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Insurers push clinic sleep testing into homes
Sleep apnea testing was a time commitment. For years, patients were required to stay overnight at a sleep clinic, plugged in to machines and watched over for seven hours by sleep technologists. Now, most people can strap a portable monitor to their chest and get tested as they doze in their own beds.

Researchers have found that the cheaper and often more convenient home tests are about as good at detecting the breathing interruptions that characterize obstructive sleep apnea. Massachusetts insurance companies looking to clamp down on the booming field of sleep medicine have responded by restricting use of the in-lab tests, which run about $650 to $1,000, in favor of home testing at about one-third the cost.

Sleep HealthCenters, a chain of sleep clinics that included 11 in Massachusetts, cited the drop in insurance payments when it closed suddenly last week, leaving nearly 150 employees looking for work.

Sleep medicine physicians say the change, which is likely to spread to other states, has occurred too quickly for them to adjust their business models and that insurers have taken it to an extreme, cutting some patients off from tests their doctors think they need. But a report released last week estimated that shifting three-quarters of the tests to the home could save New England’s health care system about $35 million a year.

Though workers have lost their jobs, the change in sleep testing is a prime example of the kind of shift — the replacement of an outmoded and expensive health care service with a cheaper technology — that’s necessary to control health care costs, said Austin Frakt, a Boston University health economist. “If we’re really going to save money in health care, it means that somebody’s going to get paid less,” said Frakt, a member of the New England Comparative Effectiveness Public Advisory Council, which issued the report. “Maybe some of the ways of delivering health care just won’t be viable.”

The council, a group of physicians and policy makers who evaluate tests and treatments based on effectiveness and cost, found that home testing is “functionally equivalent” to in-lab tests for obstructive sleep apnea in those patients who do not have other serious conditions, such as heart failure or lung disease. Both tests track oxygen levels, heart rate, and breathing, while those done in clinics also monitor brain waves and other factors.

The shift to home testing, however, could increase the number of incorrect test results compared with those done at sleep clinics, the council found. And some members were concerned the convenience could lead patients unlikely to have apnea to be tested at home, resulting in overdiagnosis.

Sleep medicine is an attractive target for cost-cutters. It is a young field, formalized as a medical specialty little more than a decade ago. But it has grown quickly, with greater public awareness that apnea — affecting up to 7 percent of men and 5 percent of women — can lead to dangerous drowsy driving and increase the risk of heart failure or stroke. For-profit companies such as Sleep HealthCenters that saw an opportunity to make money from testing and treating these patients also have driven the expansion.

In 2002, 623 sleep centers were accredited by the American Academy of Sleep Medicine. Last year, there were 2,517. Medicare spending on sleep testing in clinics increased nearly fourfold in eight years, to $235 million in 2009, according to a report from the US Office of the Inspector General, which highlighted sleep testing as an area it plans to examine for patterns of fraud or overuse.

Dr. Sam Fleishman, president of the American Academy of Sleep Medicine, said there may be too few sleep doctors to meet demand for treatment — which often involves sleeping with a mask and a device that blows air into the throat to keep the airway open. The challenge the field is facing now is not because it grew too quickly in recent years, he said, but because it was too focused on diagnostic testing rather than caring for patients over time.

The movement toward home testing is appropriate in theory, said Dr. Lawrence Epstein, Sleep HealthCenters chief medical officer and an associate physician at Brigham and Women’s Hospital, but it came when the down economy had caused some patients to put off care and the company was locked into building leases.

“When revenue and volume drop and expenses don’t, it causes a problem,” he said.

Sleep technologist Joyce Mor, who worked at the company’s Weymouth clinic, said her manager called her Jan. 23 to tell her not to come to work that night.Continued...

Chelsea Conaboy can be reached at cconaboy@boston.com. Follow her on Twitter @cconaboy.

© Copyright 2013 Globe Newspaper Company.
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my search was not successful finding the thread about the Canadian study (home titration) but here some other linkage

Home Sleep Testing

Comparison of Home Sleep Test Machines / Home Sleep Testing Increases

Home Sleep Tests: Are they the future for OSA Diagnosis?

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Very interesting...

In my cynical way I have previously characterised the Sleep Disorder diagnosis and treatment field as an 'Industry' that is being driven rapidly feeding off inflated prices for studies, diagnosis, and appliances.

In Australia though the Insurers have never entered into the game. While those with Private Hospital Insurance can get a good rebate if the study is done through an overnight admission to a hospital the payments for machines are small ($500 max) and for masks and accessories there is no rebate at all.

The government has no rebate for appliances except in very limited circumstances.

Despite that there has been a spurt in the growth of 'Sleep Centres' with the biggest continuing to get bigger by buying out the smaller practices.

There is no intrinsic reason that something needed by at least 5% of the population (although used by far fewer) should be so difficult (read expensive) to access for diagnosis and the treatment appliances so expensive. Surely the economies of scale must come into play for the suppliers - and those economies must be passed on to the end user through taxpayer savings, lower insurance premiums, or lower co-payments.

The Australian government cracked down on the Pathology industry a few years by reducing the Australian Medicare rebate for pathology testing to reflect the fact that the Industry had got fat on the fees that were set back when the majority of testing involved a technologist doing the test. The labs are now all automated and the profits were getting to be obscene... As a result the labs started charging a co-payment (having previously just accepted the Govt rebate). The Patients stopped getting 'optional' tests done and the labs lost volume causing their costs per test to go up... End point of the game - most of the big labs are once again 'Bulk Billing' the govt and not asking for the gap payment.

Ultimately Capitalism is all well and good - but those paying the piper should get some of the benefit when it gets cheaper to play the tune.
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as far as I know, here sleep studies done in public hospitals or private sleep lab are covered by Medicare Australia
the only cost to patient if sleep study done in private sleep lab is the charge for the bed (about $80/100)
for now, home tests are not covered

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(02-06-2013, 09:38 PM)zonk Wrote: as far as I know, here sleep studies done in public hospitals or private sleep lab are covered by Medicare Australia

Hmmm - I am thinking back a few years but Medibank Private covered almost all of the local private hospital charge. The actual test and report might have been bulk-billed to Medicare.
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I had a home sleep study last September. I have never seen a "sleep specialist" and have never been to a sleep lab. My doctor is an Internist (internal medicine specialist). He got everything approved the day I went to see him about my problems and the home test kit packet arrived in 3 days. Insurance paid for everything, no questions asked. It came with instructions in video format on dvd. It had a harness with straps over the shoulders and around the chest. A box in the middle of the chest that everything else plugged into. It took about 20 minutes to get everything on me and plugged in the way the video showed, but was pretty easy to do. Not sure of everything that was there, but I know that a blood pressure monitor and oximeter were 2 of the 6 or so things that plugged into the chest box. I don't know if the box on the chest did anything itself or was just a battery and data processing/collection unit, but the directions were very specific about how it had to be placed. The only uncomfortable part was the tube that looped over the ears and under the nose with little soft rubber prong tubes that stuck up unto the nostrils. Had to have a combined total of 4 hours (if I remember right) of recording time in a non-awake state or have to wear a second night. Couldn't keep it more than two nights because of batteries. In the morning you watch the other part of the video and it shows you how to disassemble and what to throw away, what to put back in the box and how. Take the box to the post office and done - easy as a can of corn. Had the results in four days.

Everything went smooth, was simple and hassle free until the DME came into the picture - but that's a different story.

My doc started nagging me about 20 years ago - saying I probably had apnea and needed to go for a sleep study. Of course the symptoms were nowhere near as bad back then and there was no way anybody was going to convince me to go do an in-lab sleep study. I hadn't been back to see my doc in about 10 years or so until I eventually dragged my sorry, broken down shell of myself back in to see him last September; finally ready to address the issue.

I probably would have been on PAP for 20 years now if they would have had the home studies back then. I think that is one of the biggest benifits of the home studies. How many other people out there are like me and just dead set against going and trying to sleep in a sleep lab?
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"How many other people out there are like me and just dead set against going and trying to sleep in a sleep lab? " :jgjones1972

That would be me. No insurance here. Not enough $$ income.
I would rather go in for a formal sleep study but...money dictates.
Base line study here is $4000, followed by titration study $4000, and follow up study $4000..
I ain't got it! Angry
I was falling asleep at work, going home and falling asleep in my chair and snoring myself awake.
I write analytical software for a living, I am also a skilled technician and fabricator.
However, I was unable to keep up with the challenges at work since my head was in the
"dull & fuzzy" mode all day.
I suspected I was having sleep apnea already at this point.

I hit the internets and dug around for knowledge.
I ran into Zeo (simple brain wave monitor) then ran down to the local store and picked that up.
A couple days of sleeping with that and lo & behold. I am not getting any sleep because I am awake but not concious all night.
No wonder. Sounds more like sleep apnea (again)
Ok, how can I tell what mechanism is going on here? I went through many forums, including this one.
Hypothesis: If it is really apnea then I will be showing up with horrible oxygen desaturation events. If not then I just go see the Dr and show her all my collected data so far.
I eventually picked up a CMS50-F pulse oximeter and slept with that one night.
Holy crap I was falling down into the low 70%'s and sometimes bottoming at 70%.
Not acceptable!
I dug my old RemSTAR out that I picked up 10 or more years ago and started at the bottom setting, slowly working up and logged the observations
each day, setting the pressure up by 1cm each time I noted desats showing up.
I then went to Amazon and picked up a decent electronic manometer to keep an eye on the pressure being generated by the old RemSTAR.
So I have been titrating based on oxygen saturation vs set pressure as measured from the hose itself.
Crude perhaps but effective in my case.
The only time I get any desats now is when I suspect that I end up sleeping on my back but the CPAP is saving me there by limiting
the severity of the desats to 85% and higher.
I am thinking that when I sleep on my side I can stay well above minimums. (88%)
I'm putting in an infrared lighting system to see if I can verify that now by using the computer as a low light time lapse
video system.
Sounds like I am doing my own sleep study in house and learning as I go.
So far, so good...
I still might need to get an S9 just to get a bit better sleep quality going and have the RemSTAR as a spare.
Running at 17.3 cm now and I'm getting an aweful lot of air in the gut and that is starting to wake me up sometimes. *erp!*
All things considered though, situation is vastly improved. Staying awake all day and staying sharp.
If anything goes wrong at this point I can still hit the Dr.'s office for a consult.
With gained knowledge at this the main worry is if any real central apneas show up but I dont see any thing like that yet.
Total cash outlay, short term: < $500.
If I have to get the S9 in that will be $800-900 more but should be worth it.
No signs of my head trying to explode or anything like that, and my CPAP is on a side table so I can't pull it down on my head
while I am asleep.
From the looks of it though, the results of NOT doing all this...are too horrible to consider.
I'll keep everyone posted!

Peace, Love and Carrots,

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(02-07-2013, 02:27 PM)Shastzi Wrote: No insurance here. Not enough $$ income.
I would rather go in for a formal sleep study but...money dictates.
Base line study here is $4000, followed by titration study $4000, and follow up study $4000..
I ain't got it! Angry

I wouldn't recommend what you are doing to everyone, Shastzi; but, some folks are better at solving problems than others - so I admire what you are doing.

One thing to keep in mind with the home studies though, is that my diagnosis (according to insurance company EOBs) cost about 6 hundo from start to finish - that includes doctor's office visits.

I think the DME was already into the insurance co. for more than that by the time I parked my car out front.


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Can't say I approve of Shastzi's method, only because a lot of time and effort would have been saved by doing a home sleep study, but I am impressed by the thoroughness of it - there is a research doctor in making, if ever I've seen one... If you are getting a belly full of air all the time, the pressure is probably slightly to high, and a ramp-up from 5 - 15cm would be a safer bet, if your machine can do that, and if not, when you get your new machine, it should be able to, and you will be able to see in the printout if that is sufficient for you. I don't know how much a basic home study costs in the US, but it often more than enough to diagnose apnoea, sometimes enough to pinpoint what type(s) of apnoea and even ideal pressure settings, without bothering with sleep-overs and titrations. I am curious as to why you think sleeping on your back is a problem - do you have a strong post nasal drip or other problems that would cause you to block your breathing passage when on your back?

*full disclosure: I insisted on doing a home sleep test rather than a clinic stay-over because I knew I would get cleaner results when sleeping in my own bed at my own sleeping hours. I suspect that is true of most people. That said, if the test had indicated the problem but not defined it, the next step would be a sleep-over, like it or not. I was lucky in my case, as most are, that the home test would be sufficient to diagnose the problem. But, hey, I hate sleeping at hospitals - on the occasions I have required surgery, I finagled my way into showing up two hours before the op rather than sleep in the hospital the night before, as is the norm. If that meant getting up at 3 a.m. to be there on time, so be it.
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I agree, Wilorg.
I don't approve of my methods either. I just did it because I didn't have months and months
of time to save up all the money needed.
I was also sitting back watching my brain turn into hash and that did NOT sit well with me.
I don't seem to have a great deal of post nasal drip, just some chronic bronchitis
flare ups now & then.
Dr. got me a prescript for ventolin (inhaler) for occasional use.
When I sleep on my back it seems like my airway caves in more when in that position.
Without the CPAP running it is even hard to breathe while awake.
I will be taking time lapse infrared sequences next week to verify this as soon as I can get the rest of the parts in that I need for the job.
In the mean time I will be staying on my side as much as possible. Wink

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