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Home Sleep Testing and

Impacts for Sleep Centers

Presented by Rebecca Boarts, RPSGT

An eye catching story. . .

January 2013 Sleep

HealthCenters operating mostly in New England with some sites in Arizona abruptly closes all of its sleep centers.

Over 150 employees and thousands of patients are affected immediately

Sadly many sleep centers started to react like this. . .more on that later

Home Sleep Testing (HST) is typically defined as “an unattended form of polysomnogrpahy”

Generally HST is performed in the patient home, but can be done in the sleep center or inpatient hospital room.

Generally done with less measuring channels than traditional polysomnogram.

What is Home Sleep Testing (HST)?

There are a variety of devices. Commonly known as a type I, II, III or IV.

What devices are used for HST?

Attended full polysomnogram recording with full staging of sleep EEG patterns.

Must include these channels

EEG EOG ECG Limb EMG Respiratory effort at chest and abdomen Airflow Pulse oximetry CPAP, CO2, PH, etc channels

Type I Devices

Examples of Type 1 devices

Sapphire PSG with DreamPort

by CleveMed

Grael on Portable Unit by Compumedics

Unattended polysomnogram , with a minimum of 7 channels.

Must include these channels

EOG ECG EMG Airflow Respiratory effort Oxygen saturation

Type 2 devices

Example of a Type II device

Somte system by Compumedics, no video recording or

technologist present, no EEG channels

Unattended polysomnogram , with a minimum of 4 channels

Must include these channels

respiratory effort airflow ECG or heartrate oxygen saturation

Type III devices

Examples of Type III Devices

Nomad by Nihon Kohden

ApneaLink Plus by Resmed

Unattended polysomnogram , with a minimum of 3 channels.

Must include these channels or ability to measure the following

Channels that allow direct calculation of an AHI or RDI as the result of measuring airflow or thoracoabdominal movement

Type IV devices

Example of a Type IV device

ApneaLink by Resmed, no effort measured,

only heartrate, airflow and pulse oximetry.

Cost Patient Convenience and Comfort Push from insurance payers and CMS

Why do Home Sleep Testing?

Cost is typically about 35-25% of a traditional in center polysomnogram

For example patient cash cost at SMHC is approx. $300 for HST vs. $1200 for an in center polysomnogram

Affects both patients and medical providers

Home Sleep Testing Costs

Homebound patients-elderly, transportation issues, medical issues

Inpatient sleep testing The “comfort of the patient’s own bed”

Home Sleep Testing Convenience

As part of the Affordable Care Act, more commonly known as “Obamacare” more patients will enter healthcare on a whole.

Public aide programs, i.e. Medicaid and Medicare will undergo cost cutting measures including sleep testing.

Affordable Care Act Impacts

As a result of the Affordable Care Act, many insurance companies are looking to cut costs to offset the expected losses.

Insurance Payer Impacts

Many Insurance Payers are now requiring prior authorization for sleep testing

Requirements may include that the pt have a co-morbid condition, i.e. hypertension, CHF, COPD

May require the physician to fill out a qualification form

Depending on the conditions of the form the patient may be required to proceed with HST, and traditional in center polysomnogram denied.

Insurance Payer Impacts

Example of Pre-Auth/Qualification Form

Less in lab testing completed Increase in or begin to offer HST

alternative Develop a “total sleep health” approach

to patient care Increase in physician “facetime” Challenge to change model of care and

train staff

What are the Impacts to Sleep Centers?

Estimates vary dramatically from up to 70% home based testing, to around 25% home based testing

Shift to more HST expected Choice of sleep center and/or insurance

payer to offer sleep center based HST vs. mail order

Less in Center Testing, More HST

Changed approach to providing more for patients than just a polysomnogram

Compliance with treatment Care managed by board certified sleep

physician Expected increase in clinic or office visits Follow up testing for patient as needed

What is “Total Sleep Health”?

Many sleep centers will have to adjust the types of services they offer

Compliance follow up HST PAP nap And the skills and schedules of their staff

Challenge of Model of Care Changes and Staff Training

Research supports that the effecacy of HST is adequate in making a positive diagnosis of OSA

However there are many conflicting studies about the outcomes and compliance of the patients months or years later

Is HST Comparable to In Center Testing?

Studies published in the American Journal of Clinical Sleep Medicine indicated that HST patients had higher rate of dropout from therapy

On the other hand studies performed by the University of Pittsburgh and VA of Pittsburgh found the outcomes and compliance were similar 3 months post study

HST Outcomes and Compliance

In the fall of 2012 Priority Health became the first high volume local insurance payer to mandate HST in some cases, mostly though hospital based sleep centers

Other insurance payers with high volume in Michigan; United, Blue Cross Blue Shield, Aetna have routed some testing to HST as well.

Several sleep centers including all hospital based programs in Grand Rapids offer HST to applicable patients

Impacts for Michigan Sleep Centers

Executives and medical directors of Sleep HealthCenters did cite the changing sleep market as a factor

Other factors included the facilities lease contracts for sleep center space and lack of clear hospital base

The AASM has issued a statement to all Sleep HealthCenter patients offering advice and assistance to find a new source for sleep care

The Conclusion to Our Eye Catching Story?

The Moral of the Story. . .