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[News] Home testing for sleep apnea bankrupting U.S. sleep centers
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ApneaNews Offline
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Home testing for sleep apnea bankrupting U.S. sleep centers
Home testing for sleep apnea bankrupting U.S. sleep centers

Home Sleep Apnea Testing: New Standard is Bad Deal for Sleep Docs

Sleep doctors in the U.S. have been doubling up on their Prilosec and putting their accountants on speed-dial since the federal government and insurers began signaling they plan to eventually run the $2,000-per-sleep-study gravy train off its rails. With an estimated 18 million people with obstructive sleep apnea in the U.S., the established system for diagnosis and management of OSA was seen as financially untenable (except to the sleep centers) and has long been a declared target for cost-cutting administrators.

Home sleep apnea testing is inferior to in-lab polysomnography in terms of precision. However, multiple randomized trials have showed home sleep apnea testing worked just as well as in-lab sleep studies at diagnosing obstructive sleep apnea in people with moderate-to-high pretest probability for OSA. Many in the sleep community had their fingers crossed that home sleep testing would be a flash in the pan, but among the bureaucrats and payers who effectively set U.S. health policy, it’s caught fire.

At reimbursement rates as low as $86.46 apiece for home sleep studies, sleep centers haven’t rushed to convert their business models to feature home sleep apnea testing. Besides the obvious financial disincentives, sleep physicians prefer the higher quality information provided by full polysomnography, and the variety of home testing devices and non-standardization of their data feeds create confusion as well.

Payers aren’t waiting for the sleep community to voluntarily embrace home sleep testing, though. Insurers are simply mandating their use, in some cases suddenly cutting off the revenue streams of well-established sleep centers.

Further shifting the landscape, device manufacturers and testing companies are increasingly bypassing sleep centers altogether, sensing that their real market is the much larger pool of primary care physicians who first encounter obstructive sleep apnea patients. Auto-titrating positive airway pressure (APAP) machines are being marketed as the replacement for in-lab CPAP titration during polysomnography. Here, too, randomized trials support the conclusion that home sleep apnea testing followed by APAP treatment results in similar outcomes as sleep lab CPAP titration.

However, it still takes someone knowledgeable in sleep medicine to adequately supervise home sleep testing programs and interpret the sometimes confusing results. Here, too, insurance companies are cutting sleep centers out of the deal, instead partnering with “sleep benefits management services” to oversee the whole operation. In so doing, insurers are also establishing their control, by instituting mandatory precertification prior to home sleep testing, requiring use of their preferred home sleep testing vendors, cutting reimbursement for home sleep testing, and specifying which devices may be used.

This PCP-centered treatment pathway for obstructive sleep apnea poses an existential threat to sleep physicians and centers, most of whose business models depend on lucrative in-lab polysomnography. The initial economic results have been jarring in some areas: in early 2013, Sleep Health Centers in Boston abruptly went out of business and closed 19 sleep clinics after home sleep testing became widespread; many other sleep centers have reported a drop in polysomnography by 50% after home sleep testing emerged in their markets.

On July 1, 2013, the U.S. government (Centers for Medicare and Medicaid Services or CMS) slashed payments to durable medical equipment (DME) providers of CPAP-related devices by 47%, causing consolidation in the industry. This doesn’t directly harm sleep centers financially, but will continue to disrupt existing business relationships in the sleep community and create confusion and inconvenience among patients, as stronger DME players swallow the weak.

Thought leaders have advised practicing sleep physicians to “embrace home sleep apnea testing,” “become a center of excellence for the management of OSA,” and change their approach “from a focus on testing to a chronic disease management model focused on improvements in meaningful patient outcomes.” All good advice, but with polysomnography paying the bills, a financially successful transition incorporating such fundamental changes to their business model will be a tall order for most sleep centers. It seems safe to expect more dislocation and financial pain in the sleep community as home sleep apnea testing proliferates across the U.S.


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The above post may contain copyrighted material the use of which has not always been specifically authorized by the copyright owner. The material available is intended to advance the understanding of Sleep Apnea treatment and to advance the educational level of Sleep Apnea patients with regard to their health. Sometimes included is the full text of articles and documents rather than a simple link because outside links frequently "go bad" or change over time. This constitutes a "fair use" of any such copyrighted material as provided for in section 107 of the US Copyright Law. In accordance with Title 17 U.S.C. Section 107, the material in this post is distributed without fee or payment of any kind for research and educational purposes. If you wish to use copyrighted material from this post for purposes of your own that go beyond "fair use", you must obtain permission from the copyright owner.
11-20-2014 03:21 PM
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Peter_C Offline

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Post: #2
RE: Home testing for sleep apnea bankrupting U.S. sleep centers
This is a scary thing to my thinking.

*I* am not a DOCTOR or any type of Health Care Professional. My thoughts/suggestions/ideas are strictly only my opinions.

"Only two defining forces have ever offered to die for you. Jesus Christ and the American Soldier. One died for your Soul, the other for your Freedom."
11-20-2014 06:30 PM
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surferdude2 Online

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Post: #3
RE: Home testing for sleep apnea bankrupting U.S. sleep centers
I'll have to disagree. I feel that the sleep industry is overcharging for equipment and the sleep labs are overcharging for the tests. They also maintain an air of secrecy of information and "prescription only" status for their own protection of income. Many DME are so arrogant as to criticize the patient that has the nerve to learn about the machines and make intelligent changes to the settings. What a bunch of crap from these phonies that are practicing what they call sleep medicine, like it was something that only they can understand.

That's my general feeling and I appreciate that there are some in the industry that don't deserve to be slated in such a way but by and large it's called for.
11-20-2014 06:43 PM
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Post: #4
RE: Home testing for sleep apnea bankrupting U.S. sleep centers
They created their own problem. Created huge waiting lists by insisting on two sleep tests vs one. Insurance companies and patients won't wait and won't pay that, not after so many years of doing the same thing. Insurance companies expect waiting lists to shorten, not stay as long or get longer. So they look for cheaper alternatives. They found it.

Either way, it is the patient getting screwed.

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11-20-2014 06:49 PM
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archangle Offline
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Post: #5
RE: Home testing for sleep apnea bankrupting U.S. sleep centers
One big problem is that a small fraction of the patients really DO need an in-lab PSG test.

Perhaps most people should start their treatment with an in-home sleep test, and proper followup with a good data capable CPAP machine, but some people need more in-depth testing.

I hope that throwing out the "rip off the insurance for all patients with an in-lab test" doesn't leave those who DO need a sleep test out in the cold.

We also need to realize that an in-home sleep test followed by APAP/CPAP needs proper followup and monitoring of the in-home data collected by the CPAP machine, and the vast majority of doctors don't actually follow through properly on this.

When they cut off the in-lab sleep tests, they need to mandate fully data capable CPAP and mandatory analysis of the in-home data by a competent evaluator.

Get the free SleepyHead software here.
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11-20-2014 07:27 PM
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lab rat Offline

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Post: #6
RE: Home testing for sleep apnea bankrupting U.S. sleep centers
They milked everyone for years, bought mansions and maseratis yet still expect the gravy train to continue.

The doctors who write up the reports have never met their patients. They get the clinic staff do do everything at fiddy cents an hour.
11-20-2014 08:36 PM
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Post: #7
RE: Home testing for sleep apnea bankrupting U.S. sleep centers
I had to wait almost 4 months for a sleep study. That was 4 extra months of suffering after it was clear I was going to test positive for OSA. I only wish I could have gotten tested at home. You want to make the club exclusive and require reservations four months ahead of time just to get a table you have to expect people will get annoyed and go elsewhere, or someone will open a new place. Such is life, I'm not going to cry for them.

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11-21-2014 12:30 AM
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Post: #8
RE: Home testing for sleep apnea bankrupting U.S. sleep centers
Every industry has disrupters. For most of us, it has been the internet. Just ask Radio Shack or BestBuy, or the newspaper, magazine, and television industries. The only way to deal is to not stagnate, and adjust. Or get Napstered. I just received the final copy of MacWorld, a venerable tech magazine for 30-odd years, which has finally succumbed to being in the dinosaur medium of print journalism. Not because the product wasn't great, but because of competing delivery systems, print, which has been around since Gutenberg's bible, is now irrelevant.

The secret to long life, according to the majority of centenarians, is to be flexible and willing to adjust.

Plus, if it were not for innovation, where would we be? If Apple had not given the masses the computer GUI OS, we would all still be using line-entry computer programs. Apple is the main reason why Windows 7 is great. In turn, if it were not for innovative competitors like Samsung and HTC, Apple might not have improved the iPhone all that much, and been content to sit on their laurels since 2007.

So innovation is good, and competition is good. And they not only drive but improve the free market.

So if sleep labs are getting heat from home testing, I don't see that as a problem, although from the point of view of anyone being disrupted by new technology, it appears as a threat. Too bad. So sad. Two tears in a bucket. Change or die.

But actually, I think home testing stimulates lab testing. There may be some who have not, but I have yet to see a SA patient who took a home test who did not later need a lab test, or many lab tests. Also, the intimidation factor of lab tests is what helps keep the other 90% of SA sufferers from getting therapy, so those who will submit to a home test because it is much less of a hassle and much less intimidating, become new customers to sleep Dr.s, and eventually lab tests.

So I see this article as a "sky is falling" tempest in a teapot piece by a writer desperate to create only one thing: column inches, which is what they are paid by.
11-21-2014 01:16 AM
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Ghost1958 Offline

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Post: #9
RE: Home testing for sleep apnea bankrupting U.S. sleep centers
I was diagnosed with a home test and could have just as well let the PRS1 auto set my min and my max pressure with software.

What ive found on my new little trip down hosehead lane is this. The Doc seems to know less about sleep apnea that the folks here do or anyone that takes time to research it. My DME didnt know that any PRS1 machine newer than the 550 existed until I insisted on one. He was happy to get it. Just thought the 550 was the latest model of auto machine.

I personally wouldnt want a mandatory evaluation of my home results past the point of insurance compliance. And if im self paying I dont want any mandatory evaluations at all.

If I think I need one then Id go get one. But have no interest being forced to see a doc when I dont need too.
(This post was last modified: 11-21-2014 02:04 AM by Ghost1958.)
11-21-2014 01:59 AM
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Blaifarm Offline

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Post: #10
RE: Home testing for sleep apnea bankrupting U.S. sleep centers
It all depends on the type of home sleep study that is done. I was given a "watch pat" home study, which in my opinion should only be used to tell if a person has the possibly of having obstructive sleep apnea.

Sure, it can tell the pulse, oxygen saturation, and maybe a few other statistics when you are sleeping. But it cannot tell you what kind of sleep problems you may have.

Just my experience and my opinion.
11-21-2014 02:21 AM
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