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normal business hours; extending the availability of
hyperbaric medicine to accommodate emergencies would
increase equipment expenses. It would also substantially
raise personnel costs due to 24/7 on-call coverage and the
professional staff necessary to effectively manage these more
medically challenging patients. All this extra expense would
occur with little commensurate increase in revenue, thereby
negatively affecting the profitability of a business model
established as a revenue-generating venture. Certainly, the
prevalence of this model has improved access to HBOT for
those with chronic wounds, but it has done so while creating
a significant downside: reduced access to care for divers and
other people with emergent medical needs.
Under this business model, hyperbaric chambers are
commonly located on a hospital’s campus but often
not within the hospital itself. Adjacent medical office
buildings represent the usual location. This makes it all but
impossible for those patients hospitalized or in the ED (and,
one could argue, likely to benefit most from HBOT) to gain
necessary access. Outpatient-only hyperbaric programs
further distance themselves from the management of
emergent and typically sicker patients by not incorporating
otherwise standard biomedical monitoring and ancillary
support equipment. This includes infusion pumps,
electrocardiogram (ECG) and invasive pressure monitors,
through-hull tissue-oxygen monitoring cables, hyperbaric
ventilators and more. Treatment pressures are frequently
standardized at 2 ATA (33 feet) for all patients. This is
incorrectly assumed to eliminate any likelihood of seizures
due to central nervous system oxygen toxicity and therefore
eliminate the need for air-break delivery systems. Air
breaks are vital for the treatment of DCI and certain other
emergent conditions.
As the regional availability of this normal-business-hours-
only model rapidly expanded, hospitals providing 24/7
hyperbaric medicine soon began to feel an economic pinch.
Competing outpatient-only programs, by design, sought the
more stable, less clinically challenging and typically better-
insured patients. Costs required to maintain 24/7 capabilities
continue to increase while revenues generated trend down.
Thus, a growing number of hospitals have reconsidered their
24/7-coverage position.
Sadly, and all too frequently, the cost argument is winning
out over the best-medical-practice argument. Consequently,
a growing number of hospitals have elected to discontinue
on-call availability; others have decided to close their
hyperbaric-medicine service altogether. The predictable
net effect is a significant national decline in the resources
necessary to provide and maintain this vital standard of care.
Very few new programs are prepared to accept the 24/7
responsibility, and long-established programs continue to opt
out. Divers and others for which the immediate provision of
HBOT can make the difference between a good outcome and
a bad one are increasingly being denied necessary and
timely access.
A WAy Out
In general, the diagnosis and treatment of a broad range of
difficult-to-manage conditions has greatly improved over
the past decade, as has patient access to such care. During
this same period, however, the ability to refer patients to
hyperbaric facilities with conditions considered appropriate
by both the mainstream medical community and by those
who underwrite its costs is becoming increasingly difficult.
What solutions exist that might serve to reverse this
trend, and how can individuals for whom the early provision
of HBOT is vital obtain necessary access? As the principal
issue is financial, some possible solutions might include the
following:
1. The rates insurance companies pay to chamber facilities
for HBOT are increased for those treatments initiated
outside of normal business hours.
2. Insurance company payment rates to chamber facilities
for all HBOT are increased for those hospitals that
maintain 24/7 emergency availability.
3. Insurance company payment rates are decreased to
providers of HBOT that do not offer 24/7 access. This
could be worked out to become cost neutral for those
paying for care as these savings could be used to pay
additional fees to the 24/7-available facilities.
4. A network of hyperbaric medicine facilities is developed
to offer 24/7 call response; perhaps some of the necessary
funding support can be provided by hyperbaric facilities
that choose not to be so available.
5. Insurance companies could expect those facilities that file
claims for providing HBOT to be willing and available to
provide such therapy for all the conditions the insurance
companies consider medically necessary.
In the meantime this difficult situation will remain. For those
who plan to travel overseas to dive, the news is much better.
The business model described is limited to the U.S., where
medical services are often provided or managed by third-
party for-profit organizations such as venture capitalists,
investment houses and commercial banks. Essentially all
international hyperbaric chambers remain available to treat
divers and other emergent indications for hyperbaric oxygen
therapy.
AD
DAN maintains an extensive network of chambers willing
and able to treat divers. If you have symptoms after diving, we
will help you get the care you need. Call the DAN Emergency
Hotline at +1-919-684-9111.
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