Respiratory Funding Update: In-Home Sleep Testing

• By Elisha Bury
• Sep 01, 2007

To reimburse or not to reimburse? That is the question that has the sleep industry on the edge of its seat as CMS reconsiders its policy for in-home sleep testing. The question is also at the center of debate for sleep labs, sleep physicians and clinicians concerned about how the delivery of in-home tests might impact the health of sleep apnea patients.

“I think, from the sleep lab’s point of view, they are concerned that DMEs are going to start to do sleep studies at home, take away their business and cut them out,” Terry Racciato, president of SpecialCare in San Diego, says. “The national sleep labs have bricks and mortars that they have to pay for.”

In fact, many are concerned that in-home sleep testing will be an avenue to bypass polysomnographs altogether. Tom Pontzius, president of Nationwide Respiratory, says it’s unlikely that will happen. “I believe that (CMS’s) determination is going to decide what type of patient would benefit from the facility-based test vs. a home diagnostics test. I don’t think it’s going to be carte blanche anybody that needs a test.”

The Pros of Home
Many argue that in-home testing offers many benefits for patients, namely addressing a bottleneck at sleep labs. In-home testing would help move more severe apnea cases to the front of the line and also would help diagnose patients with milder forms within 48 hours.

Racciato, who plans to implement in-home testing, sees the possible policy revision as a positive for patients. “There are so many people that are not currently receiving the sleep studies they need and therefore not receiving the CPAPs that they need,” she says.

Another benefit is that in-home testing encourages patients to follow through with a sleep study.
“There are some patients that I have who went for PSG, were just so uncomfortable with the setting — namely all of these electrodes, strange bed, sleeping with someone watching them, etc. — that they simply didn’t sleep,” Dr. Terence Davidson, University of California, San Diego, says. “We recently reviewed our own clinical experience, and the vast majority of people referred for a home sleep test took it, but as many as half of the patients who were required to have a PSG never made the appointment and never took the test simply because they just didn’t want to sleep away from home.”

Hani Kayyali, president of Clevemed in Cleveland — a manufacturer of a virtual attended sleep monitoring device called PSG At Home — calls the syndrome “the Funding Update white coat effect.” He says, “Testing patients at home is not only reliable, convenient and cost-effective, but it could really improve the diagnosis because now you are capturing the true symptoms of the disease because these patients are sleeping in their natural environment.”

CMS Factors
CMS planned to conduct a public forum Sept. 12 in Baltimore to get feedback on the issue. The decision memo, originally set for mid-September, was pushed back to Dec. 14 (at press time).

Pontzius says, “I think that that’s a good sign that it’s going to happen.”

Davidson, who planned to attend the Sept. 12 meeting, says CMS chose the group slated for the forum based on its expertise in evidence-based medicine. He believes CMS will be looking at the science of in-home sleep testing.
 
After studying the differences between PSG and home testing, Davidson found home testing to be “equally good to PSG.”

“When I canvassed the world’s literature and put it all together, I was unable to prove that home sleep studies were superior, and in fact no matter what I did, I couldn’t find that there was an ounce of difference,” he says. “They just simply time and time again come up with essentially the same outcome.”

In addition, Davidson says CMS is looking at whether a sleep test is necessary at all and has asked for a recommendation on alternate paradigms. In fact, he says, many studies show that people who are highly suspect for sleep apnea that are put directly on CPAP or aPAP do very well or no different than if they first had a PSG.

For this to work, Davidson says seniors would need to exhibit snoring and one other known co-morbidity, such as obesity, heart failure, hypertension, arterial fibrillation, diabetes or excessive daytime sleepiness. In younger patients, those co-morbidities may not have presented yet, so snoring would be enough to do a CPAP or aPAP trial.

“By the time somebody has declared snoring a problem, they have the disease,” he says.

Industry Outlook
SpecialCare plans to introduce a comprehensive plan for in-home sleep testing in October — three months before CMS will announce its decision. The San Diego-based DME has scored a major contract with a Medicaid HMO and believes that reimbursement for the in-home tests is likely. Racciato has already developed a plan that would allow a patient to go home with a CPAP the day after completing the test.

For people on Medicaid, that turnaround is crucial, she says. “That’s a critical issue for them because when you’re looking at people who are of the Medicaid variety or the Medicaid socio-economic background, transportation is sometimes an issue.”

Racciato says in-home testing is a huge benefit for Medicaid because “they can increase the amount of compliance they’re going to have and be able to be cost-effective to reduce their overall health costs for those patients.”

For his part, Davidson thinks more focus should be placed on treatment and compliance than the diagnostics method. “The reimbursement paradigms at the moment are backward, at least from the physician perspective, where there is more money being spent on diagnosis than there is on treatment,” he says. “There’s no question if you had to do the sleep test for free, and you only got paid for CPAP, that practices would change literally overnight.”

This article originally appeared in the Respiratory Management Sept/Oct 2007 issue of HME Business.