{
Presented by Rebecca Boarts, RPSGT


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
An eye catching story. . .

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

Sapphire PSG with
DreamPort by
CleveMed
Grael on Portable
Unit by
Compumedics
Examples of Type 1 devices



Unattended polysomnogram , with a minimum of 7 channels.
Must include these channels






EOG
ECG
EMG
Airflow
Respiratory effort
Oxygen saturation
Type 2 devices

Somte system by Compumedics, no video recording or technologist present, no EEG channels
Example of a Type II device


Unattended polysomnogram , with a minimum of 4 channels

Must include these channels
 respiratory effort
 airflow

ECG or heartrate
 oxygen saturation
Type III devices

Nomad by Nihon Kohden
ApneaLink Plus by Resmed
Examples of Type III
Devices


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

ApneaLink by Resmed, no effort measured, only heartrate, airflow and pulse oximetry.
Example of a Type IV device


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. . .