPIES OF ALL CERTIFICATES YOU RECEIVE
AARC.ORG
Ohio license
Does this state require a license to practice respiratory care?
YES
What is required when you initially apply for a license?
Application form completed and notarized
Criminal Background Check
Copy of NBRC score
2x2 passport style photograph
How much money does it cost?
$75 for initial license, $100 each renewal
How often do you have to renew?
Every 2 years
Are there CEU’s required for renewal? If yes, how many?
Yes, 20 CEUs for each 2 year period
Group 1: Michigan
Group 2: Indiana
Group 3: Texas
Group 4: Alaska
Group 5: Hawaii
Ohio Laws
Can be found online, here: http://codes.ohio.gov/orc/4761
Outlines:

Scope of practice
Who qualifies for a license
How they decide to award licensure
Continuing education requirements
Fees associated with licensure
What disciplinary actions make be taken and why
Who can supervise your practice
Ethics
The Duty of a Respiratory Therapist: Professional Ethics and
Licensure

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