Funding Focus

Capturing Compliance Creates More Than Cash

• By Kelly Riley
• Jun 01, 2009

For several months, the Centers for Medicare & Medicaid Services (CMS) has been adamant that it is not going to pay for rental of PAP equipment unless it is proved that: 1) the patient is in fact using the equipment and 2) the prescribed therapy demonstrates a positive outcome in the management of the disease process, specifically obstructive sleep apnea (OSA).

On the surface that seems reasonable — after all, would you continue to pay for something you were not using or that did not produce the benefit for which you obtained it? I doubt it. In health care, however, things are not so black and white. Often, patients choose not to comply with physician-prescribed regimes, generally without the loss of benefit. For example, the diabetic patient who does not monitor blood glucose levels as ordered does not routinely lose the provision of the glucometer.

As of today, Medicare beneficiaries, and now even patients with other payor sources, who have OSA and choose not to comply with therapy will not enjoy that level of flexibility.

The time for looking closely at therapy compliance is at hand.

Measuring the adherence rate of patients whom your company sets up on PAP therapy and benchmarking that data against your historical performance and against other HMEs can be a powerful marketing tool. Measuring and communicating this data sends a strong message to referral sources that you are serious about contributing to the overall management of the disease process and positive patient outcomes.

While there is an abundance of studies and anecdotal data supporting the efficacy of PAP in treating the physiological symptoms of OSA, there is currently no standard definition of adherence/compliance. Consider, for example, data from the following two studies:

• American Review of Respiratory Diseases 1993, Kribbs, et al — Defined compliance as greater than or equal to 4 hours/night, greater than or equal to 70 percent nights; 60 percent of the patients reported nightly use but only 46 percent objectively met the usage criteria.
• Chest 2002; Sin, et al — Used a range from 2.5 to 4.5 hours/night; measured compliance from 93 to 78 percent depending on definition. Other studies have used as low as two hours per night as the definition of adherence/compliance.

It is interesting that the data from the Kribbs study (now 16 years old and with a sample size of less than 50 patients) appears to be what CMS based its definition of compliance on.

Thus, the place to start is to define what your company is going to memorialize as the definition of "compliant" and communicate that to the entire team. As you set a process in place, it is important to plan offensively by acknowledging in advance patients who have proven predisposing factors that affect compliance rates. Factors can be divided into both negative and positive.

Positive factors include:

• Severity of OSA
• Higher apnea hypopnea index (AHI)
• Increased daytime sleepiness
• Subjective benefit

Factors that are considered negative include:

• Lack of daytime sleepiness
• Side effects
• Previous Uvulopalatopharyngoplasty (UVPP)
• Nasal obstruction
• Claustrophobia

Most of this information can be gleaned during the initial setup by reviewing the sleep study as well as conducting a brief interview with the patient. If these factors are present, discuss these concerns with the patient to garner increased buy-in and commitment as patients adjust to therapy.

As new patients are initiated on therapy, address issues that relate to lifestyle and how those issues can affect sleep and compliance. These include the consumption of alcohol, weight gain or loss, changes in medications, and concerns related to traveling with equipment.

According to one study, the most common reason patients discontinue therapy is because of interface discomfort. This should not be surprising. A 2006 Cochrane Database study suggests that the optimum form of PAP interface remains unclear. We do know that it is not uncommon for patients to try multiple interfaces. In fact, this is a good reason to encourage patients to obtain a new interface each time the payor source will allow it. Patients can then use the appliances interchangeably as well as have a backup device in the event one breaks in the middle of the night or is otherwise damaged.

Also note that it is more than a perfect fit that makes an interface the best choice. Seek out products that are easy to put back together following cleaning, easy to take off and put back on in the middle of the night, and that don't take an excessive amount of time each night to get a good fit.

Measuring patient compliance and adherence to therapy is the foundation of demonstrating that your company is dedicated to delivering more than just a box with a blower.

Next month, we'll discuss some elements of what should be included in a patient follow-up program and various methodologies for tracking.

Author's Note: Joe Lewarski, BS, RRT, FAARC, vice president, respiratory products group, Invacare, contributed data for the article.

This article originally appeared in the Respiratory Management June 2009 issue of HME Business.