How Portable Oxygen Is Changing Home Respiratory Care: Doug Francis

Respiratory and mobility care is steadily moving out of hospitals and skilled nursing facilities and into patients' homes, propelled by a mix of pandemic-era lessons, patient preference, and mounting cost pressure on payers and providers, according to Doug Francis, CEO of Rhythm Healthcare, a medical device manufacturer focused on respiratory technologies that he founded in 2020 after nearly 3 decades in the home health care durable medical equipment space.

In an interview with The American Journal of Managed Care^® (AJMC^®), Francis discussed the evidence base behind portable oxygen concentrators, the barriers that have historically slowed their adoption, and what connected, data-driven devices could mean for patient outcomes and health care costs going forward.

This interview has been lightly edited for length and clarity.

AJMC: What is driving the shift of respiratory and mobility care from clinical settings into the home?

Francis: It's a good question. I think there's a confluence of things happening at the same time. It started, if you think back to COVID-19, with the realization that congregating seniors in a place where they could easily spread illness to one another was probably the first sign that care at home is a better place for people to age. There's also a preference: If you ask seniors where they'd prefer to age, they'd overwhelmingly say at home. I saw this with my own grandparents some 25 years ago—my grandfather had Parkinson’s disease, and he was able to stay at home with my grandmother, where he was comfortable, happy, safe, and around family. In general, people would prefer to be able to stay at home, where they can be around family.

There's also the money factor. I think the payers have recognized that care at home runs on a significantly different pay schedule than care in the hospital. Twenty-five years ago, the average length of stay in a hospital might have been 7 days; today, it's less than 3. That just means people are able to exit the hospital setting or the skilled nursing facility faster and get to a place where they can recover their condition at home, where they're more comfortable. And then, lastly, technology has caught up, where the very devices they were using in the hospital to recover their condition are now available in the home care setting, where they don't have to sacrifice outcomes to return to their home.

AJMC: How has portable oxygen concentrator technology evolved to make home-based respiratory therapy more viable?

Francis: When we started this business back in 2020, we recognized that there were barriers to entry for POCs [portable oxygen concentrators]. Portable oxygen concentrators were invented maybe a decade or 2 ago, but there have been barriers keeping them from widespread adoption within the HME [home medical equipment] community. Historically, they were very costly. Secondarily, they were perceived to be unreliable, just not durable enough to support the patient when the patient needed it most.

Lastly, there wasn't enough clinical evidence to support the fact that pulse dose technology—which is how POCs deliver oxygen, delivering a pulse on inhalation and stopping when the patient exhales—could do the equivalent work of continuous flow. The gold standard for treating impaired lung function, COPD [chronic obstructive pulmonary disease] in particular, had historically been 2 liters per minute continuous flow, and there wasn't much evidence built around the idea that pulse-dose technology could do that equivalent work.

When we started this business, we focused on those 3 barriers to entry. Let's focus on driving costs down so we can make the math work for the HME provider that's going to have to make this investment in new technology. Let's focus on quality first and deliver a product with a better reliability profile. And then let's gather the evidence to share with clinicians to show that pulse dose technology isn't just equivalent to continuous flow—in most cases, it's more effective at keeping patients oxygenated. We've successfully done that, and I think you can now start to see a shift away from legacy modalities like oxygen tanks, which are cumbersome and restrictive to the patient, toward POCs that unlock incredible quality of life and independence for patients. So there's a patient preference that's being addressed, but there's also a cost savings for providers that's being addressed. By focusing on those 3 things, we've really helped speed up the adoption of POCs.

AJMC: What barriers do patients and providers still face in adopting home medical equipment, and how are they being addressed?

Francis: Specifically about POCs—though we could widen that lens—we like to say that the pain of same hasn't become greater than the pain of change. We all know that change is difficult. It causes businesses to behave differently, and so continuing to do what you're doing is kind of the easy button. We've reached a point, though, with the ongoing compression of reimbursement. Medicare has taken significant cuts to Part B reimbursement for these products, and there are ongoing inflationary pressures that HME providers are facing—their labor rates are significantly higher, their fuel costs are significantly higher, and so their margins are being squeezed.

We've reached the point where the pain of same has become greater than the pain of change, and now we're starting to see a shift where people are engaging in a conversation about making this transition. But that's the biggest obstacle: change and willingness to make that conversion so patients can get more modern technology and have a more independent life.

AJMC: How does home health care technology affect patient outcomes and health care costs for payers and providers?

Francis: There's a lot of data around this, and you can go back to the 1980s. There was a landmark study called the Nocturnal Oxygen Therapy Trial, the NOTT trial, and what that study did was determine that the gold standard for treating COPD was 2 liters per minute continuous flow, using oxygen 24 hours a day, 7 days a week—continuous flow, not just nocturnally but during the day as well. Investigators did a retrospective analysis, going back and looking at thousands of patients who participated in the study, and categorized them into high walkers, medium walkers, and low walkers. What they determined was that the patients in the high-walker category, who were active for 20 minutes a day, doubled their life expectancy compared with the patients who weren't active.

What that study told us is that if we can get people using oxygen 24 hours a day and get them walking for 20 minutes a day, we can help them double their life expectancy—in essence, dying with the disease, not from the disease. That's the realization we have as a manufacturer: If that's the possibility, how do we unlock it for the patient? That comes down to creating a device that encourages that activity.

An oxygen tank, if you think about it, is big and bulky. Patients have to drag it behind them. It doesn't really inspire somebody to leave their home. Versus a POC that weighs less than 5 pounds, can go from outlet to outlet, and has battery life that allows patients to stay away for hours at a time before recharging—that unlocks that very possibility. There's also a lot of evidence to show that when a patient is active like that, it drives down other morbidities. It improves quality of life. It certainly addresses isolation and depression and other things that happen when a patient can't or won't leave the home because of the device they're using. It also drives down the readmission rate—there are fewer exacerbations when a patient is actively participating in their therapy and out being social with their community.

I think there's a lot of evidence to support the idea that this technology is driving down costs for payers by driving down readmission rates and reducing other morbidities, but also, more importantly, improving quality of life for the patient and helping them return as an active member of their community.

AJMC: What's next for home health care technology, and how should HME providers and health systems prepare?

Francis: I think there's going to be a lot of connectivity. The Internet of Things is starting to become more prevalent in the home. There's a lot of data to suggest that if you can get somebody walking for 20 minutes a day and using their oxygen, you can double their life expectancy. But if you can't tell whether that's happening, if you can't tell that each patient is participating in their care, there's no way to really inspire them to become active so they can benefit from their therapy—which would drive down costs for payers.

There are also going to be a lot of connected devices that will be able to talk to each other and do predictive analytics to predict when somebody is about to have an exacerbation before it happens—in essence, preventing an emergency visit and turning that into maybe a virtual call, where they can talk through their circumstances with their care provider and make sure they're addressing it in the right way. I think we're going to see a big shift to connectivity—to the cloud, devices connected to the cloud, devices connected to each other—and using all of that data to do a better job of keeping the patient safe in the home.