Bridging the Gap

AutoPAP and Home Titration Target Patients Who Would Otherwise not be Tested for OSA

• Sep 01, 2009

For many, the thought of having someone watch over them while they’re asleep can be down right eerie. For that same faction of people, going into a sleep lab to be tested for obstructive sleep apnea would be out of the question.

However, being tested and titrated in the home can fill that niche.

“Autotitration opens up an opportunity for a group of patients who would not have gone to the lab and now can in fact be both tested and titrated in the home,” says Gretchen Jezerc, director of U.S. marketing for sleep disordered breathing at Philips Respironics Home Healthcare Solutions.

AutoPAPs were first introduced in the 1990s for two main reasons: to screen patients for nasal CPAPs and for those patients whose health conditions prevented lab visits, according to Kelly Riley, director of The MED Group’s National Respiratory Network.

Autotitrating machines may just be catching on here, but the Europeans have recognized autotitration’s advantages for a while. Matt Borer, ResMed director of health care economics, says the vast majority of devices sold by Europe are autotitration machines.

“The physicians realized early on that the people are compliant and happier,” he says. “Their quality of life is better.”

Since CMS has allowed for the use of home sleep testing devices to diagnose obstructive sleep apnea, it’s highly likely that in the near future there will be an increase in both HSTs and titration performed in the comfort of one’s home.

Autotitration has been increasing in the market place and makes up for about 10 percent of CPAP units sold, Riley says.

“Autotitration opens up an opportunity for a group of patients who would not have gone to the lab.”
— Gretchen Jezerc, director of U.S. Marketing, sleep disordered breathing, Philips Respironics Home Healthcare Solutions

“I think that autotitration units are the fastest growing in percentage terms of our flow generator business so HMEs are really getting their arms around autotitration as the product of choice,” Borer says. “And I’ve talked to many HMEs including the larger ones that have hundreds of branches that said, ‘We only put out auto devices because it’s more comfortable for the patient.’”

The Benefits of AutoPAP and Titration

There’s another very heavy influencer in the decision to go auto — the person who shares the room or bed with the patient, says Drew Terry, ResMed senior director of product management for sleep. That person pushes the patient to seek treatment and have the problem fixed because they’re affected by the situation. The patient and the bed partner benefit from a quieter machine. “That’s something that has factored into the decision making process for a lot of our customers and patients,” Terry says.

One positive about an autotitrater is that it adjusts by itself and can be used for several nights in the patients home in a normal sleep environment and the device adjusts by itself, DeVilbiss Healthcare, global sleep product manager, Doug Hudiburg says.

“In terms of advantages, you can do it for multiple nights,” he says. “You’re in a normal home environment, so it’s more natural sleep and less hassle for the patient to come back to the lab for titration.”

The AutoPAP, if used for several weeks or longer with a good data capturer, such as EncoreAnywhere with a modem or Smartcard, allows for a long enough period to analyze what is the therapeutic pressure for the patient, says Jezerc. Most devices will indicate that between 90 to 95 percent of all events are apnea/hypopnea and other events are eradicated at a specific pressure level. At that point, the homecare company must decide whether to put that patient on an auto device that has certain benefits, leave them on the device that would titrate them essentially, or swap for a fixed CPAP.

AutoPAP and CPAP essentially deliver the same therapy. But there are specific instances where AutoPAP works better for a certain group of patients. For example, if patients sleep in a frontal position on their backs, they more likely will suffer from apnea than if they slept on their side.

“That’s probably one case where there’s a clear, clinical, identifiable issue with the patient that makes sense for an autotitrater,” Hudiburg says. “But generally when patients use it longterm, it’s simply about patient satisfaction and overall comfort.”

“If nothing else, it results in an increase of comfort for the patient,” Riley says. “Anytime you have increased comfort, you have increased compliance. Having auto out there will help facilitate the expansion of patients getting treatment and diagnoses in the home.”

Night after night, an AutoPAP is going to set to the patient’s needs. It senses the therapy a patient needs based on his or her current condition and will adjust to things like weight gain, fatigue, sleep deprivation and even alcohol consumption, Jezerc explains. “Anything that might have an impact on OSA, an auto device is going to react to that and deliver the therapeutic pressure level that is needed by the patient at that time,” she says. A fixed CPAP, on the other hand, will deliver the therapeutic pressure level only after it has been determined.

AutoPAP and Home Titration Does Not Replace a Sleep Lab

“Anytime you have increased comfort, you have increased compliance. Having auto out there will help facilitate the expansion of patients getting treatment and diagnoses in the home.”
Kelly Riley, director of The MED Group’s National Respiratory Network

Patients with different types of co-morbidities, central sleep apneas, periodic breathing, heart failure and neuromuscular diseases are patients who should not be targeted for home testing or titration, Jezerc says. AutoPAP achieves an adequate titration level for successful therapy if the patient doesn’t have other co-morbidities.

Autotitration was not meant to replace a full-night study in the lab for those patients who need it. A polysomnography study can determine the phase of sleep a person is in or whether or not a patient is asleep.

“It comes down to following the symptomology of the patient,” Riley says. “Sometimes patients are put on auto and are never titrated in a lab and that does go completely away from the practice standards that have been developed by the American Association of Sleep Medicine in regards to AutoPAP. They don’t want everybody running out and putting folks on auto because there is a concern that we’ll let machines start to treat the patients instead of having the patient have adequate follow-up.”

“Anytime a physician prescribes therapy for a patient, it’s a common thought that the patient goes back to see how it’s working,” she says. When patients are put on AutoPAP that doesn’t mean that everything should go on autopilot, but instead, there should be good physician oversight which is really needed.

Although AutoPAPs should never, and will never take the place of spending the night in a lab, it is helpful for the following people:

• A patient who is having weight fluctuations or who is undergoing bariatric surgery.
• A patient who didn’t get a solid sleep study in a lab.
• A patient who has compliance problems because he or she is on higher pressure.

This physician may choose to put this patient on AutoPAP as it might decrease pressure.

“It makes sense that physicians stay in the loop,” Terry says. “As great as our auto adjusting machines are there are still conditions that aren’t treated by them so the physician needs to make the determination even if the plan is to keep the patient on the Autoset long-term.”

Is AutoPAP an Opportunity for providers?

After being tested by a lab, some patients won’t be able to return there for titration because of financial or geographic reasons, making home titration an ideal option. Although the sleep lab is capable and authorized to do a home sleep test, someone has to set up the patient for a home titration, and this is where the home care company comes in, Jezerc says.While providers will not get an additional reimbursement for doing a home titration, they are entitled to the same reimbursement for setting up a patient on PAP.

It’s a doctor’s and clinician’s responsibility to dose medication and find the correct pressure, Borer says. “But at the end of the day, clinicians don’t have devices in their offices,” he says. “They don’t dispense equipment. HME providers are going to be required to handle the logistics of actually doing the set up, introducing the therapy at the patient’s home and bringing back the data from the device to make the final pressure recommendation. So, the HME definitely has a fast and hard role in all of this.”

“It makes sense that physicians stay in the loop. As great as our auto adjusting machines are, there are still conditions that aren’t treated by them so the physician needs to make the determination.”
— Drew Terry, senior director, product manager, Sleep, ResMed

Auto and home titration are ways that providers can deepen their relationship with referral sources, doctors and sleep labs by helping provide the titration, Hudiburg says. The clinical and business sides of sleep therapy have converged over the past couple of years. Increasingly, Hudiburg says, the sleep therapy business is about patient satisfaction. And if the patients aren’t satisfied and comfortable, then they’re not going to continue with coverage and won’t be a profitable patient for the provider. Autotitraters give providers an edge by delivering therapy to patients with the lowest pressure.

The other side of it is providers have to increase the costs of managing these patients. There’s no doubt that there’s a downward pressure on the market for people to cut costs, Hudiburg says. But providers should keep in mind that they might pay more for the autotitraters but a least they will have higher patient satisfaction and a different story to tell.

“Where many of my competitors are trying to cut costs by using cheaper devices to make up for this burden, we have chosen a different approach,” he says. “We’re using an auto adjusting machine. It’s going to costs us more, but we think that it’s better for the program.’ You can use it as a marketing tool because one referral source is a lot more profit than saving $100 on a device.”

Borer agrees. The price differential between a CPAP and AutoPAP used to be several hundred dollars, but it’s much smaller now. He says some providers believe that if they can put out a better piece of equipment, get happier, more compliant patients all while still being able to re-supply them with interfaces, masks, filters and tubing—that they are better off in the long-term.

Because autotitration has more bells and whistles than a CPAP, Riley believes providers can use auto and charge it as an upgrade. At this point, there’s not a reimbursement code for AutoPAP and it’s highly unlikely that CMS will assign one. “We’d like to see it because it’s more expensive and it’s a useful therapy but there’s no substantial clinical evidence that says the patient would do better,” Hudiburg says.

But if CMS considered reimbursing more for AutoPAP, patients would ultimately see the benefit. So, could providers, if they play their cards right.

Someone can be paid to fill the gaps in education, follow-up, trouble shooting and coaching, which is where the opportunity lies. If providers instituted rates for all these different areas, Hudiburg believes, compliance rates could rise from 50 percent to 80 percent.

Jezerc agrees that there’s not likely to be additional reimbursement on a home titration and auto device. However, there are a number of factors to consider. The incremental cost of an AutoPAP versus a CPAP needs to be weighed against the cost of going out to the patient’s home again to pick up the AutoPAP and put in a straight CPAP, to do a swap out or to have patients come in again. Another factor is the economic opportunity for a homecare company associated not with just the initial setup and 13 months of PAP therapy reimbursement, but with the resupply of that patient overtime ensuring that the patient has new masks and tubing could help the patient to stay compliant. AutoPAP helps providers to keep patients comfortable and compliant over time.

“It doesn’t take too many additional re-supplied masks to make up for the (variable) in cost between an AutoPAP and CPAP,” Jezerc says.

Ways Around the Extra Cost Associated with Auto

ResMed has gone to CMS half a dozen times requesting an AutoPAP code, and each time the answer was no, Borer says. However, Borer believes that a CPT code for unattended home titration could happen over time. AutoPAPs have a higher function level and works for patients who are noncompliant with normal therapy.

AutoPAPs also are similar to bi-level devices in that it uses algorithms and other more advanced technology to get the noncompliant patient compliant. Therefore, Borer says, it should have higher reimbursement.

While there isn’t a new AutoPAP reimbursement code, there is a code for compliance monitoring. Respironics was able to get CMS to establish Code A9279 for compliance monitoring equipment. Auto devices typically require a higher level of compliance data. Jezerc says that home care companies have been successfully submitting the code to their private insurance companies and receiving reimbursement for the additional work they’re doing. The code is for the equipment (i.e. the Smartcard reader with a modem, SmartCode) that enables you to actually gather the data. However, the implication is that if one is gathering the data one is working on providing better support for the patient.

“A number of private pay insurance companies have in fact been reimbursing for the A9279 code, and that is in fact, a way that home care companies can explore to achieve reimbursement in line with the service that they’re providing to the patient,” Jezerc says.

SleepQuest, a service provider, has come up with a bundle package that includes a home sleep test, an unattended home titration using an autotitrating device and CPAP setup for one price under the national contract with AETNA, a large commercial payor. Borer believes that this agreement is a great example of a new type of third party service provider.

Private insurance companies are clearly interested in home testing because of the costs savings and higher patient satisfaction, Hudiburg says. “It’s likely that they’ll get more patients diagnosed and treated, which means they’ll avoid much more expensive conditions down the road,” he says. “I think what may happen with private insurance companies is some may develop programs around home sleep testing that either directly or indirectly provide the appropriate reimbursement for all the elements associated with it, which would include titration.”

Hudiburg admits that this may not happen soon. But clearly, there’s a cost savings involved for insurance companies requiring support from the home health care provider, he says. Although AutoPAPs are more costly for the provider, Hudiburg believes that if providers took a step back and looked at their overall business profits, they’d find the devices beneficial.

If an HME wanted to be progressive, it could potentially go to a commercial payor with some type of a program for a carve out.

“We’ve heard stories from HMEs that said ‘I talked to my payor, and yes it’s a small payor, and yes it’s a small area; but they did actually give me some incremental dollars with the requirement that I track compliance and my compliance actually is in the 75, 80, 90 percent rating. So as long as I keep it there, they’re willing to pay a little extra for an AutoPAP.’ “But that’s certainly not the standard,” Borer says. “But it does exist in a small, small way.”

HME companies that understand the value of keeping a patient compliant and all of the additional opportunities and long-term care associated with AutoPAP are seeing its value. Providers should consider the cost of what will happen when they lose a patient.

“The typical reimbursement depending on the payor or the government insurance will take place over a number of months, and they may not get reimbursed for the entire costs of the unit if the patient doesn’t remain on therapy,” Terry adds.

The Future of AutoPAP and Titration

In general, the CPAP population is younger, able to work and possesses more disposable income than other Medicare populations. These are the people that providers want to target. Providers have patients in their existing patient population who may need a travel unit or, want an upgrade and are willing to pay out of pocket, Hudiburg says.

In this environment, the provider hopefully is focusing on the younger, non-Medicare patient that has more disposable income and that likes the convenience of having a second device, Riley says. As a selling point, providers could tell clients that because their sleeping pattern may be different at home than when on vacation that it may take different pressure levels to keep that airway open, Riley says. In addition, anytime providers sell the item in ways other than a cash sale, they should explain all the features and benefits to the patient and ask them to pay an additional $10 to $15 for the upgraded device.

“There’s a definite role for auto: we as providers just need to understand how it works, why it works, when it works, and know that there’s never a substitution for clinical assessment and follow-up from a patient’s primary care or sleep provider,” Riley says.

Borer says that if consumers are going to have to sleep eight hours each night on a machine, they’d be willing to pay more for a device that will keep them comfortable. “The more the consumer has understanding of the technology, and has some ability to request and get technology, even if they do have to kick in a little money it certainly bodes well for us in getting the patient to their goal therapy and getting them adherent to therapy,” he says.

Should home sleep testing continue to take off, people will see an increased role for auto because it serves as a backup for sleep testing. In recent years, testing devices have become more sophisticated, Riley says.

“I think we all recognize that home sleep testing is here and will likely continue to grow,” Jezerc says, adding that one of its challenges is that there’s not very significant reimbursement for it. The goal of the major players in the industry is to maximize the percentage of OSA sufferers who are identified and put on the appropriate treatment that they can stick with, she says.

“It is especially our job to continue raising the bar in terms of the ability of these devices to both titrate and also deliver the appropriate level of therapy for the patient,” she says. “Autotherapy, in our view, is a bright spot in the future.”

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