Home Testing Continues Growth
More sleep labs indicate that they are offering portable monitoring or plan to offer the testing modality in the near future.
The practice of sleep medicine is changing with more centers adopting home testing and more insurers preferring portable monitoring. A number of Massachusetts insurers have implemented a preauthorization process for sleep testing where a gatekeeper determines the appropriate testing modality (see sidebar). Among those insurers, the majority of patients are being directed to home testing rather than in-laboratory polysomnography.1 While it remains to be seen whether these policies become more widespread, respondents to Sleep Review's 1Q12 Sleep Center Survey have stepped up their involvement with home testing. At the same time, bed growth for sleep centers appears to be slowing.
HOME TESTING SURGING
Currently, 35% of sleep centers offer home sleep testing for Medicare patients (up from 28% in our prior survey) and 41% offer home testing for privately insured patients (up from 35% in our prior survey). Additionally, another 48% of the sleep centers plan to start to administer home tests in the next 6 months. In two other questions about how the sleep centers were responding to home sleep testing, 33% of respondents have changed their expansion plans as a result of home testing and 58% of respondents indicated that they expect to increase involvement in home testing (up from 48% in our prior survey). Putting the responses to these questions together, we think that the use of home testing is expanding rapidly at sleep centers.
SLEEP CENTER EXPANSION APPEARS TO BE SLOWING
Respondents reported bed growth of 0.9% during the last 12 months and reported an average of 8.5 beds per respondent versus 8.4 beds per respondent 12 months ago. Respondents also expect greater sleep center capacity expansion in the next 12 months (7.9% to 9.2 beds per respondent) than the growth seen in the last 12 months. Compared with our prior survey, both last 12 month and next 12 month bed growth declined to 0.9% from 3.6% and to 7.9% from 8.5%, respectively.
We offer a few caveats about these results. First, we note that sleep center growth covers only part of the entire sleep market, as sleep center growth drives new diagnoses and flow generator sales, while mask sales are mostly driven by replacement sales. Second, sleep center growth as defined in our survey represents only organic growth (beds per center) versus inorganic growth (new sleep centers). Third, as home testing becomes more prevalent, it is possible that sleep center growth may become less correlated with the overall growth in the sleep market. Finally, we note that many respondents are indicating the total number of beds for multiple sleep centers, which pushes the average number of beds per respondent higher (ie, we doubt that the average individual sleep center has 8+ beds).
Overall, we think that the survey indicates that sleep center growth has stabilized in the mid-single digits. For 2012, we expect the domestic sleep therapy equipment market to grow by 6% to 9% with 6% to 7% volume growth in new patients.
PATIENT VOLUME GROWTH APPEARS STABLE
On average, respondents have seen patient volume grow 3.1% in the last 12 months and expect 7.2% growth in the next 12 months. We note that the most common responses were for 0% to 4% growth in both the last 12 months and the next 12 months. The reported and expected patient volume growth rates are different from the reported and expected bed growth rates (which were 0.9% and 7.9%, respectively).
Compared with our prior survey, last 12 month patient volume growth was stable at 3.1% while next 12 month patient volume growth declined slightly to 7.2% from 7.9%.
Additionally, Medicare's 2011 Physician Fee Schedule included a reduction to the professional component for sleep testing. Respondents indicated that this change would reduce their bed growth by an average of 0.8% (in line with -0.8% in our prior survey).
ORAL APPLIANCE USE EXPECTED TO RISE SLIGHTLY
In response to recent coverage updates, respondents expect to increase the number of their patients receiving oral appliances by an average of 1.7% (down from 4.4% in our prior survey).
APAP UTILIZATION SLOWS, BI-LEVEL FLOW GENERATOR USE STABILIZES
We asked the sleep centers how many of their patients use higher-end flow generators. According to the respondents, 12% of patients use auto-setting flow generators, a small decrease from 12.7% in our 1Q11 survey. And 11.9% of patients use bi-level flow generators, about in-line with 12% in our 1Q11 survey.
Sleep Centers Selling CPAP Equipment StabilizesOnly 17% of sleep centers report selling flow generators and masks. We think that some centers view equipment as an additional revenue source and a way to offset potential losses to home sleep testing. Over time, however, the portion of sleep centers selling CPAP equipment has remained relatively stable.
ABOUT THE SURVEY
Sleep Review and Mizuho Securities USA conducted a survey of sleep centers. We sent the survey to ~12,500 sleep professionals, and 622 responded to one or more of the survey questions for a response rate of 5%. None of the questions were mandatory, therefore response rates varied from question to question. Of the 622 respondents, 464 (75%) completed the entire survey. The responses were collected between January 9 and January 23, 2012.
We received responses from a range of sleep industry participants with registered polysomnographic technologists (34% of respondents) and sleep center directors/supervisors/managers (32% of respondents) representing the most common titles. Responses also covered every geographic region and all 50 US states with the Southeast (29% of respondents) and Midwest (29% of respondents) the most heavily represented regions.
MASSACHUSETTS: A STATE OF CHANGE
Sleep centers in Massachusetts have been among the first to be impacted by insurers who have implemented policies that direct patients to home sleep tests as a preferred diagnostic method over in-lab polysomnography. With reports that sleep labs such as Massachusettsbased Sleep HealthCenters have seen 10% to 20% of its activity overall switched from in-laboratory to inhome sleep studies,1 we surveyed labs in the state to see how they fared in comparison to the rest of the country. While our sample was very low (10 respondents), those polled indicated a drop in average beds and patient volume growth.
DROP IN BED GROWTH
In Massachusetts, respondents reported a decrease in bed growth of 5.5% during the last 12 months and reported an average of 13.8 beds versus 14.6 beds 12 months ago. We note that many respondents are indicating the total number of beds for multiple sleep centers, which pushes the average number of beds per respondent higher. Bed growth expansion is predicted to be flat with respondents expecting 0% growth. In the state, last 12 month bed growth and expected bed growth were below the national averages. Nationally, respondents saw 0.9% growth in the last 12 months and expected 7.9% growth in the next 12 months.
PATIENT VOLUMES DECLINE
On average, respondents saw patient volume decrease 5.3% over the last 12 months, although next 12 month growth is expected to be 6.3%. Nationally, respondents’ last 12 month patient volume growth was 3.1% and average next 12 month patient volume growth is predicted to be 7.2%.
Eleven percent of Massachusetts respondents said they offered home testing for Medicare patients, 33% offer the form of testing to privately insured patients, and 67% indicated they plan to offer home testing in the next 6 months.
Seventy-eight percent of respondents said the rise of home testing has impacted their facility’s expansion plans, compared to 33% nationally. In response to increased use of home testing, respondents said they will decrease beds per facility (24%), close facilities (12%), and increase involvement with home testing (35%). Nationally, respondents said they will decrease beds per facility (6%), close facilities (3%), and increase involvement with home testing (58%). Again, we emphasize that readers should keep in mind the small response rate when analyzing the Massachusetts results.
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